Every finding on record at Gardens of Mcgregor and Amasa Stone

Based on observation, interview, and review of the facility policy, the facility failed to ensure palatable food and drink were served at a safe and appetizing temperature. This affected four residents (#15, #36, #89, and #93) and had the potential to affect 131 residents who received meals from the facility kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #82, #128 and #78). The facility census was 134. Findings include:Interview on 08/11/15 at 11:58 A.M. revealed Resident #15 stated the vegetables were cold and the meat was dry.Interview on 08/11/25 at 10:21 A.M. revealed Resident #36 stated the food was not good and the breakfast was always cold.Interview on 08/11/25 at 1:56 P.M. revealed Resident #89 stated the food was warm, but not hot, and was tasteless.Interview on 08/13/25 at 5:00 P.M. with Resident #93's daughter stated she needed to bring outside food for her father because her father did not like the taste of the facility food.Observation on 08/12/25 at 11:00 A.M. revealed the holding temperatures of the food items on the tray line. The pasta with vegetables and tomato sauce was 199.2 degrees Fahrenheit (F.), the coffee was 143.9 degrees F., and milk was 39.7 degrees F. A test tray was prepared which included the pasta with vegetables, milk, and coffee and the test tray left the kitchen on 08/12/25 at 12:44 P.M. The test tray reached the Two South Unit at 12:44 P.M. Nursing staff started to pass the trays on 08/12/25 at 12:54 P.M. with the last tray passed at 1:17 P.M. Registered Dietitian (RD) #735 used a calibrated facility thermometer to obtain the test tray food temperatures. The test tray temperatures revealed the coffee was 124.3 degrees F., the two percent milk (one pint carton) was 56.8 degrees F., and the pasta with vegetables and tomato sauce was 115.0 degrees F. The mildness was not palatable, and it was warm to the taste. RD #735 verified the pasta with vegetables and tomato sauce was not palatable and did not taste warm.Review of facility policy titled Taste and Temperature Control, revised May 2025, revealed food was maintained at palatable temperatures during service to meet resident expectations.This deficiency represents non-compliance investigated under Complaint Number 1280432.

Based on observation and staff interview, the facility failed to store food and beverages in a safe and sanitary manner. This had the potential to affect 41 residents (19 residents who resided on the Two South Unit and 22 residents on the One South Unit) who had the ability to utilize the One and Two South Unit refrigerator/freezers. Findings Include:1. Observation on 08/12/25 at 11:15 A.M. revealed the Two South resident nourishment refrigerator located in the dining area contained a large brown bag of Olive Garden food with no resident name or date on the bag and a half gallon of Minute Maid Fruit Punch was expired as of 06/11/25.Interview at the time of discovery with Registered Dietitian #735 verified the findings in the Two South resident nourishment refrigerator and revealed the dietary staff were to clean out the refrigerators.2. Observation on 08/12/25 at 12:15 P.M. of the One South resident nourishment refrigerator located in the dining room contained a white grocery bag with a pound of bacon with no room number, resident name, or date, and the freezer had a half quart of Butter Pecan ice cream and a half quart of Strawberry ice cream that had no resident name or date received/opened. Interview at the time of discovery with Dietary Services General Manager #662 verified resident food was to be labeled with names and dates and dietary services were to clean out the refrigerators on the units. Dietary Services General Manager #662 verified the findings in the One South resident nourishment refrigerator/freezer.

Based on record review, observation, interview, and review of facility policy, the facility failed to ensure Resident #45 received appropriate care and services for a non-pressure related wound, including wound treatments as ordered and accurate documentation regarding the completion of the wound treatments. This finding affected one (Resident #45) of six residents reviewed for non-pressure skin conditions.Findings Include: Review of Resident #45's medical record revealed the resident was admitted on [DATE] with diagnoses including cellulitis of the right lower limb, primary osteoarthritis of the knee and essential hypertension.Review of Resident #45's physician orders revealed an order dated 07/29/25 (discontinued 08/07/25) to cleanse the left lateral foot open area with normal saline (NS), pat dry, apply Santyl and calcium alginate to the wound bed and cover with a foam dressing every night shift for wound care; an order dated 08/07/25 (discontinued 08/13/25) to cleanse the left lateral foot open area with NS, pat dry, apply Santyl and calcium alginate to the wound bed and cover with a foam dressing and apply an ace wrap every night shift for wound care; and an order dated 08/13/25 to cleanse the left lateral foot open area with NS, pat dry, apply Santyl and calcium alginate to the wound bed and cover with a foam dressing and apply an ace wrap every evening shift for wound care.Review of Resident #45's skin care plan revealed an intervention dated 07/29/25 for the resident to receive treatments per the physician's order.Review of Resident #45's wound evaluation notes dated 08/07/25 revealed the resident had a diabetic ulcer to her left lateral malleolus measuring 1.2 centimeters (cm) by 2 cm by an undetermined depth with 100 percent (%) slough at the wound base. The note revealed the treatment plan for the wound included the importance of adhering to prescribed treatments and dressing changes to prevent infection. Review of Resident #45's Treatment Administration Record (TAR) from 08/01/25 to 08/14/25 revealed Licensed Practical Nurse (LPN) #542 provided wound care on 08/03/25, 08/07/25, 08/08/25 and 08/11/25.Interview on 08/11/25 at 10:37 A.M. with Resident #45 revealed she was not getting wound care as ordered. Resident #45 said she received wound care on 08/07/25 by Registered Nurse (RN) #626 and Wound Nurse Practitioner #740 and told them she was not receiving wound care daily. She was told by RN #626 that she would look into the issue. Resident #45 said she did not receive wound care again until 08/10/25 when she asked the day shift nurse to change her bandage because it was hurting.Interview on 8/12/25 at 4:20 P.M. with Resident #45 and RN #626 revealed RN #626 confirmed the conversation with Resident #45 from 08/07/25 about wound care not being completed daily. Resident #45 also revealed that it was one nurse that was not completing the wound care. RN #626 confirmed she had spoken with the nurse about falsifying records and they were given a verbal warning. Resident #45 stated she had not received wound care since 08/10/25.Interview on 08/12/25 at 4:40 P.M. with RN #626 revealed the nurse not providing the wound care was identified as LPN #542.Observation on 8/12/25 at 4:23 P.M. of RN #626 providing wound care to Resident #45 revealed RN #626 removed the residents wound dressing and there was no date documented on the dressing.Interview on 08/14/25 at 10:22 A.M. with LPN #542 revealed on 08/11/25 he documented that he provided wound care for Resident #45, but he got distracted and never provided the wound care. He said the facility had called him and educated him on documenting after you provide care.Interview on 08/12/25 at 2:16 P.M. with RN #626 revealed she spoke with LPN #542 about the documentation issues on 08/07/25. She stated she had talked to him prior about correct documentation in addition to the conversation on 08/07/25. RN #626 confirmed that the TAR did not accurately reflect the wound care provided.Review of the facility policy titled Skin Alteration, Pressure Prevention and Risk Identification, dated January 2024, revealed a care plan would be developed and updated as needed and interventions would be implemented as indicated by the physician/nurse practitioner and as determined by the interdisciplinary team.This deficiency represents non-compliance investigated under Complaint Number 1280432.

Based on observation, record review and interview, the facility failed to ensure medications were administered as ordered and best practice guidelines. This finding affected two (Residents #34 and #142) of five residents observed for medication administration. A total of 35 medications were administered with three errors for a medication error rate of 8.57%.Findings include:1. Review of Resident #34's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, diabetes and muscle weakness.Review of Resident #34's physician orders revealed an order dated 08/08/25 to use 5 milliliters (ml) of heparin and flush the peripherally inserted central catheter (PICC) line intravenously (IV) every 12 hours; an order dated 08/08/25 for vancomycin 1500 mg (milligrams)/300 ml with instructions to administer 500 ml IV one time a day for infection until 09/01/25; and an order dated 08/08/25 to use sodium chloride solution (normal saline or NS) 10 ml IV every 12 hours for a flush.Observation on 08/12/25 at 8:24 A.M. revealed Licensed Practical Nurse (LPN) #650 administered Resident #34's oral medications. The nurse then washed her hands, put on gloves and flushed Resident #34's right arm PICC line with heparin solution, wiped the PICC hub and flushed with 10 ml of NS and then administered the IV vancomycin antibiotic via an administration pump. Interview on 08/12/25 at 8:35 A.M. with LPN #650 revealed she was not aware that she was required to flush Resident #34's PICC line with the NS syringe, administer the IV antibiotic, flush the PICC a second time with NS and then use the heparin to maintain patency of the resident's PICC line.Interview on 08/12/25 at 9:40 A.M. with the Director of Nursing (DON) confirmed LPN #650 should have used best practice guidelines when administering Resident #34's IV antibiotic which included the SASH method (saline flush, administer medications, saline flush, heparin flush).Review of the Flushing Considerations and Technique policy dated 2011 revealed for catheters requiring heparin use the S-A-S-H method which included to flush with saline prior to each use, administer the prescribed drug or infusion therapy, flush immediately afterward with saline and final flush with heparin to maintain patency during the time that the device was not in use.2. Review of Resident #142's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, major depressive disorder and generalized anxiety disorder.Review of Resident #142's physician orders revealed an order dated 03/18/20 for cetirizine give 5 mg by mouth one time a day for allergies; and an order dated 12/15/22 for vitamin D3 50 MCG (micrograms) with instructions to administer one tablet by mouth one time a day for a supplement.Observation on 08/11/25 at 8:43 A.M. revealed LPN #668 administered eight medications to Resident #142 including cetirizine 10 mg and vitamin D3 25 mcg (1000 IU).Interview on 08/11/25 at 11:38 A.M. with LPN #668 confirmed she gave the wrong dose of cetirizine and vitamin D3 to Resident #142.Review of the undated Medication Administration policy revealed the purpose was to ensure safe, accurate and timely administration of medications to residents in accordance with federal and state regulations, professional standards of practice, and facility procedures.This deficiency represents non-compliance investigated under Complaint Number 1280432.

Based on medical record review and staff interview, the facility failed to timely provide care and services to a resident's change in condition. This affected one (Resident #40) of three residents reviewed for change in condition. The facility census was 136. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included pain in right hip, low back pain, and disorders of bone density. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/20/24, revealed Resident #40 had intact cognition. Review of the care plan dated 12/16/24 revealed Resident #40 was at risk or had pain related to right hip and left shoulder pain. Interventions included observe for signs and symptoms of pain, assess pain, provide comfort measures, medicate per physician's order and consult with physician for ineffective pain relief. The nursing notes dated 12/30/24 at 5:00 P.M. revealed the nurse was notified by the Certified Nursing Assistant (CNA) that Resident #40 was on the floor in the resident's room. Upon entering her room, resident observed sitting on her buttocks with her lower extremities stretched outward in front of her. When asked what happened, a staff member stated the resident rolled out of bed while caring for her. This nurse assessed resident and vital signs were taken and within normal limits, resident denied head injury nor pain. No evident sign of injuries, full range of motion (ROM) of extremities. Review of the Social Worker #500's statement dated 01/02/25 revealed Resident #40 was going down to therapy and requested a follow up from her fall. The social worker brought the Assistant Director of Nursing (ADON) #307 into the conversation. Resident #40 explained she had pain her shoulder prior to the fall, but this pain was different. She was told by staff earlier in the day that she had bruising on her back. ADON #307 explained an x-ray would be ordered. Resident #40 appeared to be reluctant on getting the x-ray. Resident #40 was pleased with conversation and continued to go to scheduled therapy. Review of ADON #307's statement dated 01/02/25 revealed Social Worker #500 obtained ADON #307 to speak with Resident #40. Resident #40 explained stated she was having pain in her left shoulder that was not new but a little different. ADON #307 explained an x-ray would be ordered. There was nothing documented in the medical record on 01/02/25 and 01/03/25 regarding the physician being notified of Resident #40's reported pain in the left shoulder that was described by the resident as different and the request to obtain an x-ray of the shoulder. Review of physician orders dated 01/03/25 at 6:53 P.M. revealed an order to obtain an x-ray of the left shoulder and left arm. There was no diagnosis/reason for x-ray. Review of the x-ray results stated 01/04/25 at 4:10 P.M. revealed x-ray results showed evidence of a new or more conspicuous nondisplaced distal clavicle fracture is seen. The x-ray was obtained at 1:02 P.M. and the results were reported to the facility at 4:10 P.M. The nursing note dated 01/04/25 at 5:49 P.M. revealed an x-ray of the left arm and shoulder were reported to physician that x-ray results show evidence of a new or more conspicuous nondisplaced distal clavicle fracture was seen. The new order was to send Resident #40 to the hospital for evaluation. Family was made aware. The note dated 01/04/25 at 10:32 P.M. revealed Resident #40 left the facility to go to emergency room for evaluation and treatment of x-ray results. The nursing note dated 01/05/25 at 4:47 A.M. revealed Resident #40 returned from hospital with left arm in a sling with no new orders from hospital. The interview on 1/09/25 at 12:25 P.M. with Director of Nursing (DON) revealed the DON did not know that she was in pain because she did not tell anyone until 01/03/25 when she told ADON #307 that she was experiencing pain that was different than her usual pain. ADON #307 ordered an x-ray. DON stated the resident thought she fractured the left shoulder before and had an x-ray done. An interview on 01/15/25 at 12:19 P.M. with ADON #307 stated Resident #40 stopped her as she was walking in the hall on 01/02/25 and Resident #40 stated she was having a different kind of pain. ADON #307 recommended that an x-ray should be taken. ADON #307 verified there was no documentation in the medical record on 01/02/25 regarding the conversation with Resident #40 and notifying the physician on 01/02/25. ADON #307 explained she did notify the physician on 01/02/25 and the physician did not respond to her prior to her leaving the facility for the day, which was around 5:00 P.M. to 5:30 P.M. ADON #307 stated she returned to work on 01/03/25 and and asked the charge nurse, Licensed Practical Nurse (LPN) #310 to contact the physician to follow up on a order for an x-ray for Resident #40. ADON #307 confirmed there was no documentation in Resident #40's medical record for the follow up on 01/03/25. An interview on 01/15/25 at 12:38 P.M. with LPN #310 stated ADON #307 told her late morning or early afternoon on 01/03/25 to follow up with the physician to obtain an x-ray of Resident #40's left shoulder. LPN #310 stated she got a hold of the physician around 4:30 P.M. to 5:00 P.M. and the physician ordered the x-ray to be completed routinely, and the x-ray was completed on 01/04/25. This deficiency represents non-compliance investigated under Complaint Number OH00161352.

