Every finding on record at Greenbriar Nursing Center

Based on medical record review, staff interviews, and policy review, the facility failed to notify the physician for a change in orthostatic blood pressure and failed to notify a resident's family of new physician orders and changes in condition. This affected one (Resident #58) of twelve residents reviewed for change in condition. The facility census was 66.Findings include:Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Diagnoses included pulmonary fibrosis and congestive heart failure (CHF). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had moderately impaired cognition.Review of the physician progress notes dated [DATE] revealed Nurse Practitioner (NP) #190 assessed Resident #68 related to reports of acute cough and congestion, worsening over the last several days. Plan of care included to continue as needed (PRN) medications for cough and new orders for a chest x-ray.Resident #68 had physician orders dated [DATE] for a chest x-ray two view.The physician progress notes dated [DATE] revealed NP #188 assessed Resident #68 as a follow-up to the chest x-ray obtained [DATE] for dyspnea. Abnormal chest x-ray showed interstitial nodular fibrosis. Plan of care included new orders for outpatient chest Computed Tomography (CT) scan with contrast and Prednisone (steroid) 20 milligrams (mg) by mouth daily for five days for cough with follow-up as needed.Resident #68 had physician orders dated [DATE] for CT of the chest, outpatient, related to post chest x-ray results. On [DATE], an order for prednisone oral tablet 20 mg: Give one tablet by mouth one time a day for cough for five days. The physician progress notes dated [DATE] revealed NP #190 assessed Resident #68 regarding complaints of multiple dizzy spells over the last several days, primarily with movement. Physical examination revealed respirations were even and unlabored, and bilateral lungs were clear to auscultation. New orders were placed for orthostatic blood pressure (BP) (to monitor for change in BP that occurs when a person moves from lying down to standing) and a basic metabolic panel.Resident #68 had physician orders dated [DATE] for orthostatic BP for three times daily every shift for monitoring. Review of orthostatic BP readings taken on [DATE] at 6:00 A.M. revealed while lying down, Resident #68's BP measured 126/72, when sitting measured 77/47 (this was a systolic drop of 40 millimeters of mercury (mm Hg) and diastolic drop of 25 mm Hg; this indicates a severe form orthostatic hypotension), and when standing measured 79/53.There was no documentation of Resident #68's family being notified when Resident #68 had a change in condition and new physician orders on [DATE], and when Resident #68 had abnormal chest x-ray results and two new orders including outpatient diagnostic testing and a new medication on [DATE]. There was no documentation of Resident #68's family being notified when Resident #68 had a change in condition on [DATE] and new physician orders. Additionally, there was no documentation of physician notification related to abnormal orthostatic blood pressure readings recorded on [DATE]. During an interview on [DATE] at 2:10 P.M., the Director of Nursing (DON) verified there was no family notification documented in Resident #68's medical record when Resident #68 had changes in condition on [DATE] and [DATE], abnormal x-ray results on [DATE], new physician orders on [DATE] and [DATE]. The DON stated Resident #68 did not want her family to be notified because they would insist she go to the hospital, and she did not want to go. The DON verified this was not documented and could not be verified on the medical record. During an interview on [DATE] at 12:45 P.M., NP #190 stated she was not notified of any abnormal blood pressure readings for orthostatic hypotension. She stated she would have expected the nurse to notify the physician if a reading showed a change from 126/62 lying to 77/47 sitting. Review of the policy titled Change in a Resident's Condition dated 08/2023 revealed the facility notified the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition.This deficiency represents non-compliance investigated under Complaint Numbers 2785662 and 2748144.

Based on medical record review, staff interviews, and policy review, the facility failed to schedule Computed Tomography (CT) testing and obtain results in a timely manner. This affected one (Resident #68) of twelve reviewed for diagnostic services. The facility census was 66.Findings include:Review of the medical record revealed Resident #68 was admitted to the facility on [DATE] and expired in the facility on [DATE]. Diagnoses included pulmonary fibrosis and congestive heart failure (CHF). Review of the care plan dated [DATE] revealed Resident #68 had altered respiratory status and difficulty breathing related to CHF and pulmonary fibrosis. Interventions included obtaining and monitoring labs and diagnostic work as ordered.The physician progress notes dated [DATE] revealed Nurse Practitioner (NP) #188 assessed Resident #68 as a follow-up to the chest x-ray obtained [DATE] for dyspnea. Abnormal chest x-ray showed interstitial nodular fibrosis. Plan of care included new orders for outpatient chest Computed Tomography (CT) scan with contrast.Resident #68 had physician orders for [DATE] for CT of the chest, outpatient, related to post chest x-ray results.There were no results of the CT of the chest in Resident #68's medical record.During a telephone interview on [DATE] at 9:58 A.M., NP #188 confirmed he re-assessed Resident #68 on [DATE] after an abnormal chest x-ray on [DATE] and ordered a CT chest with contrast. NP #188 stated he did not see the CT results and was unaware that the CT had not been performed until [DATE]. If staff notified him the CT was unable to be performed sooner, NP #188 would have re-assessed Resident #68 to determine if she needed more urgent treatment.During an interview on [DATE] at 2:10 P.M., the Director of Nursing (DON) and Regional Registered Nurse (RN) #195 confirmed CT results from CT chest on [DATE] were not available in Resident #68's medical record. Regional RN #195 stated she expected nursing would call to check on results if not received within 48 hours of outpatient testing performed.During an interview on [DATE] at 12:28 P.M., Transporter #162 confirmed he routinely scheduled appointments and transportation with outside providers. Scheduler #162 verified the order for Resident #68's appointment for CT was missed, and he had not called to schedule Resident #68's CT chest until [DATE]. Scheduler #162 stated he only recently learned how to run a new order report in the computer to check for appointments needing to be scheduled. In addition, Scheduler #162 stated he usually provided a fax number for the results to be sent after the test. He did not remember if he had provided a fax number for this test. Review of the policy titled Provision of Physician/Medical Practitioner Services dated [DATE] revealed nurses were to submit timely requests for practitioner-ordered services, including laboratory, radiology, and consultations, to the appropriate entity.This deficiency represents non-compliance investigated under Complaint Number 2748144.

Based on medical record review and staff interview, the facility failed to ensure skin care treatments were timely initiated when a resident was admitted with a pressure ulcer. This affected one (#75) of three reviewed for wound care and services. The facility census was 70. Findings include: Medical record for Resident #75 revealed an admission on [DATE] with diagnoses including but not limited to hypertension, type two diabetes mellitus with diabetic neuropathy, peripheral vascular disease, and congestive heart failure. Resident #75 was transferred to the hospital on [DATE] and did not return to the facility. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #75 revealed cognitive impairment. Resident #75 required supervision for eating and minimal assistance with bed mobility, transfers and toileting. Resident #75 was coded in section M of the MDS as being at risk for developing pressure ulcers and coded for as having one more unhealed pressure ulcers. Resident #75 was coded with one unstageable deep tissue injury that was present on admission. Resident #75 was not coded with any pressure ulcer care, applications of dressings or topical ointments. Further review of section M revealed it was signed as completed on 08/07/25. Review of the plan of care for Resident #75 dated 08/01/25 was silent for any documentation related to altered skin integrity. Review of hospital discharge orders for Resident #75 dated 07/31/25 was silent for any orders related to impaired skin integrity. Review of the weekly skin assessment for Resident #75 dated 07/31/25 revealed scatter bruising and scabs, buttocks red and skin beginning to peel. Review of the weekly wound assessment for Resident #75 dated 08/01/25 revealed resident had pressure ulcer to sacrum classified as suspected deep tissue injury. Wound measurements documented were 7 centimeters in length, 7.4 cm in width and 0.0 depth. Wound description was documented as resident was admitted from the hospital with this deep tissue injury (DTI) to coccyx, purple in color, top layer of skin peeling and no drainage noted. Wound status was stable, treatment plan documented for zinc-based barrier cream two times a day. Review of the weekly skin assessment for Resident #75 dated 08/05/25 revealed admitted with unstageable to coccyx seen by wound nurse practitioner (NP). Review of the weekly wound assessment for Resident #75 dated 08/11/25 revealed resident had pressure ulcer to sacrum classified as unstageable. Wound measurements documented were 6.5 cm x 4.5 cm x 0. Wound description was documented as resident was admitted from the hospital with this deep tissue injury (DTI) to coccyx, purple in color, top layer of skin peeling and no drainage noted. Wound status was stable, treatment plan documented for cleanse with soap and water, pat dry, apply wound gel and dry dressing daily. Review of the initial wound NP visit for Resident #75 dated 08/11/25 revealed coccyx wound pressure and staged as unstageable. Coccyx wound measures 6.5 cm x 4.5 cm x 0.1 cm. Wound had scant amount of serous drainage. Adherent slough (dead non viable tissue) present on wound was documented as 50 percent of wound area and 50 percent eschar. Treatment plan documented for wound gel and bordered foam dressing everyday and as needed. Recommendations documented included NP was notified by facility on admission of coccyx wound, treatment was initiated upon evaluation today. Will start with wound gel to soften slough and eschar and for chemical debridement. Resident #75 would benefit from low air loss mattress. Review of the weekly skin assessment for Resident #75 dated 08/11/25 revealed resident has previously identified skin areas/abnormalities. Review of the weekly skin assessment for Resident #75 dated 08/18/25 revealed has previously identified skin areas/abnormalities with coccyx pressure noted. Review of the weekly wound assessment for Resident #75 dated 08/18/25 revealed resident had pressure ulcer to sacrum classified as unstageable. Wound measurements documented were 7.0 cm x 4.0 cm x 0. Wound description was documented as resident was admitted from the hospital with DTI, unstageable to coccyx, 100 percent slough with no drainage noted. Wound status was stable, treatment plan documented for cleanse with soap and water, pat dry, apply wound gel and dry dressing daily. Review of the wound NP visit notes for Resident #75 dated 08/18/25 revealed coccyx wound pressure and staged as unstageable. Coccyx wound measures 7.4 cm x 4.0 cm x 0.1 cm. Wound had scant amount of serous drainage. Adherent slough (dead non viable tissue) present on wound was documented as covering 100 percent of wound. Treatment plan documented for wound gel and bordered foam dressing everyday and as needed. Recommendations documented included continue wound gel to help soften slough and promote debridement. Air mattress was ordered per nursing. Review of the weekly wound assessment for Resident #75 dated 08/25/25 revealed resident had pressure ulcer to sacrum classified as unstageable. Wound measurements documented were 7.0 cm x 4.0 cm x 0. Review of the physician orders for Resident #75 revealed an order dated 08/12/25 to area on coccyx, cleanse with soap and water, pat dry, apply wound gel, cover with dry dressing, change daily and as needed for soiling and dislodgement. An order for moon boots to bilateral feet when in bed every day and night initiated on 08/11/25. Review of the monthly medication administration record (MAR) and treatment administration record (TAR) for July 2025 for Resident #75 was silent for any wound treatment orders to the coccyx/sacrum. Review of the MAR and TAR record for August 2025 for Resident #75 revealed an treatment order dated 08/11/25 was documented to area on coccyx, cleanse with soap and water, pat dry and apply calcium alginate cover with dry dressing and change everyday. Order was discontinued on 08/12/25. An order dated 08/12/25 was initiated for area to coccyx cleanse with soap and water, pat dry, apply wound gel, cover with dry dressing and change every day. Interview on 09/30/25 at 3:05 P.M. with Licensed Practical Nurse (LPN) #101 revealed that monitoring skin treatments and rounding with Wound NP verified the facility did not have any documentation that the stated barrier cream which was documented on the weekly skin assessment on 08/01/25 was being applied as ordered. LPN #101 verified July and August 2025 MAR/TAR did not contain any orders for coccyx/sacrum wound care until 08/12/25. LPN #101 further stated the orders for Resident #75's skin breakdown were just missed. This deficiency represents non-compliance investigated under Complaint Number OH002593689.