Based on observation, record review, hospital record review and interview the facility failed to provide adequate supervision and intervention to prevent and mitigate a fall with injury for Resident #30. Actual harm occurred on 06/08/23 when Resident #30, who required the assistance of two staff for bed mobility, fell from a bed in high position when receiving incontinence care by one staff member resulting in a right hip dislocation and hospitalization . This affected one resident (#30) of two residents reviewed for accident hazards. The total census was 135. Findings include: Record review for Resident #30 revealed the resident was admitted to the facility 10/11/21 and had diagnoses including cognitive communication deficit, osteoarthritis, and anxiety disorder. Review of the care plan for falls, dated 10/11/21, identified the need to provide a safe environment, including keeping the bed in low position. The plan of care interventions were updated on 06/08/23 for the use of fall mats to be kept on both sides of the resident's bed. Review of a fall assessment, dated 04/07/23 revealed Resident #30 was at high risk for falls. Review the most current occupational therapy assessment, dated 05/09/23, revealed Resident #30 had total dependence on staff for sitting balance, toileting, hygiene, and all other self-care activities of daily living. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/03/23 revealed she had moderate cognitive impairment and required total dependence on two or more staff to provide bed mobility, including turns. Review of Resident #30's progress notes revealed a note dated 06/08/23 at 10:38 P.M. indicating State tested Nursing Assistant (STNA) notified the nurse the resident rolled onto the floor during patient care. The nurse entered and found the resident lying on her side by the bed. The resident said, I rolled out of bed, and denied pain. Assessment at the time showed no sign of injury, however, notes on 06/09/23 revealed the resident complained of pain. An x-ray done the same day revealed the resident had a dislocated hip and was sent to the emergency room . Review of Resident #30's hospital documentation revealed the resident was admitted to the hospital and received a right total hip arthroplasty closed reduction under anesthesia (a procedure to put the hip back in place without need of incision). She was hospitalized until 06/29/23 when she returned to the facility. Review of a facility fall investigation for Resident #30's revealed the resident rolled out of bed on 06/08/23. A skin assessment was (initially) completed with no injuries noted. Bilateral safety mats to the side of the bed were applied in response to the fall. The next day the resident had complaints of pain in the right hip, and an x-ray revealed she had an injury. A witness statement from STNA #816 dated 06/09/23 revealed she rolled Resident #30 onto her right side, then went to the sink to retrieve an extra towel and the resident fell over as soon as she turned back around. STNA #816 received discipline by the facility and education to ensure residents were in a safe position prior to walking away. Observation of Resident #30 on 08/07/23 at 11:43 A.M. revealed she was not interview able and demonstrated no verbal or nonverbal signs of pain. She did not make any motions with her hands or arms nor demonstrate any ability to move around by herself in the bed. Interview with Resident #30's power of attorney on 08/08/23 at 2:13 P.M. revealed that on 06/08/23 at roughly 11:00 P.M. the facility informed her Resident #30 had a fall. The nurse informed her the fall occurred when the aide turned their back on the resident during incontinence care. The nurse said she believed the air mattress might be responsible, which may have shifted beneath the resident and caused her to roll. The next day the facility took x-rays, found had dislocated her hip, and they sent her to the hospital. Resident #30 was admitted to the hospital for 22 days, although she was treated for other conditions besides the dislocated hip during the hospitalization . Resident #30 was not capable of independent positioning in the bed. Interview with Licensed Practical Nurse (LPN) #982 on 08/09/23 at 3:43 P.M. revealed she was Resident #30's nurse at the time of her fall on 06/08/23. The LPN revealed Resident #30 was dependent on staff for bed mobility both before and after the fall and there should have been two staff members present when giving incontinence care. At roughly 10:30 P.M. on 06/08/23, STNA #816 informed her Resident #30 fell . The nurse arrived at the bedside to find the resident laying on her right side next to the right side of the bed. The bed was in a high position due to the fall occurring during incontinence care. The resident denied pain at the time, denied hitting her head, and a skin assessment revealed no evidence of injury. Interview with STNA #816 08/09/23 at 5:18 P.M. revealed on the evening of 06/08/23, Resident #30 had a large bowel movement and STNA #816 provided incontinence care without other staff in the room. She said the resident usually only needed one staff member to provide incontinence care, although sometimes needed two staff if they were unfamiliar with the resident. She stated she ran out of towels while giving care and left the resident on her right side to go to the bathroom to get more. STNA #816 stated she heard the resident fall to the floor while she was in the bathroom and came out to find the resident laying on the floor on her right side. STNA #816 immediately retrieved the nurse. The STNA stated Resident #30 denied pain all throughout that night. The resident could grip the bed 'a little bit' during turns, but otherwise had no ability to contribute to bed mobility both before and after the fall. The surveyor confirmed the above record review findings with the Director of Nursing during an interview on 08/10/23 at 9:55 A.M.

Based on interview and record review, the facility failed to ensure monthly pharmacy reviews were completed for Resident #3, #9, #35 and #71. This affected four residents, (Resident #3, #9, #35, and #71), out of five residents reviewed for unnecessary medications. Facility census was 135. Findings include: #1. Resident #35's medical record revealed an admitted [DATE] with diagnosis to include Multiple Sclerosis (MS), muscle wasting/atrophy right upper arm, hypertension, epilepsy, spondylolysis lumbosacral region, anxiety disorder and sleep apnea. Record review of the care plan dated 06/07/23 revealed antipsychotic medications used for the diagnosis of insomnia, depression, and schizoaffective disorder. Interventions included to administer psychotropic medications as ordered by physician, monitor for side effects, attempt general dose reduction (GDR) as indicated, and referral to psychiatric services. Record review of the physician orders for Resident #35 for August 2023 revealed orders for Escitalopram Oxalate 20 milligram (MG) for depression, Remeron 30 MG for depression, and Latuda 40 MG for depression. Record review of the Medication Administration Record (MAR) for August 2023 revealed Resident #35 received Escitalopram Oxalate 20 milligram (MG), Remeron 30 MG for depression, and Latuda 40 MG everyday as ordered. Review of the facility records showing the list of residents reviewed monthly by the pharmacist for October 2022, January 2023, February 2023, and March 2023 revealed no documentation of pharmacy reviews completed for Resident #35. 37095 2. Record review of Resident #71 revealed she was admitted to the facility 07/23/20 and had diagnoses including unspecified dementia, anxiety disorder, auditory hallucinations, and major depressive disorder. Review of the facility records showing the list of residents reviewed monthly by the pharmacist for January 2023, February 2023, March 2023 and April 2023 revealed no documentation of pharmacy reviews completed for Resident #71. 3. Record review of Resident #9 revealed she was admitted to the facility 02/22/20 and had diagnoses including multiple sclerosis, major depressive disorder, and chronic kidney disease. Review of the facility records showing the list of residents reviewed monthly by the pharmacist for January 2023, February 2023, March 2023 and April 2023 revealed no documentation of pharmacy reviews completed for Resident #9. 39969 4. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type 2, hyperglycemia, chronic obstructive pulmonary disease, ad major depressive disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, required extensive assistance of two staff for bed mobility and transfers. The resident also received insulin, antianxiety medication, diuretic, and opioids. Review of the facility records showing the list of residents reviewed monthly by the pharmacist for October 2022, January 2023, February 2023, March 2023, June 2023 and July 2023 revealed no documentation of pharmacy reviews completed for Resident #3. Interview was conducted on 08/10/23 at approximately 11:00 A.M. with the Director of Nursing (DON) who explained her former Assistant Director of Nursing (ADON) had kept track of the monthly pharmacy review binder containing the lists of residents reviewed by the pharmacist each month, the ADON no longer worked for the facility and the DON could find no record at all of pharmacy reviewes from October 2022. The DON verified for Resident #3, #9, #35 and #71 there was no evidence those residents had received monthly pharmacy reviews for the months in question by the surveyors.

Based on observation and interview, the facility failed to ensure all nursing unit serveries were maintained in a clean and sanitary manner to prevent the risk of attracting pests, and contamination of clean cups for use by the residents. This affected 22 residents (#14, #19, #29, #30, #31, #37, #40, #58, #61, #66, #79, #80, #83, #86, #95, #101, #108, #110, #115, #120, #122, and #387) who resided on one South nursing unit, 22 residents (#2, #10, #11, #36, #46, #56, #70, #94, #97, #123, #127, #287, #288, #289, #290, #291, #292, #293, #294, #295, #296, and #297) who resided on two North nursing unit, and 25 residents (#1, #5, #9, #17, #18, #20, #24, #41, #43, #49, #51, #52, #59, #60, #62, #69, #71, #74, #77, #78, #89, #99, #112, #117, and #118) who resided on three South nursing unit. The facility census was 135. Findings include: Observations on 08/09/23 between 10:11 A.M. through 10:27 A.M. of the tour of the nursing unit serveries with Certified Dietary Manager (CDM) #931 revealed the three South, two North and one South nursing unit serveries were not maintained in a clean and sanitary manner. The three South servery had food and/or beverage spills and sugar packets on the floor, salt or sugar spilled on a tray holding clean cups, dried reddish food splatter near the steam table, and brownish drippings on white cabinet doors where the microwave was located. The reach-in freezer had spillage and food splatter on the inside bottom part of the freezer. Observations in the two North nursing unit servery revealed dried brownish spillage on the white cabinets near the microwave and on the cabinets near sink. The counter near the sink had various build up of food debris. Observed on the one South nursing unit servery inside of the reach-in freezer there was a reddish spillage and various food residue stains and ice frozen to the bottom of the inside freezer. Interview on 08/09/23 between 10:11 A.M. through 10:27 A.M., CDM #931 verified the above findings and stated she would have it all cleaned up. CDM #931 stated housekeeping was responsible for the floors and the dietary staff was responsible for wiping everything down after each meal.

Based on resident representative, staff interviews and record review, the facility failed to provide the resident and resident representative a written notification for the reason for transfer to the hospital for Resident #28, #30, #67, #135 and #136. This affected five residents (#28, #30, #67, #135, and #136) of five residents reviewed for hospitalization s. The facility census was 135. Findings include: 1.Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, dysphagia, and congestive heart failure (CHF). Resident #28 was sent to the hospital on 05/13/23 due to a change in condition, as documented in a nurse's note dated 05/13/23 at 1:24 P.M., following a physician order to send the resident to the emergency room . The medical record showed no evidence Resident #28 nor their power of attorney (POA) was provided a written notification for the reason for transfer to the hospital. 2.Review of the closed medical record for Resident #135 revealed an admitted [DATE]. Diagnoses included stroke, left eye blindness, low vision right eye, hyperlipidemia, hypertension, and seizures. Resident #135 was transferred to the emergency department via ambulance on 07/03/23 per a nurses note dated 07/03/23 at 4:43 P.M. The medical record showed no evidence Resident #135 nor their representative was provided a written notification for the reason for transfer to the hospital. 37095 3. Record review of Resident #30 revealed she was hospitalized [DATE] following a fall and returned to the facility 06/29/23. No evidence could be found indicating the resident or family received written notification of the reason for transfer to the hospital. Interview with Resident #30's power of attorney on 08/08/23 at 2:13 P.M. revealed the facility informed her verbally of the hospitalization and gave her a paper bed hold notice, however, they did not provide a written notification for the reason for the transfer to the hospital. 4. Record review of Resident #136 revealed she was hospitalized on [DATE] and did not return to the facility. No evidence could be found indicating the resident or family received written notification of the reason for the transfer to the hospital. 43061 #5. Review of the medial record for Resident #67 revealed an admitted [DATE] with diagnoses of chronic diastolic congestive heart failure, cardiomyopathy, unspecified atrial fibrillation, hypertensive heart disease with heart failure, and hypertension and a discharge to the hospital on 07/23/23 and returned to the facility on [DATE]. The record contained no evidence that a written notification of the reason for the transfer had been given to the resident or the resident's representative. Interview was conducted on 08/09/23 at 11:32 A.M. with the Administrator who verified the facility did not provide written notice of transfer to the hospital to Resident #28, #30, #67, #135, #136 or their representatives because the facility practice was to notify all residents and resident representatives verbally if a resident needed transferred to the hospital. The Administrator explained the facility did provide bed hold notices, but only did verbal notifications to residents and resident representatives on reason for the transfer to the hospital. Review of the undated facility policy titled Transfer and Discharge Guidelines, under the area notice, before a facility transfers or discharges a resident permanently, the facility must: notify the resident and, if known, a family member or legal representative of the resident transfer or discharge and the reasons for the move in writing and in a language and manner they understand.

Based on record review and interview the facility failed to ensure Resident #120, who required a mechanical lift (Hoyer lift) for transfers was transferred in a safe manner to prevent injury. Actual harm occurred on 04/04/22 when two staff manually transferred Resident #120 from the wheelchair to the bed, using only his arms and legs, resulting in a fracture of his upper right femur (thigh bone)/hip. Resident #120 was admitted to the hospital and required surgical repair of his fracture. This affected one of three residents reviewed for accidents. Findings include: Review of the medical record for Resident #120 revealed an admitted [DATE] with diagnoses including end stage renal (kidney) disease requiring [CONDITION(S)], type two diabetes mellitus, [CONDITION(S)] with behavioral disturbance, history of traumatic fracture, age related [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and hypertension. Review of the current plan of care for activities of daily living (ADL) revealed Resident #120 had an ADL self-care deficit related to end stage renal disease. Interventions included for staff to utilize a mechanical (Hoyer) lift to transfer Resident #120. This intervention was initiated on 08/05/19. Resident #120's weight was recorded at 164.4 pounds on 02/21/22. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/26/22 revealed Resident #120 had intact cognition and was dependent on staff assistance for transfers. Review of the nurse progress note dated 04/04/22 at 7:53 P.M. revealed Resident #120 was transferred from his wheelchair to his bed without the Hoyer lift since he had slid down in his wheelchair and the lift pad could not be used. Immediately following this transfer, Resident #120 complained of right hip pain. The nurse practitioner was called and an x-ray was ordered. The nurse's note from 04/04/22 at 11:43 P.M. indicated the x-ray company indicated they would not complete Resident #120's x-ray until the next morning. The nurse's notes after this incident on 04/04/22 at 7:53 P.M. and 04/05/22 indicated Resident #120 complained of pain, but no description of his pain was documented in any of the notes. According to the nurse's note on 04/05/22 at 6:50 A.M., Resident #120's x-ray was completed. The nurse's note on 04/05/22 at 8:36 A.M. indicated Resident #120 was transported to the hospital due to a fracture. Review of the facility radiology report dated 04/05/22 revealed Resident #120 sustained a fracture to his right proximal femur (the top area of his thigh bone, near the hip joint). The facility investigation for Resident #120's incident was dated 04/04/22. The summary of the incident revealed Resident #120 slid down to the edge of his wheelchair and the Hoyer lift pad was not in position to use the Hoyer lift to transfer him. Facility staff completed a two person assist to transfer him back to his bed, without the Hoyer (mechanical) lift. Review of the local hospital record dated 04/05/22 revealed Resident #120 sustained an acute, mildly displaced, right proximal femoral subtrochanteric fracture (a fracture of the thigh bone just below the ball joint of the hip) extending from the inferior aspect of the greater trochanter to the proximal medial diaphysis. The nurse's note from 04/06/22 at 3:07 P.M. indicated the facility staff contacted the hospital for an update on Resident #120. The hospital indicated Resident #120 required surgical repair on 04/06/22 and was admitted for periprosthetic fracture of his right hip. Resident #120 was readmitted to the nursing facility on 04/10/22. The pain assessment completed on 04/11/22 indicated Resident #120 complained of mild pain. Resident #120 indicated that over the last five days his pain made it hard to sleep and limited his day to day activities. Resident #120 was ordered acetaminophen, 325 milligrams, three tablets, every eight hours for pain. Review of a witness statement dated 04/11/22, authored by State tested Nurse Aide (STNA) #509, indicated Resident #120 had scooted himself down in his wheelchair and the Hoyer pad could not be used. STNA #509 informed Licensed Practical Nurse (LPN) #508 she needed help with Resident #120. STNA#509 indicated to prevent the resident from falling to the floor, she and LPN #508 assisted Resident #120 to his bed without the use of the Hoyer lift. A witness statement dated 04/11/22, authored by LPN #508, indicated STNA #509 asked her to assist her with Resident #120. Resident #120 was sliding out of his wheelchair and off the Hoyer pad, therefore she and STNA #509 assisted him into his bed without using the Hoyer lift. LPN #508 indicated Resident #120 began complaining of pain and the nurse practitioner was notified. An x-ray was ordered. On 04/20/22 at 3:10 P.M., interview with the Director of Nursing (DON) confirmed Resident #120 sustained a fracture after being transferred from his wheelchair to his bed without the Hoyer lift. The DON said the transfer was completed with the assistance of two staff members. The DON stated Resident #120 had scooted himself to the edge of his wheelchair and the Hoyer pad was no longer in the proper position under him and they could not use the Hoyer lift. The DON stated LPN #508 and STNA #509 initiated a two person transfer from the resident's wheelchair to his bed without utilizing the Hoyer lift. The DON did answer when asked why Resident #120 could not be repositioned properly in his wheelchair for a Hoyer transfer or why staff could not lower him to the floor and transfer him with a lift sheet and/or additional staff support. The DON verified, Resident #120 complained of pain immediately after the transfer and was sent to the hospital and the fracture was identified. On 04/21/22 at 11:25 A.M., interview with Physical Therapist #507 verified Resident #120 required a Hoyer lift with maximum staff assistance for all transfers. On 04/21/22 at 11:46 A.M., interview with LPN #508 verified Resident #120 was transferred without a Hoyer lift. She stated on the day of the incident, Resident #120 had scooted himself to the edge of his wheelchair and the Hoyer pad could not be used due to his positioning. LPN #508 stated she and STNA #509 proceeded to transfer Resident #120 from his wheelchair to his bed without utilizing the Hoyer lift. LPN #508 said she was on one side of the resident and STNA #509 was on the other side of the resident, and they lifted him with each of them lifting one arm and one leg and transferred him to the bed. She stated Resident #120 complained of right hip pain immediately following the transfer and an x-ray was ordered. This deficiency substantiates Complaint Number OH 740.