Based on medical record review and staff interview, the facility failed to ensure resident preadmission screening and resident reviews (PASARRs) were accurate and included resident mental health diagnoses and mental health services. This affected three (Residents #02, #61 and #63) of three residents reviewed for PASARRs. The facility census was 71 residents. Findings include: 1. Review of the medical record for Resident #02 revealed an admitted [DATE] with diagnoses including anxiety disorder, major depressive disorder, schizoaffective disorder, type two diabetes mellitus, cerebral infarction, and epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #02 dated 01/02/25 revealed the resident was severely cognitively impaired and required assistance with activities of daily living (ADLs.) Review of the PASARR for Resident #02 dated 08/19/24 revealed the resident had mood disorders and panic or other severe anxiety disorders but did not include the resident's diagnosis of schizoaffective disorder. Interview 02/25/24 at 11:18 A.M. with the Administrator confirmed the facility had not listed Resident #02's diagnosis of schizoaffective disorder on the PASARR dated 08/19/24. 2. Review of the medical record for Resident #61 revealed an admitted [DATE] with diagnoses including psychotic disorder with delusions due to known physiological condition, anxiety disorder, major depressive disorder, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, cerebral atherosclerosis, and type two diabetes mellitus. Review of the MDS assessment for Resident #61 dated 12/14/24 revealed the resident was severely cognitively impaired and was dependent on staff assistance with ADLs. Review of the diagnosis list for Resident #61 revealed the resident had the following psychiatric diagnoses: psychotic disorder with delusions due to known physiological condition, anxiety disorder, and major depressive disorder. Review of the psychiatric progress note for Resident #61 dated 11/18/24 revealed the resident was seen by a mental health provider for neuropsychiatric assessment and management of mood and cognition. Review of the PASARR for Resident #61 dated 01/03/25 revealed there were no mental disorders or psychiatric services listed. Interview on 02/25/24 at 11:23 A.M with the Administrator on confirmed the facility had not listed Resident #61's diagnoses of psychotic disorder with delusions due to known physiological condition, anxiety disorder, and major depressive disorder on the PASARR dated 01/03/25 nor had the facility noted Resident #61's psychiatric services. 25908 3. Review of the medical record for Resident #63 revealed a admitted [DATE] with diagnoses including Parkinson's disease, and bipolar disorder. Review of the MDS assessment for Resident #63 dated 01/01/25 revealed the resident had severely impaired cognition and required maximum staff assistance with ADLs. Review of the PASARR for Resident #63 dated 01/03/25 revealed it did not include the resident's diagnosis of bipolar disorder. Interview on 02/27/25 at 1:18 P.M. with Social Worker (SW) #31 confirmed the facility did not include Resident #63's diagnosis of bipolar disorder on the PASARR dated 01/03/25.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff properly monitored residents receiving anticoagulants for bruising and bleeding. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The facility census was 71 residents. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including end stage renal disease, chronic obstructive pulmonary disease, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 12/16/24 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and received anticoagulant medication. Review of the care plan for Resident #16 dated 05/01/24 revealed the resident was on an anticoagulant related to a history of stroke. Interventions included the following: administer medications as ordered, monitor for side effects, include the resident in the treatment plan, monitor vital signs and laboratory values. Review of the physician's orders for Resident #16 revealed an orders dated 12/26/23 for Eliquis 2.5 milligrams (mg) twice daily and to monitor the resident for signs and symptoms of bleeding and report to the physician due to Eliquis administration. Review of the progress note for Resident #16 dated 08/20/24 per Nurse Practitioner (NP) #500 revealed the resident had dry nostrils and had a minor nosebleed. NP #500's plan was for staff to apply petroleum jelly to the resident's nostrils as needed. Review of the progress notes for Resident #16 dated 12/27/24 to 02/24/25 revealed no documentation of bruising and/or bleeding (nosebleeds.) Review of the skin assessment for Resident #16 dated 02/10/25 revealed the resident had scattered scabs on the arms where the resident had picked the skin. Review of the skin assessment for Resident #16 dated 02/17/25 revealed the resident had no new skin areas. Observation on 02/24/25 at 11:04 A.M. revealed Resident #16 had a piece of tissue paper in his right nostril that had a red drop on it. Resident #16 also had large bruises that were approximately two inches long by two inches wide on both hands. Interview on 02/24/25 at 11:14 A.M. with Resident #16 confirmed he had frequent nose bleeds and bruises on both of his hands because he was on an anticoagulant. Interview on 02/25/25 at 4:30 P.M with the Director of Nursing (DON) confirmed Resident #16 had large bruises on both of his hands and there was no documentation of the bruising or notification to the physician of the bruising in the resident's medical record. The DON confirmed Resident #16 also had frequent nose bleeds and was on an anticoagulant. The DON confirmed the facility had not documented appropriate monitoring of Resident #16 for side effects of Eliquis. Review of the facility policy titled Anticoagulant Medications dated 03/07/23 revealed residents that received anticoagulants should be assessed for adverse reactions such as bruising, bleeding gums, rectal bleeding, bloody urine and changes in mental status. Any adverse reactions should be reported to the attended physician and documented in the medical record.

Based on record review, review of personnel files, staff interview and review of job descriptions, the facility failed to ensure the services of a qualified Activities Director (AD). This had the potential to affect all residents who resided in the facility with the exception of four (#15, #18, #21, and #52) residents who the facility identified as not participating in activities. The facility census was 57. Findings include: Interview on 02/21/24 at 2:16 P.M. with the AD #154 confirmed she did not have the required certification to be an AD. AD #154 stated she was informed that the facility would provide the education to meet the qualifications to become a Certified AD; however, the facility had not provided the funds to complete the education. Interview on 02/21/24 at 3:07 P.M. with the Administrator, confirmed AD #154's background, experience, and education failed to meet the qualifications of a Certified AD. Review of the personnel record for AD #154 revealed she was hired as the facility's AD on 06/05/23. AD #154 did not have a certification in AD or the appropriate training and/or education to hold the position of AD. Review of the job description titled, Activities Director, revealed the facility requires the position to be certified to complete the 90-hour course for Activities Directors within a reasonable timeframe.

Based on medical record review and staff, resident and eye specialist staff interviews, the facility failed to schedule an eye specialist appointment timely. This affected one (#112) out of the three residents reviewed for appointments. The facility census was 60. Findings included: Review of the medical record for Resident #112 revealed an admitted [DATE] with medical diagnoses of cerebral palsy, restless leg syndrome, paraplegia, anxiety, and depression. Review of the medical record for Resident #112 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #112 was cognitively intact and was dependent upon staff for toileting, bathing, bed mobility and transfers. Review of the medical record for Resident #112 revealed an Optometrist note, dated 09/25/23, which stated Resident #112's assessment revealed low vision to right eye, normal vision to left eye, ocular hypertension to left eye, retinal hemorrhage right eye and pseudophakia (fake lens) to both eyes and requested a referral for ophthalmologist. Review of the medical record revealed a physician order, dated 09/28/23, to call and schedule appointment for eye specialist per in house eye doctor request. Further review of the medical record for Resident #112 revealed no documentation to support the facility scheduled an ophthalmologist appointment. Interview on 12/05/23 at 10:30 A.M. with Resident #112 stated she has asked to see an eye doctor because she can't see very well. Interview on 12/05/23 at 2:17 P.M. with Receptionist #7 from eye specialist office stated the facility called on 12/05/23 to schedule Resident #112 an appointment for 01/10/24. Receptionist #7 confirmed there was no prior attempts to schedule an appointment prior to 12/05/23 for Resident #112. Interview on 12/05/23 at 2:30 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #112 did not contain documentation to support the facility scheduled an eye specialist appointment as ordered on 09/28/23. This deficiency represents non-compliance investigated under Complaint Number OH00147644.