Based on observation, interview, record review and policy review, the facility failed to accurately communicate with appropriate signage residents on droplet isolation precautions, don appropriate personal protective equipment (PPE) prior to entering a resident's room on droplet isolation precautions or change their N95 mask, cleanse their goggles or face shields, or perform hand hygiene after exiting a resident's room on droplet isolation precautions. This affected three (Resident's #23, #25 and #58) of three residents on respiratory droplet isolation precautions and had the potential to affect all 126 residents residing in the facility. Findings include: Observation during the tour of the facility on 01/31/22 from 7:54 A.M. to 8:02 A.M. revealed three (Resident's #23, #25 and #58) identified on the second floor that had signage on the outside of their rooms indicating they were on respiratory droplet precautions. Resident's #23, #25 and #58 also had a white bin outside each of their rooms containing PPE. 1. Review of Resident #23's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 01/17/22 revealed Resident #23 was at risk for COVID-19 respiratory illness. Interventions included droplet precautions. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 01/31/22 at 8:13 A.M. with Agency Licensed Practical Nurse (LPN) #601 revealed during medication administration for Resident #23 she donned shoe covers, gown, and gloves. LPN #601 wore the same eye protection and N95 mask without covering the N95 mask she had previously been wearing to enter Resident #23's room. Agency LPN #601 doffed her shoe covers, gown, gloves, and performed hand hygiene and exited Resident #23's room stating she needed to get a new multivitamin as it had stuck to the cup. Agency LPN #601 walked down the hallway to the medication cart and did not change her N95 mask or cleanse her eye protection upon exiting the room. Observation on 01/31/22 at 8:19 A.M. with Agency LPN #601 revealed she obtained a new multivitamin for Resident #23 and donned new shoe covers, gown and gloves but continued to wear the same N95 mask without covering the mask and the same eye protection. Agency LPN #601 then proceeded to doff the shoe covers, gown, gloves and performed hand hygiene and exited the room. She walked down the hallway without changing her N95 mask or cleansing her eye protection. Interview on 01/31/22 at 8:22 A.M. with Agency LPN #601 revealed Resident #23 was on respiratory droplet precautions as she revealed she had a sign outside her door indicating she was. She revealed she was on precautions due to being a new admission but did not have active COVID-19. Agency LPN #601 verified she had worn the same N95 mask into and out of Resident #23's room and had not changed or covered her mask. She also verified she had not cleansed her eye protection after exiting Resident 23's room. She revealed she had never been educated that she needed to cover or change her N95 mask or cleanse her eye protection. Interview on 01/31/22 at 1:42 P.M. with the Director of Nursing revealed Resident #23 was not supposed to have a sign still on her door for respiratory droplet precautions, but she verified the facility had not removed Resident #23 from isolation per order and verified Agency LPN #601 was not aware Resident #23 was not to be on isolation. The Director of Nursing also verified Agency LPN #601 should have cleansed her eye protection upon exiting Resident #23's room. She verified she never educated staff to change and/or cover their N95 mask upon entering and/or exiting a room of a resident on respiratory droplet precautions. 2. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 01/25/22 revealed Resident #58 was at risk for COVID-19 respiratory illness. There were no interventions regarding isolation or droplet precautions identified in the care plan. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 01/31/22 at 1:02 P.M. revealed signage outside of Resident #58's room indicating he was on droplet respiratory precautions. Observation revealed State tested Nursing Assistant (STNA) #610 walked into Resident #58's room carrying his lunch tray without donning any PPE except eye protection and a N95 mask which he was already wearing. STNA #610 adjusted Resident #58's bedside table over him and then proceeded to set up Resident #58's tray. STNA #610 exited the room without changing the N95 mask, cleansing his eye protection or without performing hand hygiene and went to obtain another tray off the meal cart. Interview on 01/31/22 at 1:04 P.M. with STNA #610 verified Resident #58 was on respiratory droplet precautions but stated Resident #58 did not have COVID-19. Resident #58 was on droplet precautions because he was a new admission. STNA #610 revealed he did not don PPE to enter Resident #58's room to drop off a tray as he only donned and doffed PPE when he performed actual hygiene care for residents on droplet isolation as precaution. STNA #610 revealed he would have donned PPE if Resident #58 had active COVID-19. STNA #610 verified he was within six feet of Resident #58 as he adjusted his bedside table over him and assisted with setting up his tray. STNA #610 also verified he did not perform hand hygiene after exiting Resident #58's room. Interview on 01/31/22 at 1:42 P.M. with the Director of Nursing verified STNA #610 should have donned appropriate PPE including gown, gloves, mask, and eye protection upon entering Resident #58's room to pass his tray due to Resident #58 was on respiratory droplet precautions. The Director of Nursing verified STNA #610 should have then doffed the PPE appropriately including cleaning his eye protection and performing hand hygiene upon exiting the room. She stated she never educated staff to change and/or cover their N95 mask upon entering and/or exiting a room of a resident on respiratory droplet precautions. 3. Review of the medical record revealed Resident #25 had an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 01/21/22 revealed Resident #25 was at risk for COVID-19 respiratory illness. Interventions included droplet isolation. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 01/31/22 at 1:27 P.M. revealed signage outside of Resident #25's room indicating he was on droplet respiratory precautions. Observation revealed STNA #611 applied gown, gloves, and shoe covers and entered Resident #25's room to pass his lunch tray. She wore the same eye protection and N95 mask without covering her N95 mask. She assisted Resident #25 with setting up his tray in front of him and then exited his room doffing the shoe covers, gown, gloves and performed hand hygiene. STNA #611 proceeded down the hallway wearing the same N95 mask and without cleansing her eye protection. Interview on 01/31/22 at 1:30 P.M. with STNA #611 verified she wore the same N95 mask into Resident #25's room without covering it and when she exited the room, she did change her N95 mask as well as did not change or cleanse her eye protection. She revealed she never knew she had to change or cover her N95 mask. She also verified she was not aware she had to cleanse or change her eye protection upon exiting a resident room on respiratory droplet precautions. Interview on 01/31/22 at 1:42 P.M. with the Director of Nursing verified STNA #611 should have cleansed her eye protection upon exiting Resident #25's room. She revealed she never educated staff to change and/or cover their N95 mask upon entering and/or exiting a room of a resident on respiratory droplet precaution. Review of undated facility policy labeled Donning and Doffing Personal Protective Equipment (PPE) - COVID-19, revealed it was the facility policy to put on and remove PPE in the correct sequence in accordance with best practice approach for infection prevention and control when caring for a resident with confirmed or suspected COVID-19. The policy revealed the proper sequence was to perform hand hygiene, don gown, facemask, face shield or goggles, again perform hand hygiene and then apply gloves. The policy revealed the proper doffing sequence included remove gloves, gown, perform hand hygiene upon exiting room, and once outside of room remove eye protection clean with alcohol wipes or other cleaner. The policy then stated to remove facemask and perform hand hygiene. This deficiency substantiates Complaint Numbers OH 441 and OH 283.

Based on interview and record review the facility failed to notify the physician, and/or nurse practitioner, or responsible party for Resident #129's decreased oxygen saturation level and implementation of oxygen. This affected one (Resident #129) of four (Resident's #129, #58, #23 and #25) reviewed for COVID-19 precautions/change in condition and had the potential to affect all 126 residents residing at the facility. Findings include: Review of the closed medical record for Resident #129 revealed an admitted [DATE], and she had passed away on 01/18/22 at the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #129's daughter was listed as her responsible party. Review of the physician's orders for December 2021 and January 2022 revealed Resident #129 had no physician's orders for oxygen. Review of the care plan dated 12/29/21 revealed Resident #129 had acute respiratory infection related to positive COVID-19 results. Interventions included monitor cough, fever, temperature, shortness of breath, notify the physician of pulse oxygen level below 95 percent, and notify the physician and responsible party of condition changes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #129 had impaired cognition. She required extensive assist of one staff with bed mobility and transfers. The MDS 3.0 assessment revealed no oxygen use. Review of the nursing notes dated 01/14/22 to 01/18/22 revealed no notifications to physician, nurse practitioner or responsible party for Resident #129 regarding her decreased oxygen saturation level and the implementation of oxygen on 01/14/22. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/14/22 at 3:45 P.M. completed by Licensed Practical Nurse (LPN) #620 revealed Resident #129's vital signs were stable, and her oxygen saturation rate was 98 percent with oxygen per nasal cannula and her respirations were 18. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/14/22 at 5:11 P.M., completed by LPN #626 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 98 percent on room air, and her respirations were 20. Resident #129 had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Resident #129 was not on oxygen. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/15/22 at 7:24 A.M. completed by LPN #625 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 95 percent on room air, and her respirations were 17. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/15/22 at 5:31 P.M. completed by LPN #624 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 98 percent on room air, and her respirations were 16. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/15/22 at 10:07 P.M. completed by LPN #603 revealed Resident #129's vital signs were stable, her oxygen situation rate was 98 percent on room air, and her respirations were 16. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/16/22 at 6:56 A.M. completed by Registered Nurse (RN) #623 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 98 percent on room air, and her respirations were 16. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/16/22 at 3:30 P.M. completed by LPN #605 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 98 percent on room air, and her respirations were 16. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/16/22 at 9:25 P.M. completed by LPN #622 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 97 percent on room air, and her respirations were 18. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/17/22 at 5:47 P.M. completed by RN/ Wound Nurse #608 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 97 percent on room air, and her respirations were 18. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the facility form labeled Cold-Flu Coronavirus Signs and Symptoms Review dated 01/17/22 at 7:48 P.M. completed by LPN #621 revealed Resident #129's vital signs were stable, her oxygen saturation rate was 97 percent on room air, and her respirations were 18. She had no fever, headache, fatigue, exhaustion, stuffy nose, sneezing, sore throat, cough, or shortness of breath. Review of the nursing note dated 01/18/22 at 8:45 A.M. and authored by LPN #605 revealed she observed Resident #129 sitting in her wheelchair unresponsive with a thready weak pulse, and her breathing was shallow at 8:20 A.M. LPN #605 was put to bed and sternal rub initiated with no response. Resident #129's vital signs included: blood pressure 98/79, pulse 88, respirations 6 and her oxygen saturation level was unable to be obtained. Oxygen was applied, and emergency rescue squad was notified. Resident #129 stopped breathing and cardiopulmonary resuscitation was initiated. The emergency rescue squad took over and transferred Resident #129 to the hospital. Resident #129's Primary Care Physician #901 and responsible party were notified. Review of the late entry nursing note authored by LPN #620 with a created date for 01/18/22 at 6:03 P.M. and an effective date of 01/14/22 at 12:00 P.M. revealed LPN #620 assessed Resident #129, and she was alert and oriented with periods of confusion. Resident #129's vital signs included: temperature was 98 degrees Fahrenheit, blood pressure 110/63, pulse 75, respirations 18 and her oxygen saturation rate was 88 percent on room air. Resident #129's lungs were clear, no cough, and no shortness of breath. Resident #129 stated she did not feel good and ate zero percent for breakfast. Resident #129's capillary refill was less than three seconds, and her mucous membranes were moist. LPN #620 placed Resident #129 on two liters of oxygen per nasal cannula, and her oxygen saturation rate increased to 98 percent. LPN #620 noted per the nursing notes the unit manager would make notifications Nurse Practitioner #627 and Resident #129's responsible party. Interview on 01/31/22 at 1:42 P.M. with the Director of Nursing revealed she completed a facility investigation, and it was determined on 01/14/22 at 12:00 P.M. Resident #129's oxygen saturation rate decreased to 88 percent. She revealed LPN #620 applied oxygen per nasal cannula, and Resident #129's oxygen saturation level improved to 98 percent. She stated LPN #620 notified LPN/ Unit Manager #609 of the change in condition, and LPN/ Unit Manager #609 stated she would make notifications to Nurse Practitioner #627 and Resident #129's responsible party, but the Director of Nursing revealed LPN/Unit Manager #609 did not make the notifications. The Director of Nursing revealed LPN/ Unit Manager #609 stated she got distracted and forgot. The Director of Nursing revealed she educated LPN/ Unit Manager #609 on proper notifications as she verified there was no physician order obtained for Resident #129 to be placed on oxygen, and she revealed the facility had no standing orders for oxygen. The Director of Nursing verified any resident's change in condition, including decrease in oxygen saturation level, the physician and/or nurse practitioner was to be notified. The Director of Nursing revealed the evening of 01/14/22, Resident #129 no longer required oxygen and her oxygen saturation levels remained stable. Interview on 01/31/22 at 12:36 P.M. with LPN/ Unit Manager #609 revealed LPN #620 notified her of Resident #129's decreased oxygen saturation rate of 88 percent and LPN #620 applied oxygen. LPN/ Unit Manager #609 verified she told LPN #620 she would make notifications to Nurse Practitioner #627 and Resident #129's responsible party due to her change in condition. LPN/ Unit Manager #609 verified she did not make the notifications as she got tied up with other tasks and forgot. Interview on 01/31/22 at 4:22 P.M. with Nurse Practitioner #627 for Resident #129 stated she was not notified of Resident #129's oxygen saturation rate decreasing and requiring the implementation of oxygen on 01/14/22. She verified anytime a resident's oxygen saturation rate decreases requiring oxygen the primary care physician or herself should be notified as she then evaluates the change in condition and implements potential further orders. Review of the facility policy labeled Oxygen Administration, dated October 2010, revealed the purpose of this policy was to provide guidelines for safe oxygen administration. The policy revealed the staff was to verify a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy labeled Notification of Change in Resident's Condition or Status, dated 02/15/20, revealed the objective of the policy was to communicate in an effective and timely manner any changes in a resident's condition or status. The policy revealed all notifications must be made as soon as practical, but notifications shall not exceed twenty-four hours. The policy revealed nursing shall be responsible for notifying the resident's attending physician and or nurse practitioner and documenting this in the medical record including when there was need to alter treatments. The policy revealed the nurse was responsible for notifying the resident's representative when there was a change in the resident's physical, mental or emotional status. This deficiency substantiates Complaint Number OH 441.

Based on record review and interview, the facility failed to ensure staff correctly documented a report of a fall. This affected one resident (Resident #143) of three residents reviewed for falls. The facility census was 142. Findings include: Review of the medical record for Resident #143 revealed an admitted [DATE] and a discharged date of 08/09/21. Resident #143 was admitted for a respite stay with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) dated 08/05/21 revealed Resident #143 was moderately impaired, but alert and oriented with some cognition impairment. Review of the care plan dated 08/04/21 revealed Resident #143 was at risk for falls and had impaired cognitive function and/or dementia. Review of the nursing note dated 08/06/21 at 4:11 P.M., located in Resident #143 old chart dated for the year of 2014, revealed Resident #143 had an unwitnessed fall. Resident #143 had fallen from her wheelchair onto the floor, on her left side, close to the bed. Resident #143 stated she fell out of her wheelchair trying to get her snacks off her bed. Resident #143 was educated on calling for help, and staff educated on how important it was to keep items near for reaching. Resident #143's physician was notified. Review of the note revealed it was located in a different chart from Resident #143 current medical record. Interview on 10/20/21 at 11:35 A.M. with the Director of Nursing (DON) with the Administrator present, revealed she did not recall Resident #143 and would need to review her chart in order to answer direct questions. Interview on 10/20/21 at 1:01 P.M. with Licensed Practical Nurse (LPN) #325 revealed she was the nurse on the unit when Resident #143 had a fall. LPN #325 revealed Resident #143 was sitting in her wheelchair and over-reached for her snacks when she fell . LPN #143 revealed Resident #143's family would bring in snacks and have them too far out of reach for her. LPN #325 revealed Resident #143 was alert and oriented to person, place, and time. LPN #325 revealed Resident #143 wore glasses and when she had a fall, the glasses caused a small carpet-burn like abrasion above her right eyebrow. LPN #325 revealed she completed a fall incident report, and a progress note was placed in her chart in Point Click Care (PCC), the electronic medical record. LPN #325 revealed Resident #143 had a fall care plan in place at the time of the incident. LPN #325 confirmed she placed the note in Resident #143 old chart. Interview on 10/20/21 at 1:05 P.M. with the DON revealed Resident #143 was a resident in the facility on two separate occasions. The DON revealed she was in the facility in 2014 and her latest stay was in 2021. The DON revealed LPN #325 placed the progress note and fall assessment in the correct chart but the wrong location located in PCC. The DON revealed she looked throughout Resident #143's chart from her most recent stay but could not locate the fall report or progress note. The DON revealed she searched recent fall reporting and was able to see that the incident was documented in another location. This deficiency substantiates Complaint Number OH 006.