Based on medical record review, staff interviews, and policy reviews, the facility failed to notify the physician of a resident's significant weight loss. This affected one (#100) resident out of the three residents reviewed for weight loss. The facility census was 63. Findings included: Review of the medical record for Resident #100 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease (COPD), hypertension and dementia. Review of the medical record for Resident #100 revealed a significant change Minimum Data Set (MDS), dated [DATE], which indicated Resident #100 had severe cognitive impairment and required supervision with eating and supervision with dressing, transfers, and toileting. The MDS revealed no weight was documented and no weight loss noted. Review of the medical record for Resident #100 revealed no documentation to support her weight was obtained upon admission 05/17/23. Further review revealed a weight on 07/01/23 at 117.2 pounds, on 10/02/23 at 103.8 pounds, and on 11/03/23 at 92.2 pounds. Review of the medical record did not contain documentation to support Resident #100 refused to be weighed or any other weights were obtained. Review of the medical record for Resident #100 revealed a nutrition note, dated 10/16/23 at 3:19 P.M. which indicated Resident #100 weight was 103.8 pounds and had a 7.5% decline in weight in three months which triggered a significant weight loss. The note stated a supplement would be recommended to help maintain weight. The note did not contain documentation to support the physician was notified of the weight loss. Further review of the medical record revealed a nutrition note, dated 11/13/23 at 3:22 P.M. which stated Resident #100's weight was 92.2 pounds and had a 5.0% decline in one month which triggered a significant weight loss. The note recommended to reweigh the resident to confirmed weight loss and update weight. The note did not contain documentation to support the physician was notified of the significant weight loss. Interview on 11/29/23 at 1:12 P.M. with Dietician #400 stated Resident #100 was considered a nutritional risk resident and should have been weighed weekly after significant weight loss documented on 10/16/23. Dietician #400 confirmed the medical record for Resident #100 did not contain documentation to support the facility notified the physician of the significant weight loss or that the facility obtained weights as per policy to monitor Resident #100's nutritional status. Dietician #400 stated Resident #100 has had a gradual decline due to her dementia and nutritional supplements were implemented to help maintain her weight. Review of the undated policy titled, Resident Weight, stated the policy was to ensure staff were monitoring and obtained weights as indicated. The policy stated the staff were to record and monitor weights monthly or as indicated by the resident's condition. The policy stated residents at high nutritional risk would be weighed weekly. Review of the policy titled, Change of Condition, dated May 2020, stated the facility would immediately notify the resident, physician, or resident representative of a significant change in resident's physical, mental, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00148182.

Based on medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure resident weights were obtained to monitor nutritional status. This affected two (#54 and #100) out of the three residents reviewed for weight loss. The facility census was 63. Findings included: 1. Review of the medical record for Resident #54 revealed an admitted [DATE] with medical diagnoses of chronic respiratory failure, hypertension (HTN), hypothyroidism, and epilepsy. Review of the medical record for Resident #54 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #54 had moderate cognitive impairment and was dependent upon staff for bed mobility, dressing, toileting, and bathing, required extensive staff assistance for transfers, and set-up assistance with eating. Review of the MDS revealed no weight documented. Review of the medical record for Resident #54 revealed a nutritional risk care plan, dated 06/26/22, which indicated the facility would monitor Resident #54 for weight loss. Review of the medical record for Resident #54 revealed a weight of 189.4 pounds on 01/17/23 and 194.2 pounds on 06/01/23. Review of the medical record did not contain documentation to support the facility obtained weights or resident refused to be weighted from February 2023 to May 2023 or from July 2023 to November 2023. Review of the medical record for Resident #54 revealed a dietary progress note, dated 11/27/23 at 1:36 P.M., which stated last recorded weight was 06/01/23 and current weight was requested. Interview on 11/29/23 at 10:02 A.M. with Resident #54 stated staff do not weigh her regularly. Interview on 11/29/23 at 2:55 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #54 did not contain documentation to support the facility obtained monthly weights or Resident #54 refused to be weighed. DON confirmed Resident #54 weight was obtained on 11/29/23 and was 189.7 pounds. DON confirmed Resident #54 is at risk for weight loss and weights should be monitored. 2. Review of the medical record for Resident #100 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease (COPD), HTN, and dementia. Review of the medical record for Resident #100 revealed a significant change MDS, dated [DATE], which indicated Resident #100 had severe cognitive impairment and required supervision with eating and supervision with dressing, transfers, and toileting. The MDS revealed no weight was documented and no weight loss noted. Review of the medical record for Resident #100 revealed a potential for decline in nutrition and hydration due to COPD, dysphagia, and dementia. The interventions included monitoring weights and diet as ordered. Review of the medical record for Resident #100 revealed no documentation to support her weight was obtained upon admission 05/17/23. Further review revealed a weight on 07/01/23 at 117.2 pounds, on 10/02/23 at 103.8 pounds, and on 11/03/23 at 92.2 pounds. Review of the medical record did not contain documentation to support Resident #100 refused to be weighed or any other weights were obtained. Review of the medical record for Resident #100 revealed a nutrition note, dated 10/16/23 at 3:19 P.M. which indicated Resident #100 weight was 103.8 pounds and had a 7.5% decline in weight in three months which triggered a significant weight loss. The note stated a supplement would be recommended to help maintain weight. The note did not contain documentation to support the physician was notified of the weight loss. Further review of the medical record revealed a nutrition note, dated 11/13/23 at 3:22 P.M. which stated Resident #100's weight was 92.2 pounds and had a 5.0% decline in one month which triggered a significant weight loss. The note recommended to reweigh the resident to confirmed weight loss and update weight. The note did not contain documentation to support the physician was notified of the significant weight loss. Interview on 11/29/23 at 1:12 P.M. with Dietician #400 stated Resident #100 was considered a nutritional risk resident and should have been weighed weekly after significant weight loss documented on 10/16/23. Dietician #400 confirmed the medical record for Resident #100 did not contain documentation to support the facility notified the physician of the significant weight loss or that the facility obtained weights as per policy to monitor Resident #100's nutritional status. Dietician #400 stated Resident #100 has had a gradual decline due to her dementia and nutritional supplements were implemented to help maintain her weight. Review of the undated policy titled, Resident Weight, stated the policy was to ensure staff were monitoring and obtained weights as indicated. The policy stated the staff were to record and monitor weights monthly or as indicated by the resident's condition. The policy stated residents at high nutritional risk would be weighed weekly. This deficiency represents non-compliance investigated under Complaint Number OH00148182.