Based on interview and record review the facility failed to ensure a nursing assessment was completed prior to moving a resident after a fall. This affected one (Resident #129) of three residents (Resident #17, Resident #99 and Resident #129) reviewed for falls. The facility census was 128. Findings include: Review of the medical record revealed Resident #129 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dementia, difficulty walking, and unsteadiness on feet. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for bed mobility, locomotion on the unit, dressing, eating, toilet use and personal hygiene. The resident required extensive assistance of two staff for transfers and was unable to walk. Review of the fall risk assessments dated 05/25/21, 05/21/21, 05/19/21, and 05/14/21 all revealed Resident#129 was at high risk for falls. Review of the plan of care dated 05/02/21 revealed the resident was at risk for falls due to a [CONDITION(S)] (CVA) and impaired mobility. Interventions included: Move commonly used articles within easy reach, 05/02/21. Encourage to transfer and change positions slowly, 05/02/21. Reinforce need to call for assistance, 05/02/21. Orientate to room and call light system, 05/04/21. Keep personal items within reach, 05/04/21. Maintain a clear pathway, free of obstacles, 05/04/21. Be sure call light is within reach and encourage resident to use it for assistance as needed, 05/04/21. The resident needs a safe environment with even floors, free from spills, and/or clutter, adequate lighting, a working reachable call light, the bed in low position, personal items within reach, 05/04/21. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, 05/04/21. Resident to be placed in common area when up in wheelchair for supervision from staff, 05/12/21. A non-slip pad (Dycem) applied to top and bottom of cushion in wheelchair for resident safety, 05/21/21. Resident to eat meals in dining room for closer supervision from staff, 05/21/21. Bilateral floor safety floor mats, 05/24/2.1 Review of the nurse's note from 05/25/21 at 3:49 P.M. revealed it was reported by State tested Nursing Assistant (STNA) #220 Resident #129 was observed on the floor. Registered Nurse (RN) #219 went quickly to the resident's room and observed the resident in her wheelchair. The resident had good trunk control, was alert but confused as was her normal, had good color, skin was warm and dry, range of motion for all extremities was within normal limits for the resident, there were no open areas noted to the skin. Resident #129 had a hematoma to the right side of her forehead just above the brow, no other injuries were observed. The resident denied pain and no signs of pain were observed i.e. moaning, groaning, or grimacing, pupils appeared to be equal. The resident's physician was contacted, and a new order was placed to send Resident #129 to the emergency department. Interviews on 06/08/21 from 2:10 P.M. through 3:14 P.M. with STNA #206, STNA #207, STNA #208, and STNA #209 revealed the STNA's were familiar with fall prevention techniques. Each noted they were to get the charge nurse immediately when a resident fell . They could make sure the resident was okay but were not to move them until after the nurse assessed the resident. Interview on 06/09/21 at 2:40 P.M. the Director of Nursing (DON) verified on 05/25/21 agency STNA #220 had put Resident #129 back in her wheelchair after her fall before the nurse assessed her. That was against normal nursing practice. The STNA had not returned to the facility. Interview on 06/09/21 at 3:04 P.M. with RN #219 (the RN on duty at the time of Resident #129's fall on 05/25/21) revealed she observed Resident #129 in her wheelchair after the fall. The resident had about a quarter size lump on head right after injury. RN #219 verified STNA #220 had gotten Resident #129 off the floor before she assessed her. This deficiency substantiates Complaint Number OH 872.

Based on observation and interview, the facility failed to ensure staff treated residents with dignity and respect. This affected one (Resident #10) of 134 facility residents. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's quarterly Minimum Data Set (MDS) assessment, dated 02/22/21, revealed she was rarely/never understood and required total assistance with bathing, eating, and personal hygiene. On 04/01/21 at 8:52 A.M., observation outside of Resident #10's room which had the door closed, revealed loud and profound language that was able to be heard in the hallway outside of the room. Continued observation revealed State tested Nursing Aide (STNA) #444, STNA #488, and STNA #499 exiting the room laughing together at 9:01 A.M. There were no additional STNAs working on that unit during this time. Interview on 04/01/21 at 9:03 A.M. with the STNA #488 verified she was in Resident #10's room with STNA #444 and STNA #499 talking loudly and inappropriately. STNA #488 stated they were talking about an employee that no longer works at that facility while performing care for Resident #10. Interview attempted on 04/01/21 at 9:10 A.M. revealed Resident #10 was unable to understand and make her needs known. Interview on 04/01/21 at 12:06 with Licensed Practical Nurse (LPN) #502 revealed Resident #10 usually requires two people to assist with personal care. LPN #502 stated she never requires three people to assist her. Review of Resident Rights handbook given to residents upon admission, states The right to be free from physical, verbal, mental, and emotional abuse and be treated at all times with courtesy, respect, and full recognition of dignity and individuality. This deficiency substantiates Master Complaint OH 184.

Based on record review, observations and interview, the facility failed to maintain infection control standards when caring for residents on droplet precautions. This had the potential to affect all 17 residents (Resident's #4, #6, #16, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210, #211, #212 and #213) residing on the south hall. The facility census was 127. Findings include: Review of the medical record for Resident #16 revealed an admission date of [DATE] and discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 03/23/21 revealed the resident was on droplet isolation per Centers for Disease Control (CDC) guidelines due to acute respiratory infection with positive signs of cough, fatigue, and elevated temperature. Interventions included to provide droplet isolation. Observation on 03/22/21 at 11:43 A.M., Licensed Practical Nurse (LPN) #56 was observed walking into Resident #16's room who was on droplet isolation precautions. The Unit Manger #57 on the unit walked by and observed LPN #56 walking out of Resident #16's room without wearing personal protective equipment (PPE). Unit Manger #57 asked LPN #56 if she realized the mistake she made, and LPN#56 stated she did. Continued observation on 03/22/21 revealed LPN #56 donning a gown and gloves before entering Resident #14's room, also on droplet precautions. LPN #56 was observed reading the signs on the resident's door before she entered. LPN #56 was observed leaving Resident #14's room, taking off the gown and walking across the hall to put the gown in the trash can attached to the medication cart. Unit Manger #57 was still standing there and stated the gown needed to be discarded before leaving the resident's room. Observations of both resident rooms revealed a PPE cart and appropriate signage directing staff to don and doff PPE before entering and exiting the room. Interview on 03/23/21 at 12:15 P.M. with LPN #56 verified that she was not wearing appropriate PPE. Interview on 03/23/21 at 1:00 P.M., the Director of Nursing (DON) stated that LPN #56 was taken off the unit, was given in-service training to review pending investigation and would probably be terminated. The DON stated the facility has been dealing with COVID-19 for a year, and staff should know when and where to wear PPE. Review of the undated facility policy titled Infection Control, revealed that the facility did not implement the policy as evidenced by staff entering an isolation room without donning appropriate PPE. This deficiency substantiates Complaint Number OH 240 and is an example of continued noncompliance from the survey completed on 02/23/21.

Based on record review and interview, the facility failed to complete quarterly assessments every three months. This affected three residents (Resident's #1, #13 and #14) of three residents reviewed for assessments and had the potential to affect all residents. The facility census was 127. Findings include: 1. Review of the medical record for the Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/22/21, revealed the resident had impaired cognition, required extensive assistance of one staff for toileting and was incontinent of bowel and bladder. Review of quarterly assessments revealed the facility completed a Braden Scale (risk for pressure ulcer) assessment on 03/06/20, 06/12/20, 06/30/20 and 02/11/21. No assessments were completed between 06/30/20 and 02/11/21. Review of Bowel and Bladder assessments revealed the facility completed one assessment since Resident #1 was admitted on [DATE]. 2. Review of the medical record for the Resident #13 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment, dated 03/06/21, revealed the resident had impaired cognition, was dependent on staff for toileting, was incontinent of bowel and bladder and was at risk for pressure ulcers. Review of quarterly assessments revealed the facility completed a Braden Scale (risk for pressure ulcer) assessment on 03/24/20, 01/26/21, 03/05/21 and 03/08/21. No assessments were completed between 03/24/20 and 02/11/21. Review of Bowel and Bladder assessments revealed the facility did not complete a Bowel and Bladder assessment between 05/01/19 and 03/05/21. 3. Review of the medical record for the Resident #10 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive MDS 3.0 assessment, dated 12/30/20, revealed the resident had severely impaired cognition, required extensive assistance of two staff for toileting and was always incontinent of bowel and bladder. Review of Bowel and Bladder assessments revealed the facility completed one assessment for Resident #1 in the year 2020 which was dated 07/07/20. Interview on 03/23/21 at 1:39 P.M. with the Assistant Director of Nursing (ADON) / MDS Nurse #67 stated Braden Scale and Bowel and Bladder assessments should be completed every three months.

Based on record review, observations and interview, the facility to administer medications as ordered. This had the potential to affect one (Resident #17) of six residents reviewed and observed for medication administration. The facility census was 127. Findings include: Review of the medical record for the Resident #17 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 10/09/20 revealed the resident was receiving anticoagulation therapy related to [MEDICAL CONDITION] prevention. Review of the Medication Administration Record [REDACTED]. Observations on 03/22/21 at 3:57 P.M. revealed Licensed Practical Nurse (LPN) #62 preparing to administer [MEDICATION NAME] (blood thinner) to Resident #17. The order was for 0.75 milliliters (ml) of [MEDICATION NAME] via subcutaneous injection. LPN# 62 drew up two syringes equaling 1.25 ml of [MEDICATION NAME] instead of 0.75 ml. LPN #62 was asked if the dosage was correct and asked to verify it with another nurse if needed. LPN #62 took both syringes to another nurse who explained the dose was too much. LPN#62 discarded the extra 0.50 ml of [MEDICATION NAME] administering only 0.75 ml as ordered. Interview on 03/23/21 at 4:06 P.M., LPN #62 verified the amount was 0.50 ml's over what was ordered prior to surveyor intervention. Interview on 03/23/21 at 4:30 P.M., the Director of Nursing (DON) was informed of the potential medication error. The DON stated LPN#62 had no real rationale for using two syringes. The DON stated LPN #62 was terminated at that moment. This deficiency substantiates Complaint Number OH 240.

Based on observations, staff interview, review of the facility's Coronavirus (COVID-19) in-service, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/13/20), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement appropriate and recommended infection control practices by not ensuring appropriate use of Personal Protective Equipment (PPE) for residents' on COVID-19 quarantine precautions by not ensuring the use of N95 and KN95 respirators, face shields, goggles, and proper hand hygiene was consistently implemented to potentially prevent the spread of COVID-19 infections. This had the potential to affect all 124 residents residing in the facility. Findings include: Observation on 02/10/21 at 10:25 A.M. of Licensed Practical Nurse (LPN) #202 revealed LPN #202 walking in the hallway of the quarantine unit with an N95 respirator covering her nose and mouth but was not wearing a face shield or goggles. LPN #202 confirmed she did not have a face shield or goggles on. Observation and interview on 02/10/21 at 10:38 A.M. with Activities Coordinator (AC) #209 on the quarantine unit revealed he was not wearing a face shield or goggles while assisting residents with activities. AC #209 confirmed he did not have a face shield on, and during the interview reached up multiple times to adjust his N95 respirator with his hands without using hand sanitizer afterwards. AC #209 confirmed he did not use hand sanitizer after touching his mask. Observation and interview on 02/10/21 at 10:46 A.M. with LPN #210 on the quarantine unit wearing a surgical mask underneath her KN95 respirator. LPN #210 confirmed she was wearing the surgical mask under the KN95 respirator for comfort. Observation and interview on 02/10/21 at 12:08 P.M. of State tested Nursing Assistant (STNA) #203 on the quarantine unit wearing an N95 respirator and goggles walk into Resident #82's room and assisted her to the bathroom without donning an isolation gown or gloves. After assisting Resident #82 to the bathroom, STNA #203 adjusted the sheets before helping Resident #82 into the bed. Observation revealed a sign on the door stating to STOP and see a nurse before entering resident room and a plastic cart outside Resident #82's room with PPE stocked in the drawers. STNA #203 confirmed he did not don an isolation gown or gloves before entering Resident #82's room. Observation and interviews on 02/10/21 between 12:55 P.M. and 1:10 P.M. with Assistant Director of Nursing (ADON) #211 and STNA #212 revealed surgical masks were worn under KN95 respirators. ADON #211 and STNA #212 confirmed they were wearing surgical masks under KN95 respirators. Observation and interview on 02/10/21 at 1:20 P.M. with LPN #213 on the quarantine unit revealed LPN #213 wearing a KN95 respirator and goggles enter Resident #72's room without donning an isolation gown or gloves and assisted resident to a wheelchair and pushed the resident out of the room to the elevator. Observation revealed a sign on Resident #72's door stating to STOP and see a nurse before entering the room, and a plastic cart filled with PPE supplies outside the room. LPN #213 confirmed the sign was on the door, and the PPE cart was outside the room. She stated she was told during report from the night nurse no residents were on precautions, and she did not have to don PPE. LPN #213 stated she had not donned PPE for any of the residents on the quarantine unit all day. Observation on 02/11/21 at 11:40 A.M. of Registered Nurse (RN) #201 revealed RN #201 wearing goggles and a KN95 respirator, doff PPE and exit Resident #126's room without wiping her goggles off with a disinfectant wipe or changing her KN95 respirator. Resident #126 had a STOP sign on the door and a PPE cart by the side of the entrance to the room. RN #201 walked into Resident #85's room and did not wipe her goggles off or change her KN95 respirator before entering the room. Resident #85 was not on transmission-based precautions. RN #201 walked out of Resident #85's room and walked to Resident #4's room. Resident #4 had a STOP sign on the door and a PPE cart by the entrance. RN #201 donned PPE walked into Resident #4's room, provided care, exited the room and did not wipe her goggles off or change KN95 respirator before proceeding with her assignment. Interview on 02/11/21 at 11:54 A.M. with RN #201 confirmed she did not wipe her goggles off or change the KN95 respirator between Residents #4, #85 and #126. RN #201 stated she changed her KN95 respirator daily unless it became soiled, and she wore it all day. Observation and interview on 02/11/21 at 11:58 A.M. of LPN #214 on the quarantine unit wearing goggles and a KN95 respirator standing at the medication cart preparing resident medications. While placing medications in a small plastic cup, LPN #214 reached up with her right hand and adjusted her KN95 respirator several times, did not use hand sanitizer, then continued placing medications in the cup. LPN #214 picked up the medications in the cup, walked to Resident #72's room, donned PPE, entered Resident #72's room without using hand sanitizer. LPN #214 reached up with her gloved hand and adjusted her KN95 respirator then reached down and touched Resident #72 on the shoulder. LPN #214 reached underneath her isolation gown with her gloved right hand and pulled a blood pressure cuff out of the pocket of her uniform. LPN #214 took Resident #72's blood pressure, put the cuff back in her uniform pocket without cleaning it with disinfecting wipes. LPN #214 doffed the PPE, walked out of the room, did not use hand sanitizer, pulled the blood pressure cuff out of her pocket, placed it on the medication cart without cleaning it and stated Resident #72's blood pressure was low and needed to be re-checked with a different blood pressure machine. LPN #214 found a facility blood pressure machine on wheels and took it into Resident #72's room, stopping to don PPE, proceeded to take residents blood pressure, doffed PPE, walked out of the room, rolled the blood pressure machine to an outlet located in the hallway and plugged it in. LPN #214 walked away from the blood pressure machine and back to the medication cart without using disinfecting wipes to clean it. LPN #214 confirmed she did not wipe either the blood pressure cuff from her pocket or the facility blood pressure machine on wheels or use hand sanitizer at any time during the observation. Observation and interview on 02/11/21 at 12:23 P.M. of STNA #219 with an N95 respirator across her nose and mouth and the strap hanging below her chin. She stated the respirator strap hurt her head and her hair was also in the way, so she wore the strap below her chin. Review of the Center for Medicaid and Medicare (CMS) Services Test Positivity Classification for Cuyahoga County, dated 1/21/21 through 02/03/21, revealed Cuyahoga County had a 15.0 percent positivity for the prior 14 days and the classification was red, indicating a high rate of community transmission. Review of the facility in-service titled, Proper PPE, dated 01/10/21, included: when wearing a facemask don't allow a strap to hang down. Review of the facility in-service titled, COVID-19 Guidelines, dated 12/08/20, included: staff are required to wear a respirator mask while on the second floor as well as a face shield, goggles, when they enter an isolation room they must wear a gown and gloves. Face shield and goggles need to be cleaned with an alcohol wipe, bleach wipe, or an approved cleaner. Review of the Centers for Disease Control and Prevention (CDC) guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Feb. 10, 2021, included: Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Review of the Centers for Disease Control and Prevention (CDC) guidelines, titled, Strategies for Optimizing the Supply of Eye Protection, updated Dec. 22, 2020, included: carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered external hospital disinfectant solution. Review of CMS policy memo QSO-20-14-NH revised 3/13/20 titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes, revealed facilities were to Increase the availability and accessibility of alcohol-based hand rubs, and to reinforce strong hand-hygiene practices. Review of the Centers for Disease Control and Prevention (CDC) training titled, Hand Hygiene in Nursing Homes, dated 02/25/19, revealed hand hygiene was an element of standard precautions. It was an important Infection Prevention Control (IPC) practice for breaking the chain of infection. Hand hygiene protects both residents and staff. Hand hygiene was a simple and effective method for preventing the spread of pathogens by direct and indirect contact. The hands of staff members may become transiently contaminated with pathogens after touching a resident or surfaces in their environment. Staff members can transfer those pathogens to themselves and they can also transfer those pathogens to other residents or surfaces. Performing hand hygiene removes pathogens and protects both staff and residents. Since staff cannot tell whether their hands have been contaminated with a pathogen, hand hygiene should be consistently performed. Review of the World Health Organization (WHO) Hand Hygiene brochure titled Hand Hygiene: Why, How, and When?, revised August 2009, revealed hands are the main pathways of germ transmission during health care and hand hygiene is therefore the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. The brochure further revealed hand hygiene is indicated after touching any object or furniture when leaving the patient surroundings to protect the health-care environment against germ spread.

Based on record review, facility policy review and interview the facility failed to implement a comprehensive and effective pain management program for Resident #125. This affected one resident (Resident #125) of one resident reviewed for pain. The facility census was 124. Findings include: Review of Resident #125's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/16/21, revealed the resident had moderate cognitive impairment and required one-person physical assist with activities of daily living. Further review of the MDS assessment revealed Resident #125 had pain or hurting in the last five days that affected his sleep and limited day to day activities. He was discharged from the facility on 01/26/21. Interview on 02/10/21 at 1:45 P.M. with Family Member (FM) #200 revealed Resident #125 was no longer a resident at the facility. FM #200 stated she took her father out of the facility on 01/26/21 after he did not receive his pain medication for 32 hours, and she was never going to let that happen again. FM #200 stated her father called her during the night of 01/25/21 through the morning 01/26/21 stating he was in severe pain, couldn't sleep and was really terrified because he was not getting his pain medication. FM #200 stated she called the facility many times to talk to someone about her father's pain on 01/25/21 and 01/26/21. FM #200 stated she spoke to Nursing Supervisor (NS) #204 and Nurse #205 about her father's pain and was told they were unable to give the pain medication because it had not been re-ordered by the physician. Interview on 02/16/21 at 2:25 P.M. with State tested Nursing Assistant (STNA) #203 revealed Resident #125 told him he was in pain and needed pain medication around 7:00 A.M. on 01/25/21. STNA #203 stated he told a nurse, but he could not remember the nurse he talked to. Interview on 02/16/21 at 3:38 P.M. with Resident #125 stated the facility does not make serious pain a priority. Resident #125 stated while he was a resident in the facility, he would wait long periods of time before he received his pain medication, especially during the night. Resident #125 stated he laid in pain and if he put his call light on the STNAs were rude to him and would say what do you want? He stated the last day (01/25/21) and night (01/26/21) he was in the facility was the worst. Resident #125 stated he asked for pain medication and was told his prescription had run out and had not been re-filled, and he could not have any. He stated he was in a great deal of pain all day and all night, and all the next morning until the pain pills were delivered from the pharmacy. He stated he called his daughter multiple times telling her he was in severe pain, could not sleep and needed his pain medication. He stated he told her to take him out of the facility because he could not take another night with this kind of pain. He stated Medical Doctor (MD) #208 visited him on 01/25/21 and wrote a re-fill order for his pain medication. Resident #125 told MD #208 he often waited a long time before pain medication was brought to him after he asked for it, and he also told MD #208 the Tylenol worked well with the pain medication and helped control his pain when he took them together. Interview on 02/17/21 at 11:44 A.M. with the Assistant Director of Nursing (ADON) #211 revealed Licensed Practical Nurse (LPN) #215 received a pain prescription from MD #208 around 5:00 P.M. on 01/25/21. ADON #211 stated she was preparing to leave the facility for the day and LPN #215 asked her how to use the fax machine to send the prescription to the pharmacy. ADON #211 showed LPN #215 how to fax the prescription then left for the day. ADON #211 did not see LPN #215 fax the prescription. ADON #211 further stated LPN #215 made phone calls all morning on 01/25/21 to get a prescription as soon as possible for Resident #125 and called MD #208 at least twice. LPN #215 tried to get a verbal order so she could send it to the pharmacy to replenish Resident #125's pain medication, but MD #208 told her he wanted to write a prescription when he got to the facility after he had visited Resident #125. Repeated requests to the facility for LPN #215's phone number revealed LPN #215 was an agency nurse, and the facility was unable to provide a phone number for an interview. Interview on 02/17/21 at 1:02 P.M. with NS #204 revealed she spoke to FM #200 regarding Resident #125's pain medication the night of 01/25/21 through morning 01/26/21. FM #200 was very upset and told NS #204 it was unacceptable that Resident #125 was unable to receive pain medication. NS #204 stated she told FM #200 she agreed with her and would investigate the matter. NS #204 stated she spoke with the nurse assigned to Resident #125's unit and was told FM #200 told LPN #216 it was unacceptable for Resident #125 to not be given pain medication. LPN #216 stated she told FM #200 the resident did not have any [MEDICATION NAME] (opioid pain medication) she could give him. NS #204 stated she called the pharmacy to find out the status of Resident #125's prescription and was told the fax sent earlier for the pain medication was not received by the pharmacy. NS #204 stated she re-sent the fax and spoke to Resident #125 who told her he was in pain. NS #204 stated she asked the pharmacist about getting an emergency authorization code to take an [MEDICATION NAME] out of the automatic dispensing system in the facility, the pharmacist told her it would take about an hour to get a code, and also stated the [MEDICATION NAME] should be delivered to the facility at 4:00 A.M. NS #204 decided to wait for the 4:00 A.M. delivery. NS #204 stated she checked on Resident #125, he was sleeping, and she did not know what happened after that. NS #204 stated LPN #216 was from a staffing agency. Repeated requests to the facility for LPN #216's phone number revealed LPN #216 was an agency nurse, and the facility was unable to provide a phone number for an interview. Interview on 02/22/21 at 7:40 A.M. with MD #208 revealed a nurse called him on the morning of 01/25/21 and told him Resident #125 was out of his [MEDICATION NAME] and needed a re-fill. MD #208 stated he told the nurse to give Tylenol and if that did not help, he would write a prescription for [MEDICATION NAME] when he visited the resident later on 01/25/21. MD #208 stated Resident #125's pain seemed generally controlled and giving [MEDICATION NAME] every four hours helped the pain when he got the medication on time. MD #208 stated Resident #125 told him the Tylenol helped more than the [MEDICATION NAME], but Resident #125 had some cognitive impairment and might have been confused about the Tylenol. MD #208 stated Director of Therapy (DT) #217 told him Resident #125 did not seem to be in pain during therapy. MD #208 stated he got a message from his secretary on 01/26/21 that FM #200 called because Resident #125 did not receive [MEDICATION NAME] for 24 hours, and there was also a voicemail left at midnight from FM #200 stating Resident #125 had not received [MEDICATION NAME], was terrified and needed the medication. MD #208 stated FM #200 was under a lot of stress due to her parent's medical conditions and her impression of her father's pain was more than his assessment of Resident #125's pain. Review of Resident #125's Pain Assessment (3.0), dated 01/14/21, revealed the resident responded yes to pain or hurting in the last five days, yes to pain made it hard to sleep at night, and yes to pain limited day to day activities. Review of Resident #125's Medication Administration Record [REDACTED].M. an [MEDICATION NAME] 5 milligrams (mg) tablet was administered for a pain level of 9 out of 10 (severe pain). The MAR further revealed on 01/26/21 at 11:11 A.M. an [MEDICATION NAME] 5 mg tablet was administered for a pain level of ten out of ten (excruciating pain). Resident #125 was not administered [MEDICATION NAME] for 31 hours from 01/25/21 at 4:04 A.M. through 01/26/21 11:11 A.M. while lying in severe pain and requesting the pain medication multiple times from the facility staff. Review of Resident #125's MAR indicated [REDACTED].M., 12:00 P.M. and 5:00 P.M. and each time Resident #125 stated he was in severe pain. Resident #125 was administered Tylenol tablets 975 mg on 01/26/21 at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and each time the resident stated he was in severe pain. Review of the facility Inventory on Hand, C11, revealed [MEDICATION NAME] 5 mg tablets were stocked in the automatic medication dispensing system located in the facility. Review of an email provided by Pharmacy Representative (PR) #207 stated the physician prescription for [MEDICATION NAME] 5 mg was received 12:30 A.M. on 01/26/21, and the [MEDICATION NAME] 5 mg tablets were received by the facility on 01/26/21 at 9:37 A.M. PR #207 further stated there was no documentation of any nurse calling for an authorization code to the automated medication dispensing system to administer [MEDICATION NAME] to Resident #125. Review of Resident #125's progress notes on 01/25/21 at 12:16 P.M. revealed MD #208 was notified of the need for a new pain medication prescription, and stated he would be at the facility later in the day on 01/25/21 and would write a prescription then. Review of Resident #125's progress notes on 01/26/21 at 11:11 A.M. revealed LPN #218 stated resident was complaining of severe pain throughout body and pain medication was requested. Review of Resident #125's progress notes on 01/26/21 at 12:58 P.M. revealed LPN #218 stated Resident #125 had a pain score of 10, pain was constant, non-medication interventions did not provide relief, and Resident #125 complained of pain all over body. Scheduled pain medication and as needed medication was given as ordered. Review of Resident #125's physician progress notes [REDACTED].M. revealed MD #208 stated resident pain was controlled with [MEDICATION NAME] 5 mg tablet and Tylenol as needed, but Resident #125 did complain of pain, usually in the left hip when he did not receive it right away. Review of Resident #125's care plan, dated 01/14/21, included administer [MEDICATION NAME] per current physician orders, encourage and assist resident to reposition frequently to position of comfort, and to implement non-pharmacological interventions to assist with pain and monitor for effectiveness. Review of the facility policy titled, Pain Management, revised 04/2002, included: pain assessment should occur (document in the Nurses Progress Notes) at each new report of pain, change in condition, pain medication change, and at appropriate intervals after pharmacological or non-pharmacological intervention on the MAR. This deficiency substantiates Complaint Number OH 538.