Based on medical record review, observation, staff interview, review of the manufacturers recommendations and policy review the facility failed to ensure one resident (#95) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #31, #36, #94 and #95) of four residents reviewed for oxygen use. The facility census was 47. Findings include: 1. Review of the medical record for Resident #95 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge-return modification admission minimum data set (MDS) assessment dated [DATE] revealed Resident #95 had moderate cognition deficit. The assessment indicated she was administered oxygen. Review of the physician orders revealed an order dated 02/18/22 and discontinued on 03/18/22 for oxygen two liters per minute (LPM) via nasal cannula as needed. Review of the medical record revealed Resident #95's oxygen saturation levels were monitored 61 times and indicated she was receiving oxygen via nasal cannula 46 percent of the assessments. The oxygen saturation levels were recorded as 94 to 98 percent both while resident was receiving supplemental oxygen or not (room air). Review of the skilled assessments revealed her lungs were clear to auscultation and no cough was noted. Observation of Resident #95 on 04/04/22 at 8:30 P.M., on 04/05/22 randomly throughout the day and on 04/06/22 from 1:00 P.M. to 3:30 P.M. revealed her to have oxygen on via nasal cannula at two LPM. Direct observation on 04/04/22 at 8:15 P.M. revealed no date on the oxygen tubing. Interview on 04/04/22 at 10:00 P.M. with State tested Nursing Assistant (STNA) #301 verified the oxygen tubing was undated on both Residents #94 and #95. Interview on 04/06/22 at 2:20 P.M., with Licensed Practical Nurse #201 verified Resident #95 had oxygen on and had no current order for it. Review of the facility policy titled Oxygen Administration dated 08/01/19 revealed oxygen is administered under orders of a physician. 2. Review of the medical record of Resident #94 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed Resident #94 was cognitively intact and was not receiving oxygen. Random observations on 04/04/22 through 04/07/22 revealed Resident #94 had oxygen being administered via nasal cannula at two LPM. Review of the physician orders dated 03/18/22 revealed oxygen via nasal cannula at two LPM to keep oxygen saturation above 90 percent. Review of the medical record revealed 28 documentation's of oxygen saturation ranging from 95 percent to 100 percent on oxygen via nasal cannula recorded 20 times and saturation levels of 95 percent to 98 percent on room air recorded eight times. Review of the skilled evaluations documented 10 times revealed her lungs were clear to auscultation bilaterally and no difficulty breathing or cough was noted. Review of the nurses' progress notes revealed only one entry with mention of the need for oxygen. The entry dated 03/22/22 at 12:03 A.M. revealed resident had complained of inability to breathe. Oxygen saturation was 97 percent. No lung assessment was documented and no indication if resident was on supplemental oxygen at the time. Review of the vital sign documentation revealed on 03/22/22 at 12:49 A.M. she was on supplemental oxygen via nasal cannula. Interview on 04/06/22 at 2:30 P.M., with LPN #201 verified Resident #94 had received oxygen throughout her shift and had no documentation of the oxygen being administered. Review of the facility policy titled Oxygen Administration dated 08/01/19 revealed oxygen is administered under orders of a physician. 3. Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #36 had impaired cognition and did not require supplemental oxygen. Review of Resident #36's physician orders dated 02/28/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the orders dated 03/12/22 revealed the oxygen order was revised to infuse at two to six liters per nasal cannula. Review of Resident #36's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 03/2022 and 04/2022 revealed no order was noted in the records for the use of the supplemental oxygen. Review of Resident #36's care plans dated 02/28/22 and the 03/16/22 revision revealed there was no documentation of a focus for supplemental oxygen therapy in the resident's care plans. Observation on 04/05/22 at 9:15 A.M. revealed Resident #36 was sitting in her room in the recliner. Resident #36 appeared to be pleasantly confused. Resident #36's oxygen nasal cannula was observed to be coiled up laying on the floor next to the resident's recliner and the air concentrator was on. The nasal cannula did not have a dated label noted on the tubing. Interview on 04/05/22 at 9:20 A.M. with STNA #305 verified Resident #36 wore her oxygen nasal cannula continuously. STNA #305 verified there was no dated label on the oxygen tubing and the tubing was laying on the floor during the observation. STNA #305 was observed picking up the nasal cannula off the floor and reapplying to Resident #36's face. Interview on 04/07/22 at 9:50 A.M. with the DON verified there was a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified there was no care plan focus for the oxygen and there was no records of the oxygen on the 03/2022 and 04/2022 MAR and TAR for the resident. Review of the facility policy titled, Oxygen Administration dated 08/01/2019 revealed oxygen is to be administered consistent with professional standards of practice, comprehensive care plans, and with the resident's goals and preferences. Per the policy the resident's care plans shall identify interventions for oxygen therapy based upon the residents' assessments and physician orders. 4. Review of the medical record for Resident #31 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed Resident #31 needed extensive assistance of one for bed mobility, transfer, dressing, toilet use. Section O of the MDS revealed the resident was on oxygen during the look back period. Review of physician orders revealed orders for oxygen 2 liters nasal cannula, may titrate to keep oxygen saturation above 90 percent. No orders for changing of oxygen tubing were documented. Observation on 04/05/22 at 8:31 A.M. revealed Resident #31's oxygen tubing was not dated. Review of the manufacturers recommendations for oxygen tubing/cannula use revealed the typical life span, if kept clean, a nasal cannula will last about two months.

Based on closed medical record review, staff interview, and policy review, the facility failed to ensure one resident (#44) of one reviewed for hospitalization received a bed hold notice upon transfer. The facility census was 47. Findings include: Review of the closed medical record of Resident #44 revealed an admitted [DATE] and a discharge date of [DATE] to the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed Resident #44 was sent to the hospital on 01/09/22 with complaints of abdominal pain. The note included her husband had been notified of the transfer. Review of the record revealed no evidence a bed hold notice upon transfer had been given to the resident or her family representative. Interview on 04/07/22 at 2:30 P.M., with the Administrator and the Director of Nursing provided verification the closed medical record did not contain the Bed Hold Notice Upon Transfer. Review of the facility policy titled Bed Hold Notice Upon Transfer dated 12/01/18 revealed at the time of transfer for hospitalization the facility will provide the resident or representative written notice which specifies the duration of the bed hold policy.