Based on observation, record review, policy review and interview the facility failed to ensure one resident (Resident #2) was free from a significant medication error when the resident was not provided intravenous (IV) medication as ordered by the physician. This affected one of three residents reviewed for medication administration. Actual harm occurred when the facility failed to administer IV antibiotics (to treat [MEDICAL CONDITION]) beginning on 01/09/20 resulting in Resident #2 being hosptalized on [DATE] and diagnosed with [REDACTED]. The area was assessed to be swollen, red, raised and soft, slightly warm with complaints of itching and hurting when touched. The resident was hospitalized for [REDACTED]. Findings include: Review of the medical record for Resident #2 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 significant change assessment dated [DATE] revealed Resident #2 was cognitively intact and needed two-person extensive assistance with bed mobility. Resident #2 used a walker for mobility. Review of a hospital physician history and physical assessment dated [DATE] revealed Resident #2 presented with left lower extremity thigh [MEDICAL CONDITIONS]. A hospital discharge summary, dated 01/07/20 revealed Resident #2 was ordered the antibiotic [MEDICATION NAME] two grams per 50 milliliters IV solution once a day. A left upper extremity midline catheter was placed on 01/06/20 for the administration of the IV [MEDICATION NAME] with the last day the medication was to be administered noted to be 01/18/20. Review of the nursing note, dated 01/07/20 at 5:25 P.M. revealed Resident #2 returned to the facility with an admitting [DIAGNOSES REDACTED]. The resident was treated with IV antibiotics during the hospital stay and a midline was placed to left upper extremity. The nurse's note indicated Resident #2 was due to have one additional dose of [MEDICATION NAME] ([MEDICATION NAME]) IV two grams per 50 milliliters until infusion completed. Review of the (MONTH) 2020 medication administration record (MAR) revealed Resident #2 was administered IV [MEDICATION NAME] on 01/08/20 at 11:05 P.M. Review of the administration record revealed Resident #2 did not receive any more doses of IV [MEDICATION NAME] after 01/08/20. Review of the nursing note, dated 01/10/20, timed 1:58 P.M. revealed Resident #2's left inner thigh had a soft, red raised area that was warm to the touch. The resident complained of pain upon palpation to the area. The physician was called and requested an ultrasound to the area. Review of the nursing note, dated 01/10/20, timed 2:40 P.M. revealed Resident #2 had some concerns about his left inner thigh. During assessment the nurse noted the area was swollen, red, raised and soft, slightly warm. The resident complained of itching and hurting when touched. Review of Physician #14's progress note, dated 01/10/20, timed 7:46 P.M. and entered as a late-entry revealed Resident #2 was discharged to the hospital on [DATE] for [MEDICAL CONDITION] and readmitted to the facility on [DATE]. The resident presented to the hospital with left lower extremity (LLE) thigh [MEDICAL CONDITION] with concern [MEDICAL CONDITION]. An MRI of the left lower extremity (LLE) had some concern for infectious myositis. Left upper extremity midline was placed on 01/06/20 for IV [MEDICATION NAME] ([MEDICATION NAME]) (last day of 01/18/20). Resident #2 appeared to be confused. There was an extensive area of induration with focal swelling, redness, warmth and tenderness to the medical area of his left thigh. The swollen area was about 10 centimeters (cm) by five cm, raised, soft, fluctuant. The red, swollen, tender nodule to the left medial thigh was a hematoma. The note indicated an order for [REDACTED]. If ultrasound showed abscess or white blood count elevated, would send resident back to the hospital. Review of the radiology results note, dated 01/11/20, timed 10:30 [NAME]M. revealed the results of the doppler was negative for a [MEDICAL CONDITION]. A new order was given by Physician #14 to obtain a vascular consult as soon as possible due to possible abscess or hematoma to left thigh. Review of the nursing note, dated 01/11/20, timed 11:00 [NAME]M. revealed Physician #14 was notified Resident #2 was requesting to be sent to the hospital to have his leg evaluated. Physician #14 was in agreement. Review of Physician #14's progress note, dated 01/11/20, timed 11:00 [NAME]M. revealed no change in clinical findings - red, swollen, tender, defined area that has not increased in size. The note indicated to send to emergency department for further evaluation by vascular surgery. Review of the hospital physician history and physical assessment, dated 01/11/20 revealed Resident #2 presented from the nursing home with increased redness and swelling to left thigh. The assessment revealed he had been previously discharged on [DATE] with a left upper extremity midline to receive IV [MEDICATION NAME] though 01/18/20. The resident reported he did not receive any antibiotics at the nursing home. The emergency department called the nursing home, and they confirmed that he did not get any while there. Review of the hospital physician assessment, date 01/13/20 revealed Resident #2 was diagnosed with [REDACTED]. Review of the nursing notes, dated 01/22/20 revealed Resident #2 was readmitted from the hospital. Review of Physician #14's progress note, dated 01/24/20 revealed Resident #2 had been discharged to the nursing home on 01/07/20 on IV [MEDICATION NAME] to be continued through 01/18/20. On 01/10/20, Physician #14 performed his admission visit and found the resident had developed an acute swelling and redness to this left thigh. An ultrasound on 01/11/20 suggested an abscess versus hematoma of his left thigh. The resident was sent back to the hospital on [DATE] for further evaluation. In the emergency department, the resident complained of left thigh pain and a lumpy mid-thigh area. The resident told the emergency department he had not received antibiotics. On admission to the hospital, it was determined he did not receive IV [MEDICATION NAME] in the nursing home. Physician #14 was not aware of this and reviewed the MAR and the electronic medical record that night. The resident received one dose only of IV [MEDICATION NAME] on 01/08/20 but no subsequent doses even though the order was written for the antibiotic to be administered daily though 01/18/20. The progress note revealed it appears to (have) been entered incorrectly by the nursing staff. The progress note also revealed nursing never reported to the physician the resident was not being given antibiotics. He was restarted on antibiotics and the swelling and pain subsided during his hospital stay. Resident #2 had left thigh [DIAGNOSES REDACTED] and completed antibiotics in the hospital, now resolved. Still signs of [MEDICAL CONDITION] but no acute infection. Interview on 02/04/20 at 8:10 [NAME]M with Licensed Practical Nurse (LPN) #15, with the Director of Nursing present, revealed LPN #15 readmitted Resident #2 to the facility on [DATE] and she looked over the medication orders. LPN #15 revealed a hospital nurse gave her nursing report on Resident #2 indicating an IV [MEDICATION NAME] stop date of 01/08/20. LPN #15 verified she did not ask Physician #14 if the stop date for the IV [MEDICATION NAME] was 01/08/20. LPN #15 verified she went off the hospital nurses report stop date of 01/08/20. LPN #15 verified she should have asked Physician #14 for the stop date. Interview on 02/04/20 at 8:15 [NAME]M. with the Director of Nursing revealed her expectation of LPN #15 completing admission orders [REDACTED]. Interview on 02/04/20 at 8:20 [NAME]M. with Physician #14 verified Resident #2 only received a one-day dose of a 10-day dose of IV [MEDICATION NAME] at the nursing home. Physician #14 also verified Resident #2 did not receive the entire dose of the IV [MEDICATION NAME] which resulted in Resident #2 being readmitted to the hospital with [REDACTED]. Observation on 02/04/20 at 8:40 [NAME]M. revealed Resident #2 was lying flat in bed and was able to sit up by himself. Resident #2 had a dark bluish/black discoloration to his left inner thigh approximately the size of a basketball. Resident #2 touched the discolored area and the skin was rigid. Interview, during the observation, with Resident #2 revealed when he was discharged from the hospital, the hospital staff didn't tell him he was going to be ordered IV [MEDICATION NAME]. While back at the nursing home, he had a hard and painful lump on his left thigh and was concerned it was an abscess, so he called the ambulance to take him back to the hospital. When he arrived back to the hospital, that was the first time he heard about the IV [MEDICATION NAME] he was supposed to receive at the nursing home. After he received two IV antibiotics at the hospital, the lump went down on his left inner thigh. Interview on 02/04/20 at 11:35 [NAME]M. with Pharmacist #21 revealed he received the hospital orders for IV [MEDICATION NAME] 2 grams per day on 01/07/20 for Resident #2 and didn't wait for the nursing staff to input the physician orders into the electronic medical record to begin preparing the antibiotic. The IV [MEDICATION NAME] didn't have a stop date on the prescription so six doses of IV [MEDICATION NAME] were sent to the facility. Pharmacist #21 attempted to contact the nursing staff for a stop date three times on 01/10/20 to no avail so three more doses of IV [MEDICATION NAME] was sent to the facility. Pharmacist #21 verified the nursing staff incorrectly entered the IV [MEDICATION NAME] order into the electronic medical record. Review of the facility policy titled Admission Process, dated 10/04/19 revealed the discharge summary was reviewed for orders, appointments, diets, treatment orders and verified with the physician. This deficiency substantiates Complaint Number OH 906.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, interviews with staff, review of the facility's Doctor-E Code policy and procedure, and review of the facility's follow up investigation, the facility failed to initiate cardiopulmonary resuscitation (CPR) timely for one resident (Resident #202) who was found unresponsive, without a pulse, respirations or blood pressure, and who was identified as a Full Code status. Life threatening harm and death occurred when Resident #202 did not receive ventilation along with chest compressions from staff who initiated an emergency Doctor E Code. This resulted in Immediate Jeopardy for Resident #202 who expired. This affected one of three residents reviewed for an emergent change in condition and death. The facility identified 54 current residents who were designated as having a Full Code status. On [DATE] at 5:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:10 A.M. when Resident #202 was found unresponsive, without a pulse, respirations, or blood pressure, and Registered Nurse (RN) #300 and RN #302 initiated CPR compressions at 8:15 A.M., but failed to initiate ventilation because there was no Ambu bag on the crash cart. At 8:23 A.M., the emergency squad arrived and took over CPR. The facility was notified by the hospital at 9:00 A.M. Resident #202 had expired. The Immediate Jeopardy was removed on [DATE] but continued at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 9:15 A.M., Central Supply Coordinator #1 obtained Ambu bags from Central Supply, placed them on the three crash carts, and checked each cart to ensure the carts were fully stocked. On [DATE] at 10:05 A.M., the DON initiated staff education to nursing personnel on emergency preparedness that included review of the Emergency Cart Policy, dated [DATE] and CPR procedures. The staff training was completed by [DATE] with 24 RNs and 48 licensed practical nurses (LPNs). On [DATE] the facility's Ad Hoc Quality Assurance Committee met with the Medical Director to address best practices of emergency response and preparedness to include daily crash cart equipment checks, with the unit manager monitoring weekly. On [DATE], the DON reviewed all 135 resident charts and identified 54 residents that had verified Full Code status with appropriate plans of care in place. On [DATE] at 6:41 P.M. and 6:52 P.M., two separate text messages were sent to 13 RNs and 52 LPNs to notify the nurse on call if crash cart supplies were missing. The text message noted that extra Ambu bags had been placed in each medication room on each floor. Telephone calls were placed to 13 RNs and 30 LPNs who did not communicate using text message and informed to notify the nurse on call if crash cart supplies were missing. On [DATE] at 2:00 P.M. and on [DATE] at 2:15 P.M, all three crash carts were observed by the surveyor, and were properly stocked per the Emergency Cart Policy, dated [DATE]. All medication rooms had additional Ambu bags, along with the Adult CPR Quick Check Guide and Dr. E Response Form to document time line of events during CPR administration. On [DATE], the records of Residents #204 and #206 who expired in the facility were reviewed and no CPR concerns were identified. Interviews on [DATE] between 2:15 P.M. and 2:30 P.M of LPNs #316, #318, #320 and RN #322 revealed all were aware of the required nightly checks of the crash carts and the proper procedure, including ventilation, for CPR. Findings include: Review of Resident #202's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the February, (YEAR) physician orders [REDACTED].#202's advanced directives were a Full Code. Review of Resident #202's February, (YEAR) Medication Administration Record [REDACTED]. Review of Resident #202's nursing progress note dated [DATE] at 4:03 P.M. revealed during morning report, the charge nurse, Registered Nurse (RN) #302 was notified the physician had been contacted regarding Resident #202's low blood pressure. RN #302 had assessed Resident #202 at 8:00 A.M. Resident #202 was observed sitting on the toilet receiving morning care from State tested Nurse Aide (STNA) #310. Resident #202 was alert and oriented. RN #302 noticed that the resident had large amounts of loose stools, her face was swollen, lips were puffy and pink, and the front and back of her upper torso had a red raised hive-like rash. Vital signs were blood pressure ,[DATE], apical pulse 78, respirations 20, temperature 101.2 degrees Fahrenheit orally, and oxygen saturation on oxygen at 2 liters was 100%. Resident #202 stated she had no pain, but was having itching. No difficulty with breathing was noted at that time. RN #302 called Primary Care Physician (PCP) #306 at 8:05 A.M. and obtained a new order to stop the antibiotic [MEDICATION NAME] and give the [MEDICATION NAME] 50 milligrams (mg) by mouth every six hours to relieve itching. At 8:10 A.M., before the medication was obtained, STNA #310 told RN #302 that something was wrong with the resident. RN #302 immediately went to the resident's room. Resident #202 was observed in a chair between the bed and window sitting straight up with her eyes open. When RN #302 called the resident's name, the resident did not respond. RN #302 touched the resident on her chest, gave a sternal rub, Resident #202 took a deep breath. Resident #202 did not respond to her name being called. The nurse felt for a pulse and applied a blood pressure cuff to obtain vital signs. No pulse was detected on Dina Map Machine. At 8:15 A.M. a Doctor E Code was initiated and CPR started. Nurses and STNAs, unidentified in the note, reported to the resident's room and 911 was called. No other information regarding the incident was recorded in the resident's record. Review of a telephone order dated [DATE] revealed an order was written to discharge Resident #202 to the hospital via emergency squad. Review of the follow up investigation for Resident #202 revealed a statement from LPN #308 dated [DATE] that indicated she observed Resident #202 gasping and LPN #312 and RN #302 were doing CPR. LPN #308's statement indicated that no Ambu bag, used for ventilation, was on the crash cart. LPN #308 stayed in Resident #202's room until the emergency squad arrived. Review of the clinician discharge summary completed by PCP #306, dated [DATE], revealed Resident #202 was admitted with a [DIAGNOSES REDACTED]. PCP #306 noted Resident #202 developed a delayed hypersensitivity reaction to the antibiotic [MEDICATION NAME] and developed an acute [MEDICAL CONDITION] infarction with cardiopulmonary arrest. (The resident was not documented as allergic to [MEDICATION NAME].) On [DATE] at 2:00 P.M., an interview was conducted with RN #300 with the Administrator present. RN #300 said on [DATE], she was at the nursing station and went to assist staff in Resident #202's room. RN #300 said she assisted in transferring Resident #202 to the floor, started chest compressions and LPN # 312 arrived with the crash cart. The crash cart was missing the Ambu bag. LPN #312 and RN #302 took over chest compressions and RN #300 left the room to locate and return with an Ambu bag. The EMT squad had already arrived by the time RN #300 returned with the Ambu bag RN #300 confirmed staff only conducted chest compressions and never ventilated Resident #202. The Doctor E Code was called at 8:15 A.M. and the EMT squad arrived at 8:23 A.M. RN #300 said checking the crash carts nightly was delegated to the night shift nurse on each floor to ensure the carts were stocked and ready for use. A daily log book was located on each crash cart for the nurse to sign and date that the inspection was completed. During the interview, the Doctor E Policy was reviewed with RN #300 and the Administrator. They both confirmed the policy indicated ventilation was to be conducted and the cart re-stocked immediately after use which had not occurred. Both reviewed the last progress note entry dated [DATE] written by RN #302 at 4:03 P.M. RN #300 confirmed the incident occurred between 8:00 A.M. and 8:30 A.M. on [DATE] and details and time line of the care that took place for Resident #202 were not in the clinical record. On [DATE] at 2:40 P.M. an interview was conducted with RN #302 with the Administrator present. RN #302 explained that on [DATE], after receiving morning report, she assessed Resident #202. RN #302 stated the resident was on the commode, and looked okay. The nurse noted the resident had hives, face swelling, and loose stool in the commode bowl, and the resident reported she felt itchy. RN #302 called the physician at 8:00 A.M. He called back at 8:05 A.M. and instructed her to stop the antibiotic and administer the [MEDICATION NAME]. RN #302 said she was called back to Resident #202's room before getting the needed medication. Resident #202 was sitting up in a regular chair, was unresponsive, and did not respond when the nurse called her name. RN #302 said she initiated a sternal rub. The resident took a deep breath but did not respond to her name when called. Vital signs using a Dina Map Machine auto cuff assessed no vitals. The STNA called 911, RN #302 assisted with transferring Resident #202 to the floor and RN #300 initiated CPR compressions. When the crash cart arrived, the Ambu bag for ventilation was missing. RN #302 and LPN #312 took over chest compressions. RN #300 went to locate an Ambu bag. When she returned to the room, the emergency squad was already in the room and they took over and transported the resident to the hospital. RN #302 verified staff only initiated chest compressions and never ventilated Resident #202. RN #302 made the following statement I am a new nurse, less than one year and this was my first code and she died . I still cry. But I never left her side. I know I did everything I was taught. I know my charting is not adequate. I didn't know how to chart this type of incident. I know now. I never knew the extent of what should be in the chart. RN #302 was tearful during the interview and confirmed she was trained in CPR using compression and ventilation. On [DATE] at 3:00 P.M., the Administrator said she spoke with RN #314, the night supervisor. RN #314 had reported to the Administrator on [DATE] at 9:00 A.M. that she was aware the crash cart on the second floor did not have an Ambu bag and was unable to locate one in central supply. RN #314 told the Administrator she left a note in the central supply office for staff to obtain an Ambu bag for the crash cart. On [DATE] at 2:20 P.M., observations were made with RN #300 of the three crash carts located on each floor of the facility. All carts were properly stocked per the Emergency Cart Policy, dated [DATE], and the log book for (MONTH) (YEAR) was current with daily monitoring. At the time of the observation, RN #300 verified it was the responsibility of the night shift nurse on each floor to check the crash cart and sign the log book that verified the crash cart was intact and ready for use for a 911 emergency code. On [DATE] between 2:15 P.M. and 2:30 P.M., the surveyor made observations of the three crash carts which were properly stocked with the required equipment and the monitoring log book was in place and current with daily monitoring. Observation of the four medication rooms in the facility revealed each had an additional Ambu bag as a back-up supply to the crash cart. In addition, all three crash carts now had a clip board with Adult CPR Quick Reference Guide, dated (MONTH) 2007, and a Dr. E Response Form, dated (MONTH) (YEAR), for staff to document the time line of events when a 911 code was initiated. Review of the Doctor Code E Policy, dated [DATE], revealed when the red crash cart arrived, the first nurse to respond would place a back board under the victim if needed. The person to respond will ventilate the victim with the Ambu bag attached to oxygen. The policy also noted the red crash cart would be cleaned and supplies replaced immediately. Review of the American Heart Association's CPR and Emergency Cardiovascular Care Guidelines, updated (MONTH) (YEAR), revealed in Part 5, Section 4.8 that As in past guidelines, healthcare providers are trained to provide both compressions and ventilation. This deficiency substantiates Complaint Number OH 798.

Based on record review and interview, the facility failed to ensure adequate staff assistance during a resident transfer. This resulted in Actual Harm when Resident #1 sustained a deep tissue laceration (injury) to her left lower leg during a transfer from the wheelchair to the bed by one staff and required transfer to the hospital for emergent treatment with 16 sutures. This affected one of three residents reviewed for transfers. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a care plan dated 02/06/17 revealed Resident #1 was at risk for falls and included an intervention of two person assistance with transfers. Review of an order dated 06/16/17 revealed Resident #1 required two state tested nurse aides (STNAs) during transfers. An order dated 08/03/17 revealed Resident #1 required a sit to stand lift for transfers. Review of a skilled nurse's note dated 10/01/17 revealed Resident #1 had an unsteady gait and weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 needed two person extensive assist with transfers. Review of a progress note dated 10/05/17 revealed Resident #1 sustained a deep tissue wound (injury) from a transfer. The physician was contacted to obtain an order to send Resident #1 to the emergency room for treatment. Review of a hospital progress note dated 10/06/17 revealed Resident #1 was treated for [REDACTED]. The laceration required 16 sutures to close. Review of a statement dated 10/05/17 written by STNA #53 revealed the STNA transferred Resident #1 from her wheelchair to her bed during which Resident #1 sustained an injury to her leg. STNA #53 transferred Resident #1 without assistance of another staff member. STNA #53 immediately notified the nurse on duty. Review of a statement dated 10/05/17 written by Licensed Practical Nurse (LPN) #52 revealed she was notified by STNA #53 that Resident #1 had sustained an injury from a transfer from her wheelchair to the bed. Resident #1 was transferred to the emergency room for treatment. Interview on 10/23/17 at 4:21 P.M. with the Director of Nursing (DON) revealed Resident #1 was sent to the hospital for treatment of [REDACTED]. The DON indicated Resident #3 was discharged from the hospital to another facility. Review of the investigation and written reprimand report dated 10/12/17 revealed STNA #53 was terminated for performing a one person transfer on Resident #1. The resident sustained [REDACTED]. Resident #1 was required to have two STNAs to assist her in transferring. Review of the employee file for STNA #53 revealed she was hired on 07/25/16 and terminated on 10/12/17. The employee file revealed STNA #53 had been educated on transfers during orientation and passed a competency test during her probationary period. This deficiency substantiates Complaint Number OH 966.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on closed medical record review, staff interview, policy review, review of the Ohio Revised Code (ORC), and review of the Ohio Administrative Code (OAC), the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact emergency medical services (EMS) timely for one resident (#140) who was a Full Code (requests all life saving measures be performed) and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #140 did not receive CPR or emergency medical services and expired at the facility. This resulted in Immediate Jeopardy for one (#140) of two residents reviewed for an emergent change in condition. The facility identified forty-seven residents residing in the facility designated with Full Code Status. The facility census was 138. The Administrator and Interim Director of Nursing (IDON) were notified on [DATE] at 6:15 P.M. that Immediate Jeopardy began on [DATE] at 9:50 P.M. when Resident #140 was found without vital signs and Licensed Practical Nurse (LPN) #400 failed to initiate CPR or notify emergency medical services. Resident #140 subsequently expired at the facility. The Immediate Jeopardy was removed on [DATE] but continued at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE], the facility included discussion of code status during all resident care conferences. As of [DATE] this process continued and was ongoing in the facility. On [DATE] the Administrator was informed by the DON that Resident #140 expired at the facility and CPR was not initiated. In response to this issue, an action plan was formulated and implemented as follows: Beginning on [DATE] the Administrator, Chief Executive Officer (COO) #919, Staff Development Coordinator (SDC) #920, the Director of Nursing (DON), Registered Nurse (RN) #918, and Nurse Consultant (RN #908), completed a review of the system for location of code status information, reviewed and discussed the current system in place related to the team development of an action plan with a decision made to not implement changes to these processes. The current process included an Advanced Directive divider in each resident's hard chart, code status listed on each resident info header in the facility electronic medical record system (Pointe Click Care) and a code status order in each resident's physician orders. On [DATE] the unit managers for all three floors, RN #500, RN #906, RN #916, and RN #817, completed audits on all current facility residents. The facility identified 47 residents who were full code status at that time. On [DATE] SDC #920 began in-servicing all facility nursing staff regarding CPR and the facility Advance Directive Code policy. As of [DATE] all facility nurses, 21 RNs and 51 LPNs had received the in-service training. Beginning on [DATE] the facility coordinated CPR classes for all nurses. HRD #921 reviewed the current status of CPR certification for all employed nurses. A list of nurses and their CPR certification expiration date was developed to coordinate scheduling of in-house CPR training. LPN #400 was current with CPR training as of [DATE] with a recommended renewal date of ,[DATE]. RN #500 attended the [DATE] in-house CPR training class with a certificate issue date of [DATE] and recommended renewal date of [DATE]. CPR classes were held on [DATE] for 7 LPNs and 2 RNs and on [DATE] for 1 RN and 1 LPN and 4 State tested nursing assistants (STNA). Although, STNAs were not required to be CPR certified, the facility encouraged STNA participation in CPR training for those interested. As of [DATE] the current list of facility RNs (21) and LPNs (51), were identified as all current with CPR certification. As of [DATE] one RN and two LPNs CPR certifications had expired and these employees were scheduled for a [DATE] class. A plan to ensure these nurses were not scheduled without another CPR certified nurse in the building was in place. On [DATE] the DON, RN #918 and Human Resource Director (HRD) #921 presented LPN #400 with disciplinary action and re-education regarding the need to initiate CPR for full code residents in the event of cardiopulmonary arrest. On [DATE] the DON, RN #918 and HRD #921 presented RN #500 with disciplinary action and re-education regarding the need to initiate CPR for full code residents in the event of cardiopulmonary arrest. On [DATE] between 10:52 A.M. and 5:05 P.M. and on [DATE] between 11:00 A.M. and 12:00 P.M., interviews with RN #906, RN #904, RN #500, LPN #400, LPN #901, LPN #909, LPN #914, and LPN #915 revealed they received re-education regarding the facility's CPR Doctor E Policy. All staff interviewed were knowledgeable of the requirement to initiate CPR for a full code resident presenting with cardiopulmonary arrest. An additional closed record was reviewed for Resident #150 who expired at the facility on [DATE] and was identified as a Full Code Status. Record review revealed a code was initiated which included the initiation of CPR by facility staff and 911 emergency medical team responded appropriately. Findings Include: Review of Resident #140's closed medical record revealed the resident was first admitted to the facility on [DATE]. Medical history included Alzheimer's Dementia, hypertension, diabetes, [MEDICAL CONDITION] [MEDICAL CONDITIONS], gastric reflux, depression and gout. Review of Resident #140's medical record revealed an advance directives form, dated [DATE], for Full Measures and a physician's orders [REDACTED]. Further review of Resident #140's medical record revealed the resident was not receiving Hospice services and/or palliative care at any time during his stay at the facility. Review of Resident #140's comprehensive 14-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was alert with some confusion and required extensive assist of two staff members with bed mobility, transfers, toileting and personal hygiene. The resident was always incontinent of urine and always incontinent of bowel. Review of the plan of care for advanced care planning, initiated [DATE] and updated [DATE] revealed the resident's code status and orders would be reviewed as needed. The plan of care indicated the resident was a Full Code. Record review revealed Resident #140 was in the hospital from [DATE] through [DATE] and treated for [REDACTED]. Resident #140 returned to the facility on [DATE] and was assessed daily with skilled charting in place. Vital signs were monitored daily, physician and nurse practitioner consulted as needed. Resident #140 was assessed daily for pain and medications were administered per physician orders. On [DATE] certified nurse practitioner (CNP) #911 assessed Resident #140 related to complaints of abdominal pain after lunch. Exam was noted to be unremarkable and Resident #140 was prescribed a medication to treat gastric reflux ([MEDICATION NAME]). Review of a progress note, dated [DATE] at 8:16 A.M., revealed LPN #912 initiated oxygen at two liters per physician order [REDACTED]. Review of a progress note, dated [DATE] at 11:33 P.M., revealed LPN #400 noted Resident #140 received his evening medications at 8:35 P.M., was alert and consumed his medications whole, as usual. Head of the bed was elevated for comfort. At 9:50 P.M. charge nurse, LPN #400, was doing rounds and found Resident #140 without respirations, vital signs, was non-responsive to sternal rub, no apical pulse, no radial pulses bilaterally and no pedal pulse bilaterally. The note indicated LPN #400 was unable to obtain a blood pressure reading at that time. Resident #140 was absent of breath sounds and his pupils were fixed, lacked response. The nursing supervisor, RN #500 was paged and arrived on unit at 9:54 P.M., assessed the resident and confirmed Resident #140 was without signs of life. The primary care physician, PCP #922 was paged at 10:02 P.M., 10:11 P.M., and 10:19 P.M. The covering physician, (MD #923) returned the page at 10:54 P.M. and pronounced Resident #140 dead as of 9:52 P.M., giving orders to release the resident's body to funeral home of family's choice. Family was called and arrived at the facility at 11:00 P.M. The body was released at 9:30 A.M. on [DATE] with family present who had remained throughout the night. The charge nurse, LPN #400 was interviewed on [DATE] and 3:15 P.M. The LPN stated she was the nurse assigned to care for Resident #140 on [DATE]. The LPN indicated upon arriving at the resident's room she identified the resident was not breathing and had no pulse. She reported he was dead, body was cold. LPN #400 stated the nursing supervisor, RN #500 verified the resident had passed away and indicated CPR was not done. LPN #400 stated it was her opinion that CPR wound not have helped. The resident had no signs of life and the nursing supervisor confirmed that. LPN #400 stated she now knew that no matter how a resident presented, if listed as a full code, call 911 and start CPR per the facility policy and let emergency medical team call it. The nursing supervisor, RN #500 was interviewed on [DATE] at 4:55 P.M. He confirmed, on [DATE], Resident #140 was a full code, was found without any signs of life, and staff, including himself,did not initiate CPR or call 911. RN #500 stated I based my decision on my nursing judgement versus implementing the company policy. RN #500 stated I understand the policy and will initiate CPR and call 911 per policy. Review of the facility Code Doctor E Policy, with an effective date of [DATE], revealed for any individual without a valid DNR order, staff were to initiate a 911 call and begin CPR. The policy outlined the first nurse to respond would order another staff person to get the red crash cart and back board. The nurse would prepare the victim for CPR (move to a floor if in a wheelchair, position for CPR, etc.) and start chest compressions. On [DATE] at 5:55 P.M., the Administrator was interviewed regarding the death of Resident #140. The Administrator reported that she, along with the DON, were aware Resident #140 was a full code at the time he expired and that the nursing staff on duty did not perform CPR. The Administrator stated she believed they addressed the situation following the incident. The administrator reported both nurses received correction action for not providing CPR to a full code resident and not implementing the facility policy and all nursing staff had been in-serviced regarding the policy. On [DATE] at 9:00 A.M., interview with the Administrator confirmed Resident #140 was not on Hospice at the time of death. The administrator again confirmed that following the incident with Resident #140, all nurses were in-serviced, either in person or by telephone to ensure the facility policy regarding full code status/CPR was implemented appropriately. The Administrator stated, If a resident is full code, call a code. On [DATE] at 1:50 P.M., interview with certified nurse practitioner (CNP) #911 revealed Resident #140 had a progressive medical history and recent hospitalization prior to his death on [DATE]. On [DATE] at 2:20 P.M., interview with the resident's primary care physician, PCP #922 via telephone also revealed Resident #140 had a progressive medical history with recent hospitalization . PCP #922 verified the resident's full code status. On [DATE] at 2:52 P.M. STNA #910, who was assigned to care for Resident #140 on [DATE] was interviewed by telephone. She reported I left early that day around 9:00 P.M. The STNA stated, Resident #140 had his usual routine and I put him to bed around 8:00 P.M. There was nothing unusual about him that evening. On [DATE] RN #500 was interviewed again at 3:05 P.M. and LPN #400 was interviewed again at 3:30 P.M. Both verified they were in error to not initiate the 911 code and begin CPR for Resident #140 and had since been counseled and re-educated on the facility policy. Review of the ORC Section 4723.36 titled Determination of death by certified nurse practitioner or clinical nurse specialist revealed a registered nurse (RN) may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory function are not being artificially sustained and, at the time of the determination and pronouncement of death is made, the RN is providing or supervising the individual's care through a licensed Hospice care program or any other entity that provides palliative care. Review of the OAC [DATE] titled Pronouncement of Death revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. Per the OAC [DATE] a LPN is not permitted to pronounce an individual's death. On [DATE] between 10:52 A.M. and 5:05 P.M. and on [DATE] between 11:00 A.M. and 12:00 P.M., interviews with RN #906, RN #904, RN #500, LPN #400, LPN #901, LPN #909, LPN #914, and LPN #915 revealed they received re-education regard the facility CPR Doctor E Policy. All staff interviewed were knowledgeable of the requirement to initiate CPR for a full code resident identified to be in cardiopulmonary arrest. An additional closed record was reviewed for Resident #150 who expired at the facility on [DATE] and was identified with Full Code Status. Record review revealed a code was initiated which included the initiation of CPR by facility staff and 911 emergency medical team responded appropriately. This deficiency substantiates Complaint Number OH 755.

Based on observation, record review and interview, the facility failed to initiate pressure reduction measures for Resident #75 who had a habit of extending her legs and resting her heels on the floor. This resulted in Actual Harm when Resident #75 developed suspected deep tissue injury on her left heel which progressed to unstageable and developed a blister on her right heel which evolved to suspected deep tissue injury and then an unstageable pressure ulcer. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #75 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #75 was at risk for the development of pressure ulcers and a plan of care had been in place since 07/30/15. The plan of care indicated Resident #75 had the potential for pressure ulcer development related to disease process. The Braden Scale (tool for determining pressure ulcer risk) dated 03/05/17 indicated Resident #75 was at risk for the development of pressure ulcers, and noted she was chair fast with very limited mobility. Nurses' progress note dated 03/21/17 at 12:05 A.M. (marked late entry) revealed the discovery of a large skin flap detached from the right heel of Resident #75's foot. The area measured 4.0 centimeters (cm) by 4.7 cm by 0.1 cm deep. The progress note indicated a small amount of bleeding was noted. A second progress note marked late entry, also timed and dated 03/21/17 at 12:05 A.M., revealed a small area was also discovered on Resident #75's left heel with a dark circle at approximately 12:00. The area measured 3.6 cm by 2.4 cm with no depth. The corresponding Pressure Ulcer Weekly Assessment Summary dated 03/21/17 revealed a Stage II pressure ulcer that measured 4.0 cm by 4.8 cm by 0.01 deep to Resident #75's right heel. (A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissues. A Stage II pressure ulcer is defined as a partial thickness skin loss presenting as a shallow open ulcer with a red/pink wound bed.) The assessment described the area as a large open blister, with a skin flap attached. The assessment revealed Resident #75 had a habit of sitting in her chair with her legs extended, resting her heels, which the assessment indicated was the likely source of the blister. The note indicated Occupational Therapy (OT) would be consulted related to seating. The Pressure Ulcer Weekly Assessment Summary dated 03/21/17 revealed a left heel closed blister, identified as suspected deep tissue injury (DTI). (Suspected DTI is defined as purple or maroon localized area of discolored, intact skin. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by eschar. Evolution may be rapid, exposing additional layers of tissue.) The left heel pressure ulcer measured 3.7 cm by 2.5 cm with a small dark discoloration at 12:00. The note acknowledged the resident's habit of resting her heels on the floor while sitting in her chair as the likely source of the pressure. The note indicated Resident #75's son was in the facility to visit, and alternate seating options were discussed. The note indicated Resident #75 did not have a recliner and OT would be consulted for recommendations. Pressure Ulcer Weekly Assessment summaries dated 03/23/17 revealed the right heel wound measured 4.2 cm by 4.0 cm by 0.1 with newly suspected DTI. The note revealed a discolored area in the center of the open blister that measured 1.5 cm by 1.5 cm. The note indicated OT had assessed the resident for seating. The left heel closed blister measured 3.0 cm by 5.0 cm with suspected DTI, and revealed the dark discoloration at 12:00 was more diffuse. The note indicated Resident #75's son was in to visit and alternate seating options were discussed. Pressure Ulcer Weekly Assessment summaries dated 03/29/17 revealed the right heel pressure injury had advanced to unstageable measuring 3.0 cm by 2.5 cm by 0.1 cm with a moist, white wound bed. (A wound is rendered unstageable when the wound bed is covered with slough or eschar. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist or stringy.) The summary indicated the left heel was unchanged, and noted the resident had a habit of resting her heels on the floor when sitting in her chair. The MDS 3.0 assessment dated [DATE] indicated Resident #75 was severely impaired for cognition. The MDS assessment revealed Resident #75 required extensive assistance for bed mobility, transfers, eating, dressing, toilet use and was frequently incontinent of bowel and bladder. The assessment revealed Resident #75 had an unstageable pressure ulcer due to suspected deep tissue injury (DTI) in evolution. Pressure Ulcer Weekly Assessment summaries dated 04/04/17 indicated Resident #75's right heel unstageable pressure wound was 3.0 cy by 2.5 cm by 0.1, with moist white tissue in the wound bed. The assessment revealed her left heel pressure ulcer had advanced to unstageable, measuring 4.0 cm by 3.0 cm with the wound bed black/brown eschar. (Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity.) The assessment indicated the blister was now dry and hard. The note indicated OT obtained a lift chair for Resident #75 in which she could be more easily positioned with heels slightly off the floor. The assessment indicated the staff cued and assisted the resident to reposition when she had her heels resting on the floor. A new physician's orders [REDACTED]. Pressure Ulcer Weekly Assessment summaries dated 04/10/17 indicated the right heel pressure ulcer measured 2.0 cm by 1.5 cm with a depth of less than 0.1 cm. The wound bed was described as pink/red with yellow and serosanguineous drainage. The assessment indicated the unstageable left heel pressure ulcer was hard and dark, measuring 4.0 cm by 3.0 cm. Pressure Ulcer Weekly Assessment summaries dated 04/13/17 revealed the right heel wound was again unstageable, and evolved into two smaller wounds, one measuring 0.8 cm by 0.6 cm with a red/brown crust and the other 1.5 cm by 1.4 cm with a yellow crust adhering to the wound bed. The left heel unstageable wound was unchanged. Pressure Ulcer Weekly Assessment summaries dated 04/19/17 indicated the right heel Stage II pressure area measured 1.4 cm x 0.6 cm by less than 0.1 cm with a pink wound bed. The left heel, unstageable pressure ulcer measured 3.5 cm by 3.0 cm, with black/brown eschar, described as dark and hard. Pressure Ulcer Weekly Assessment summaries dated 05/03/17 described the right heel wound as a Stage II pressure area that measured 0.8 cm by 0.4 cm with a depth of 0.1 cm. with serous exudate. The wound bed was described as granulation tissue. The left heel wound was identified as unstageable measuring 3.5 cm by 2.7 cm with black/brown eschar. On 05/05/17 at 12:39 P.M., when Resident #75's room was entered to observe wound care, Resident #75 was seated in a recliner beside her bed. The recliner's footrest was not raised. Both heels of the resident were resting on the floor. Registered Nurse (RN) #63 placed a clean towel on Resident #75's bed and placed dressing supplies on the towel. RN #63 went into the bathroom, washed her hands, put on gloves and used a remote control to raise the footrest of the resident's recliner. RN #63 removed the old dressing on Resident #75's right heel. A small open area was exposed. The wound measured approximately 1.0 cm by .5 cm by less than 0.1 deep with a dry, pink wound bed. RN #63 cleaned and dressed the wound. RN #63 then removed the old dressing on Resident #75's left heel and revealed an unstageable pressure ulcer that measured approximately 4.0 cm by 2.5 cm with a thick, dry eschar. She cleaned and redressed the wound. During an interview immediately following wound care, RN #63 indicated she was not aware Resident #75's heels were directly on the floor when RN #63 entered the room. She indicated that a short time earlier they were slightly elevated. She acknowledged Resident #75 scooted forward and staff had to frequently assist and/or cue her to sit back up into her chair. RN #63 revealed Resident #75 had a habit of sitting in her chair with the back of her heels directly on the floor. She acknowledged there were no interventions in place to reduce pressure to the heels when in her chair, despite the knowledge Resident #75 had the habit of planting the back of her heels on the floor, until after the resident had developed the pressure ulcers to both heels. RN #75 pointed to an upholstered chair that Resident #75 sat in prior to the development of the pressure ulcers. She indicated it was not a recliner and there had been no way to elevate the resident's heels. This deficiency substantiated Complaint Number OH 860.