Based on closed medical record review, staff interview, and policy review, the facility failed to ensure one resident (#44) of one reviewed for hospitalization received a transfer notice upon transfer. The facility census was 47. Findings include: Review of the closed medical record of Resident #44 revealed an admitted [DATE] and a discharge date of [DATE] to the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed Resident #44 was sent to the hospital on 01/09/22 with complaints of abdominal pain. The note included her husband had been notified of the transfer. Review of the record revealed no evidence a transfer notice upon transfer had been given to the resident or her family representative. Interview on 04/07/22 at 2:30 P.M., with the Administrator and the Director of Nursing provided verification the closed medical record did not contain the Transfer Notice. Review of the facility policy titled Transfer and discharge date d 12/01/18 revealed at the time of transfer (or as soon as practicable) for hospitalization , the facility will provide the resident or representative written notice which documents: resident status; current diagnosis, allergies and reason for transfer/discharge; contact information of the practitioner responsible for the care of resident; current medications and treatments; any special risks or precautions; and any other applicable documents necessary to ensure a safe and effective transfer.

Based on medical record review and staff interview the facility failed to ensure resident care plans were developed with measurable objectives, timelines or interventions. This affected one resident (#19) of 14 reviewed for care planning. The facility census was 47. Findings include: Review of medical record for Resident #19 revealed an admitted 02//1/18. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE] revealed Resident#19 had intact cognition and was an extensive two person assist for bed mobility, dressing and personal hygiene. Resident #19 was dependent for transfers, toilet use and supervision for eating. Section M of the MDS revealed a pressure ulcer /injury and an unhealed pressure ulcer marked as a stage three ulcer not present upon admission. The use of pressure reducing device for the bed and pressure ulcer care was documented during the assessment. Review of the care plan for potential for skin integrity was initiated on 12/03/21 with interventions to encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible. There was no care plan for the documented pressure ulcer for Resident#19. Interview on 04/07/22 at 11:42 A.M., with the MDS Registered Nurse #100 verified there was no care plan addressing the stage three pressure ulcer of Resident#19.

Based on medical record review and staff interviews the facility failed to implement new safety interventions following a fall experienced by two residents (#17 and #95) of five residents (#02, #07, #17, #32, and #95) reviewed for falls. The facility census was 47. Findings include: 1. Review of the medical record of Resident #17 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #17 had severe cognition deficit and required supervision with walking in room and transfers. She was assessed as having no impairment with upper or lower extremity range of motion and used no mobility aids. The assessment revealed she had experienced one fall, without injury, since admission. Review of the care plan with a revised date of 03/31/22 revealed Resident #17 was at a risk for falls related to dementia, anxiety, weakness, depression, hypoxemia, and [CONDITION(S)]. No new interventions were initiated after the fall experienced on 02/23/22. Review of the progress note dated 02/23/22 at 7:00 P.M. revealed Resident #17's call light had activated. Upon entering the room she was found on the floor. Her roommate stated she had been walking over to a recliner, stumbled and fell . Resident #17 was noted to have shoes on both feet and no debris was noted on the floor. 2. Review of the medical record of Resident #95 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge-return modification of admission minimum data set (MDS) assessment dated [DATE] revealed Resident #95 had moderate cognition deficit. Review of the progress notes revealed an entry on 03/18/22 at 10:45 P.M. revealed Resident #95 had fallen from her bed and had sustained a fracture to the left wrist and the left knee. Review of the care plan for Resident #95 revealed the last update with fall prevention interventions were added on 03/10/22. Interview on 04/07/22 at 11:00 A.M., with Registered Nurse #100 provided verification of the lack of modification to the care plan following Resident #17 and Resident #95's fall.

Based on medical record review, observation, staff interview and policy review the facility failed to ensure a pressure wound was assessed. This affected one resident (#19) of three residents reviewed for pressure ulcers. The facility census was 47. Findings include: Review of the medical record for Resident #19 revealed admitted 02//1/18. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident#19 had intact cognition and was an extensive two person assist for bed mobility, dressing and personal hygiene. Resident #19 was dependent for transfers, toilet use and supervision for eating. Review of the Section M of the MDS revealed a pressure ulcer /injury and an unhealed pressure ulcer marked as a stage three ulcer not present upon admission. The use of pressure reducing device for the bed and pressure ulcer care was documented during the assessment. Review of the care plan for potential for skin integrity was initiated on 12/03/21 with interventions to encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible. There was no care plan for the documented pressure ulcer for Resident #19. Review of the skin assessment for Resident#19 dated 02/13/22 revealed documentation of a sacral wound and the description which read reopened which measured 1.0 centimeter (cm) by 0.5 cm by 0.1 cm. Record review of the progress note for Resident #19 dated 02/13/22 revealed the sacral area had reopened. The area was cleansed, the physician was informed, and new orders were received. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply calcium alginate with silver and cover with a dry dressing daily. Further review of the progress notes and the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin assessment for Resident #19 dated 03/08/22 and 03/16/22 revealed documentation the wound nurse continued treating the sacrum area. No description or measurements of the wound were documented. Review of the skin assessment for Resident #19 dated 03/30/22 revealed no new areas noted. There was an existing area to the sacrum, treatments were in place. Observation and interview on 04/07/22 at 10:32 A.M. during the dressing change for Resident #19 by Licensed Practical Nurse (LPN) #202 revealed she was unsure of the wound measurements and believed the wound nurse was measuring the wound. The wound was small in size and there appeared to be a small slit or opening with sanguineous (the first drainage a wound produces, it is fresh red blood that comes out of the injury when it first occurs) drainage observed on the gauze when LPN #202 cleansed the wound. The wound measured 1.0 cm by 0.3 cm and no depth. LPN #202 said the wound had improved. Interview on 04/07/22 at 1:49 P.M., with the Director of Nursing verified the wound nurse had not seen Resident#19 since 02/01/22 and no wound measurements or description of the wound had been documented by the staff since 03/08/22. The treatments were completed just not the weekly measurements and assessments of the sacrum wound. Review of facility policy/protocol titled Wound Treatment Management dated 12/01/18 revealed the effectiveness of treatments would be monitored through the ongoing assessment of the wound. Treatment decisions would be based on the characteristics of the wound including but not limited to the size, presence of infection, condition of the tissue in and around the wound bed.

Based on medical record review and staff interview the facility failed to ensure a urine sample for the laboratory test urinalysis was obtained in a timely manner. This affected one resident (#30) of one resident reviewed for urinary tract infection ([CONDITION(S)]). The facility census was 47. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition. The assessment revealed the resident utilized an indwelling urinary catheter. Review of a progress noted dated 03/29/22 at 5:31 P.M. revealed Resident #30 was noted to be acting different. The residents urine was assessed brown in color. A new order from the nurse practitioner was received to obtain urinalysis. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #30 revealed the medical record contained no evidence of an attempt to obtain a urine sample for urinalysis on 03/29/22 or 03/30/22. Review of a laboratory test, specimen collection date 03/31/22 revealed a urine sample was collected for Resident #30 on 03/31/22. The abnormal results were reported to the facility on [DATE]. Interview on 04/07/22 at 11:20 A.M., with the Director of Nursing (DON) revealed it was the DON's expectation that a urinalysis, ordered for a resident with an indwelling urinary catheter, would be collected the same day of the urinalysis order unless specified otherwise in the order. The DON verified Resident #30 utilized an indwelling urinary catheter. The DON verified a urinalysis was ordered for Resident #30 on 03/29/22 and the urine sample was not collected until 03/31/22.

Based on medical record review and staff interview the facility failed to notify the primary care provider (PCP) of urinalysis culture and sensitivity results. This affected one resident (#30) one resident reviewed for urinary tract infection. The census was 47. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition. The assessment revealed the resident utilized an indwelling urinary catheter. Review of a laboratory test reported 03/13/22 revealed Resident #30 had abnormal urinalysis results. A culture and sensitivity was indicated. The organisms identified were Escherichia coli growth was greater than 100,000 colony forming unit (CFU) per milliliter (ml) and enterococcus faecalis 60-70,000 CFU/ml. Review of the sensitivity report revealed the organism Escherichia coli was resistant to [MEDICATION(S)] (an antibiotic). There was no sensitivity listed for [MEDICATION(S)] related to the enterococcus faecalis. Review of a progress note dated 03/13/22 9:36 P.M. revealed a new order was received for the antibiotic [MEDICATION(S)] DS (double strength) 800 milligram (mg) -160 mg by mouth twice a day for 10 days due to urinary tract infection. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 03/14/22, revealed Resident #30 was on antibiotic therapy ([MEDICATION(S)] DS) related to infection ([CONDITION(S)]). Interventions include report pertinent laboratory results to the medical doctor (MD). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #30 as ordered for 10 days. Review of the medical record for Resident #30 revealed there was no evidence of the PCP being notified of the culture and sensitivity results for the urinalysis or of the PCP being notified of the [MEDICATION(S)] resistance. Interview on 04/07/22 at 11:20 A.M., with the Director of Nursing (DON) verified Resident #30 was ordered [MEDICATION(S)] to treat a urinary tract infection ([CONDITION(S)]). The DON further verified according to the culture and sensitivity results the [CONDITION(S)] was resistant to [MEDICATION(S)]. The DON did not know if the PCP was notified of the culture and sensitivity results. Interview on 04/07/22 at 11:30 A.M., with the Nurse Practitioner (NP) #600 revealed the NP was the provider who ordered the antibiotic [MEDICATION(S)] for Resident #30 for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP #600 revealed the order for the [MEDICATION(S)] was given prior to the culture and sensitivity results. The NP #600 revealed the facility staff had not notified the NP of the culture and sensitivity results. If the NP #600 would have been made aware of the culture and sensitivity results then the [MEDICATION(S)] would have been discontinued and a different antibiotic would have been ordered.

Based on medical record review, observation, staff interview, and policy review the facility failed to ensure proper infection control protocols in regards to equipment used to provide supplemental oxygen. This affected one resident (#36) out of four residents reviewed for supplemental oxygen use. The facility census was 47. Findings include: Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Minimum Dat Set (MDS) comprehensive assessment dated [DATE] revealed Resident #36 had impaired cognition and did not require supplemental oxygen. Review of Resident #36's physician orders dated 03/12/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/05/22 at 9:15 A.M., Resident #36 was sitting in her room in the recliner. Resident #36 appeared to be pleasantly confused. Resident #36's oxygen nasal cannula was observed coiled up laying on the floor next to the resident's recliner and the air concentrator was on. The nasal cannula was undated and there was no label noted on the tubing. Interview and observation on 04/05/22 at 9:20 A.M. with State tested Nursing Assistant (STNA) #305 verified Resident #36 wore her oxygen nasal cannula continuously. STNA #305 verified there was no dated label on the oxygen tubing and the tubing was laying on the floor during the observation. STNA #305 was observed picking up the nasal cannula from the floor and reapplying it to Resident #36's face. Interview on 04/07/22 at 9:50 A.M., with the Director of Nursing (DON) verified if a nasal cannula was observed on the floor the aide should report to the nurse for a new clean cannula. Review of the facility policy titled, Oxygen Administration dated 08/01/2019 revealed oxygen is to be administered consistent with professional standards of practice, comprehensive care plans, and with the resident's goals and preferences. Per the policy re-usable and non-reusable equipment for the supplemental oxygen should be used by the staff per standards of practice.

Based on medical record review, staff interview, review of the infection surveillance documentation and policy review the facility failed to implement antibiotic stewardship protocols to ensure appropriate antibiotic use. This affected one resident (#30) of one resident review for urinary tract infection. The census was 47. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition. The assessment revealed the resident utilized an indwelling urinary catheter. Review of a laboratory test reported 03/13/22 revealed Resident #30 had abnormal urinalysis results. A culture and sensitivity was indicated. The organisms identified were Escherichia coli growth was greater than 100,000 colony forming unit (CFU) per milliliter (ml) and enterococcus faecalis 60-70,000 CFU/ml. Review of the sensitivity report revealed the organism Escherichia coli was resistant to [MEDICATION(S)]. There was no sensitivity listed for [MEDICATION(S)] related to the enterococcus faecalis. Review of a progress note dated 03/13/22 9:36 P.M. revealed a new order was received for the antibiotic [MEDICATION(S)] DS (double strength) 800 milligram (mg) -160 mg by mouth twice a day for 10 days due to urinary tract infection. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 03/14/22, revealed Resident #30 was on antibiotic therapy ([MEDICATION(S)] DS) related to infection ([CONDITION(S)]). Interventions include report pertinent lab results to the medical doctor (MD). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #30 as ordered for 10 days. Review of the medical record for Resident #30 revealed there was no evidence of the PCP being notified of the culture and sensitivity results for the urinalysis or of the PCP being notified of the [MEDICATION(S)] resistance. Review of infection surveillance documentation dated 03/13/22 revealed Resident #30 was evaluated for a [CONDITION(S)]. The criteria with indwelling catheter was purulent discharge from around the catheter or acute pain and urinary catheter specimen culture with greater than or equal to 100,000 CFU/ml of any organism. Documentation revealed [MEDICATION(S)] DS 800-160 mg one tablet oral for 10 days was ordered. The urinalysis results including culture and sensitivity report date 03/13/22 was attached. The document reported [CONDITION(S)] evaluated with criteria met. Interview on 04/07/22 at 11:20 A.M., with the Director of Nursing (DON) verified Resident #30 was ordered [MEDICATION(S)] to treat a urinary tract infection ([CONDITION(S)]). The DON further verified, according to the culture and sensitivity results the [CONDITION(S)] was resistant to [MEDICATION(S)]. The DON did not know if the PCP was notified of the culture and sensitivity results. Interview on 04/07/22 at 11:30 A.M., with the Nurse Practitioner (NP) #600 was the provider who ordered the antibiotic [MEDICATION(S)] for Resident #30 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP #600 revealed the order for the [MEDICATION(S)] was given prior to the culture and sensitivity results. The NP #600 revealed the facility had not notified the NP of the culture and sensitivity results. If notification would have been made of the culture and sensitivity results then the [MEDICATION(S)] would have been discontinued and a different antibiotic would have been ordered. Review of a policy titled, Antibiotic Stewardship Program dated 12/18, revealed it is the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed, whenever possible, narrow spectrum antibiotics that are appropriate for the condition being treated shall be utilized. Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness.