Based on observation, medical record review, review of the facility's notification of change policy, review of a facility self-reported incident, review of the ambulance run sheet and interviews of facility staff, the facility failed to ensure timely care and treatment was provided for Resident #15, who was found face down in bed, with her head wedged between the bed frame and the night stand. Resident #15 sustained a head injury identified as a subarachnoid hemorrhage (brain bleed) and was not assessed by a physician for approximately six hours. This resulted in Immediate Jeopardy for one resident (Resident #15) of three residents reviewed for injuries of unknown origin. The resident census was 143. On 12/11/14 at 12:25 P.M., the Administrator and Director of Nursing (DON) #50 were notified that Immediate Jeopardy began on 11/06/14 at approximately 4:30 A.M. when State-tested nurse aide (STNA) #174 found Resident #15 face down in bed, with her head wedged between the bed frame and the night stand. Resident #15 had two scratches and an egg sized hematoma (bruise) on her forehead. Resident #15 showed facial grimacing, had a change in demeanor and was medicated for pain. Resident #15's physician was not notified of the head injury and immediate care of the injury was not provided. On 11/06/14 at approximately 10:45 A.M., six hours after the resident was found, certified nurse practitioner (CNP) #176 ordered Resident #15 to be sent to the emergency room for a computerized tomography (CT) scan of the head. At 11:32 A.M. Resident #15 was transported to the emergency room by ambulance where she was diagnosed with [REDACTED]. The Immediate Jeopardy was removed on 12/12/14 when the facility implemented the following corrective measures: ? On 11/06/14 at 11:45 A.M. Resident #15 was sent to the emergency room for treatment of [REDACTED]. ? Interviews conducted on 12/11/14 from 3:15 P.M. through 3:45 P.M. revealed two Licensed Practical Nurses (LPNs #8 and #38) verbalized knowledge of the importance to call the physician and provide immediate care to a resident who suffered a head injury. ? On 12/12/14 at 2:00 P.M., the DON completed education for all licensed nursing staff (22 RNs, 42 LPNs, 4 Minimum Data Set (MDS) nurses and the Nursing Services Director) regarding the Physician / Nurse Practitioner Protocol, review of the Change of Resident Condition policy and review of the SBAR assessment form for " New Symptoms, Signs and Other Changes in Condition " . Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not yet implemented an ongoing system of monitoring the corrective actions. Findings include: Review of the medical record for Resident #15 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan initiated on 09/05/13 revealed Resident #15 had a self-care performance deficit related to dementia, limited range of motion, musculoskeletal impairment and limited mobility due to an unknown progressive [MEDICAL CONDITION] neurological disease.The care plan revealed Resident #15's extremities were stiff which prevented her from moving about freely or in a coordinated manner. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had an altered level of consciousness and an unusually decreased level of activity. The assessment revealed the resident was totally dependent and required the physical assistance of two or more people for bed mobility. Review of a nursing progress note dated 11/05/14 at 9:44 P.M. revealed Resident #15 was pain free, had a tub bath and had no skin problems. No further documentation was entered in the progress notes until 11/06/14 at 8:00 A.M. The progress note dated 11/06/14 at 8:00 A.M. revealed LPN #20 attempted to call the resident's power of attorney (Son #178) but there was no answer. The emergency contact (Son #179) was notified. The progress note reflected a certified nurse practitioner (CNP) (unidentified) would be in the facility in the morning and would be notified by the day shift nurse. No further information was provided. Review of a progress note dated 11/06/14 at 8:19 A.M. revealed an unidentified STNA informed LPN #20 that Resident #15 was found in bed, face down with her head wedged between the bed and the night stand. The resident had two scratches on the side of the forehead and an egg sized hematoma (bruise) had formed. A cold compress was applied to the area. The progress note did not reflect what time Resident #15 was found with the injury or include any head to toe assessment of the resident. Review of the nursing progress note dated 11/06/14 at 10:43 A.M. revealed Resident #15 had an incident on the third shift. The CNP (unidentified) called and ordered the resident to be sent to the hospital for a CT scan of her head. Neurological checks were completed on the resident and were within normal limits. Son #178 was notified. Review of the nursing progress note dated 11/06/14 at 5:02 P.M. indicated Resident #15' s son (Son #178) was updated. Review of the progress note at 11:50 P.M. revealed LPN #38 spoke with the hospital at 6:45 P.M. and was informed Resident #15 would be held for 24 hours due to decreased urine output, increased temperature and an intravenous antibiotic for a urinary tract infection. There was no other documentation in the nurse progress notes regarding vital signs at the time of the incident, actual description and/or measurements of the injuries, notification of physician or the DON at the time of the incident, specific details of the incident or when the resident was transferred from the facility to the hospital. Review of an ambulance run sheet dated 11/06/14 revealed the facility (no specific person identified) made a call to transport Resident #15 at 11:15 A.M. on 11/06/14. The form indicated the ambulance arrived at the facility at 11:32 A.M. The report reflected Resident #15 had an unwitnessed fall with a head injury at the facility but was picked up and placed back in bed prior to their arrival. Resident #15 had a " knot " on the left side of the forehead and had contractures in all four extremities. The ambulance arrived at the hospital at 12:06 P.M. The emergency room summary dated 11/06/14 and written by physician's assistant (PA) #180 revealed Resident #15 apparently had an unwitnessed fall sometime during the night. The resident was found on the floor of her room around 4:30 A.M. The facility said she was found with her head caught between the bed and the night stand. The facility later decided (around 11:00 A.M.) to send Resident #15 to the hospital. A CT scan of the brain revealed a small subarachnoid hemorrhage (a bleed in the brain). Neurosurgery evaluated the resident and felt there was no intervention that was needed at that time but to hold the aspirin for seven days. The resident was found to have a urinary tract infection and developed an elevated temperature, therefore she was given intravenous [MEDICATION NAME] (antibiotic) and she was admitted to the hospital. Review of the self-reported incident (SRI) # dated11/06/14 revealed an incident occurred at 4:45 A.M. that day in Resident #15 ' s room. The SRI indicated STNA #174 found Resident #15 with her head hanging over the left side of the bed between the bed and the night stand. STNA #174 stated she then put Resident #15 ' s head back in the bed and notified LPN #20. LPN #20 and RN #74 noted scratch marks and a hematoma on the resident ' s left forehead. Neurological checks were completed. The resident was assessed by the CNP (not identified) and a decision was made to send her to the emergency room . Resident #15 was diagnosed by CT scan with a small subarachnoid hemorrhage. STNA #174 was again questioned and she informed the DON that she observed Resident #15 at 4:45 A.M. with her legs off the bed so she put them back on the bed. STNA #174 told the DON that around 5:00 A.M., she saw the resident with her head off the bed, between the night stand and the bed on the left side. STNA #174 indicated she pulled Resident #15 back onto the bed and called the nurse. Resident #15 was totally dependent on staff and could not turn herself in bed. The result of the investigation revealed the facility felt the evidence was inconclusive and could not substantiate abuse or neglect, but STNA #174 was not forthright with complete information regarding the incident. STNA #174 was suspended until a decision was made. Review of an undated "neuro" assessment for suspected head injury revealed neurological checks and vital signs for Resident #15 were completed at 5:15 A.M., 5:30 A.M., 5:45 A.M., 6:00 A.M., 7:00 A.M., 8:00 A.M., 9:00 A.M. and 10:00 A.M. The assessments included vital signs and pupil reaction to light and were within normal limits for Resident #15. The neuro assessments did not indicate description of the injury or signs of pain. The instructions on the form revealed vital signs and "neuro" checks were to be completed every 15 minutes times four, every one hour times four, every four hours times 24 hours and once a shift times 48 hours. The form listed an assessment area under "nausea/vomiting/headache" and "observations." Neither of these assessments was completed. Review of the medical record revealed no physician or CNP progress notes dated 11/06/14 for Resident #15 regarding the incident, assessment, evaluation or treatment. Review of the witness statement written by LPN #20 and dated 11/07/14 revealed STNA #174 came to her between 5:00 A.M. and 5:30 A.M. and explained she found Resident #15 face down on her stomach with her head wedged between the bed and the night stand. STNA #174 told LPN #20 the resident had "a scratch and a small knot on her forehead". LPN #20 entered the resident's room and found Resident #15 on her back in bed with a cold towel on her head. "Upon assessment, an egg sized hematoma was noted to the left side of the resident's forehead, with two scratches". Neurological checks were within normal limits. Resident #15 was awake and pupils were "brisk". Review of a statement included in the SRI investigation dated 11/10/14 from CNP #175 revealed Resident #15 was not known to be able to turn or move independently. The resident required full assistance with movement. The physician progress notes [REDACTED].#15 returned to the facility from the hospital on [DATE], after being treated for [REDACTED]. Review of a nursing progress note dated 11/19/14 at 5:48 P.M. revealed Resident #15 was discharged to another skilled nursing facility per family request. An interview with the DON on 12/09/14 at 12:20 P.M. revealed Resident #15 was discovered at 4:45 A.M. on 11/06/14 with her head between the bed and night stand. The DON verified the resident had scratches and a hematoma on her forehead. The DON verified the documentation indicated a CNP would be notified on the day shift. The DON verified neither CNP (CNP #175 or CNP #176) was called at the time of the sustained injury. An interview with RN #65 on 12/09/14 at 3:15 P.M. revealed she was the third floor supervisor. RN #65 stated she came in around 8:00 A.M. on 11/06/14 and noticed an incident report in her mail. RN #65 stated she went to Resident #15 ' s room with LPN #25 sometime between 8:00 A.M. and 8:30 A.M. RN #65 stated she looked at Resident #15's head and instructed LPN #25 to call the CNP for an order to transfer the resident to the hospital. RN #65 verified the documentation did not indicate the time the CNP was called about the resident's head injury. RN #65 was not sure when the resident was transferred to the hospital and verified there was no assessment of the injuries or documentation to indicate when the resident left the facility. RN #65 verified the emergency room summary forms indicated Resident #15 was found on the floor with her head caught between the bed and the night stand. She verified the hospital information indicated that around 11:00 A.M. the facility decided to send the resident to the hospital. RN #65 verified the ambulance service was not notified until 11:15 A.M. on 11/06/14 to transfer the resident to the hospital. RN #65 verified Resident #15 ' s physician was not notified after the resident sustained [REDACTED]. An interview with LPN #20 on 12/10/14 at 7:20 A.M. revealed she worked the night shift (11:00 P.M. to 7:30 A.M.) on 11/06/14. She stated STNA #174 notified her about 5:00 A.M. that Resident #15 had a "small knot" on her head. LPN #20 went into the resident's room with the STNA and noticed a "nice size hematoma" on the left side of the resident's forehead. LPN #20 stated there was a cold wash cloth on the resident's head; the resident was nonverbal and did not move independently prior to the injury. LPN #20 observed the resident on her back in bed, completed vital signs and a neurological check. LPN #20 stated she initiated the checks as per policy. LPN #20 verified the neurological assessment form for suspected head injury (undated) revealed the initial vital signs and neurological check was completed at 5:15 A.M. LPN #20 stated STNA #174 said she found the resident leaning out of the left side of the bed on her stomach, with her head wedged between the bed and the night stand. The STNA stated she moved the resident onto her back in bed and applied the cold wash cloth. LPN #20 stated she called the supervisor (RN #74) and finished passing medications to the other residents. LPN #20 indicated Resident #15 ' s neurological check and vital signs were stable, therefore she did not see the need to notify the physician or the CNP regarding the head injury. LPN #20 stated she thought the CNP would see the resident on the day shift. LPN #20 stated there was no policy that addressed notification of the physician/CNP regarding injuries. LPN #20 verified a subarachnoid hemorrhage was discovered when Resident #15 was sent to the hospital on the day shift. An interview with RN #74 on 12/10/14 at 7:40 A.M. revealed LPN #20 called her about 5:30 A.M. and told her about the Resident #15's injury. RN #74 stated she entered Resident #15's room and observed STNA #174 repositioning Resident #15 in bed by herself. RN #74 stated STNA #174 told her she found Resident #15 in bed on her stomach with her head wedged between the bed and the night stand. The night stand was located on the left side of the bed. STNA #174 indicated she positioned the resident back into the bed on her back and notified the nurse. RN #74 stated it appeared Resident #15 hit her head on the metal bed frame on the side of the air mattress. RN #74 stated the hematoma and scratches were on the left side of the resident's forehead. RN #74 revealed she instructed LPN #20 to notify the family and the physician/CNP of the injury. RN #74 revealed Resident #15 was only a one-person assist for bed mobility. An interview on 12/10/14 at 9:10 A.M. with the Administrator verified the policy and procedure regarding notification of change in resident's condition or status (undated) included the physician must be notified with an instance of serious fall or head injury. The Administrator verified the policy was specific to the notification of the physician regarding head injury. The Administrator verified Resident #15 was not assessed in the facility by the physician or CNP on 11/06/14. An interview with LPN #25 on 12/10/14 at 10:20 A.M. revealed Resident #15 hit her head and had a hematoma on 11/06/14. LPN #25 observed Resident #15 in her room at 7:30 A.M. on that day and noticed a hematoma. Further interview with LPN #25 revealed STNA #122, who was assigned to care for the resident on the day shift remained in the resident ' s room and was cleaning the resident up by herself. LPN #25 received report from LPN #20, who told her STNA #174 reported the incident and the resident had a hematoma. LPN #20 told LPN #25 that she did not notify the CNP or the physician. LPN #25 stated she completed medication pass and frequently checked on Resident #15. LPN #25 stated she gave Resident #15 pain medication due to facial grimacing. CNP #176 was called shortly after 9:00 A.M. and LPN #25 received orders to send the resident to the emergency room for a CT scan. LPN #25 stated Resident #15 began grimacing and there was a change in her demeanor. LPN #25 stated CNP #176 instructed her to "get the resident out of there". LPN #25 instructed Secretary #177 to call the ambulance. LPN #25 notified the hospital and the resident ' s sons of the transfer. LPN #25 continued to check on the resident. LPN #25 verified there was no documentation of when the resident left the facility or her condition prior to the transfer to the hospital. LPN #25 verified the documentation from the ambulance company indicated they did not receive a telephone call from the facility until 11:15 A.M. An interview with the DON on 12/10/14 at 11:15 A.M. verified STNA #174 was terminated because the facility felt she was not completely forthright regarding what occurred that caused Resident #15's head injury. An interview with DON #50 on 12/11/14 at 2:30 P.M. verified no physician or clinical nurse practitioner was notified regarding Resident #15's head injury from approximately 5:00 A.M. until approximately 10:43 A.M. She verified there was no evidence of the resident ' s condition or head injury other than a grid with vital signs and neurological checks. LPN #20 had not been retrained regarding the notification of the physician and prompt treatment in the event of the head injury. An interview with Secretary #177 on 12/12/14 at 2:22 P.M. revealed no one requested she call the physician or CNP regarding Resident #15's head injury on 11/06/14. Secretary #177 stated she remembered working on the third floor the day Resident #15 sustained a head injury and recalled calling for the ambulance to transfer the resident to the hospital. Secretary #177 stated the ambulance arrived at about 11:45 A.M. to transfer Resident #15 to the hospital. An interview with LPN #39 on 12/12/14 at 2:30 P.M. revealed the nurse ' s responsibility was to notify the physician in a timely manner for a resident with a head injury. Review of the facility's undated policy and procedure for Notification of Change in a Resident ' s Condition revealed if any resident sustained [REDACTED]. Review of the facility's undated Physician /Nurse Practitioner Notification Protocol revealed the physician/ nurse practitioner must be notified on any change in condition or injury and the nurse must complete an SBAR form prior to notification. Review of the facility's SBAR communication and progress note for New Symptoms, Signs and Changes in Condition (undated) indicated the SBAR was to be completed prior to notifying the physician and used as a communication tool when speaking to the physician regarding a resident's change in condition. The SBAR revealed the following: *Section " S " (Situation): included the time, symptoms and condition of the resident. *Section " B " (Background): included resident diagnoses, history, current vital signs, current oxygen level, change in function, change in mental status, pain level, wound status. *Section " A " (Assessment): included what the nurse thinks the problem may be. *Section " R " (Request): Any new orders including x-rays needed, lab work needed and transfer to hospital. This deficiency substantiated allegations contained in complaint #OH 015.