Based on resident record review and staff interviews, the facility failed to ensure the medical record contained the documentation of medical treatments on the treatment administration record (TAR) or any where else in the medical record. This affected four (#2, #3, #4, and #5) of four resident records reviews for treatment administration. The census was 32. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. Review of the TAR dated 02/21 revealed lack of documentation on 02/02/21 and 02/05/21 for a wound treatment, lack of documentation on 02/09/21 for a laboratory test, lack of documentation on 02/05/21, 02/06/21, and 02/09/21 for the completion of catheter care, barrier cream, antifungal powder, and turn/repositioning. The medical record contained no other documentation to state the treatments had been completed and documented somewhere else in the record. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. Review of the TAR dated 02/21 revealed lack of documentation on 02/05/21 for the application of barrier cream, lack of documentation on 02/05/21, 02/06/21, and 02/09/21 for the application of heel protectors. The medical record contained no other documentation to state the treatments had been completed and documented somewhere else in the record. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. Review of the TAR dated 02/21 revealed lack of documentation on 02/05/21 for treatments such as wound care and application of house lotion for dry skin. On 02/05/21, 02/06/21, and 02/09/21 there was lack of documentation for treatments such as encouragement to offload heels and pain assessment. The medical record contained no other documentation to state the treatments had been completed and documented somewhere else in the record. Review of the medical record for Resident #5 revealed the resident was admitted to the facility on [DATE]. Review of the TAR dated 02/21 revealed lack of documentation 02/06/21 and 02/09/21 to offer a snack a bedtime for supplement and lack of documentation on the 02/06/21, 02/08/21, and 02/09/21 for catheter care. The medical record contained no other documentation to state the treatments had been completed and documented somewhere else in the record. Interview on 02/11/21 at 10:18 A.M., via telephone, with the Administrator verified the resident's TAR's and medical records were still missing documentation for completion of treatment. This is an incidentail finding discovered during the investigtion of the complaint surveys.

Based on record review and staff interview, the facility failed to provide one resident, (#98), with sufficient fluids. This resulted in harm for Resident #98 due to hospitalization for profound dehydration. Five residents were reviewed for pressure ulcers. The facility denied having any other residents with dehydration. The facility census was 66. Findings included: Record review revealed Resident #98 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had short and long term memory impairment, and was seriously impaired in decision making skills. The resident did not reject care. He required total care of two staff for bed mobility, transfers, dressing, and hygiene. He required total care of one staff for locomotion and toilet use. He required limited assistance of one staff for eating. The MDS also revealed the resident was incontinent of urine and stool. He was 65 inches tall and weighed 202 pounds. The resident was identified as being at risk for pressure ulcers and had four unstageable areas acquired in house. The resident received antipsychotic and antianxiety medications. The Inter-Facility Physician order [REDACTED]. The results were to be called to the primary care physician. The test was completed as ordered and the results included chloride and the BUN/Creatinine levels were slightly increased. The BUN was elevated at 32 with the normal range being 1-24 mg/dL. There was no documentation to indicate the attending physician was notified of the abnormal lab levels. Review of the initial nutritional assessment completed by the Registered Licensed Dietician (RLD #1) on 01/17/13, revealed the resident had lost 18 pounds while in the hospital. Based on the resident's current weight of 202 pounds, his estimated fluid needs were 2754 ml/day. The resident was on a no added salt diet. He fed himself with set up and assistance. The RLD #1 documented that the resident's skin appeared hydrated. The RLD #1 also addressed the elevated BUN (blood urea nitrogen) that was completed on 01/09/13. Blood Urea Nitrogen (BUN) laboratory study measures the amount of urea nitrogen, a waste product of protein metabolism, in the blood. Urea is formed by the liver and carried by the blood to the kidneys for excretion. Because urea is cleared from the bloodstream by the kidneys, a test measuring how much urea nitrogen remains in the blood can be used as a test of renal function. An elevated BUN may be caused by: impaired renal function, [MEDICAL CONDITION] as a result of poor renal perfusion, dehydration, shock, hemorrhage into the gastrointestinal tract, acute [MEDICAL CONDITION] infarction, stress, and excessive protein intake or protein catabolism. A patient who is severely dehydrated may also have a high BUN due to the lack of fluid volume to excrete waste products. The assessment also indicated the resident was offered and encouraged at, and between meal, fluids to assure adequate hydration. The resident's nutritional and hydration status would be monitored. The Plan of Care for Nutrition/Hydration, initiated on 01/17/13, revealed the resident was at risk for dehydration due to [MEDICAL CONDITION], diuretic therapy, and an elevated BUN. The goal was the hydration needs would be adequate to promote comfort, labs would be within normal limits, and skin would be intact. Review of the daily Intake and Output records for the duration of the resident's admission beginning 01/08/13, revealed his daily intake totals were as follows: 1200, 260, 120, 600, 600, 0, 360, 960, 600, 840, 360, 240, 240, 1090, 840 and 480. This averaged out to 549 cc/day, well below the 2754 cc/day recommended by the RLD. There is no documentation stating the resident was taking fluids poorly. A Comprehensive Metabolic Profile completed 01/24/13, revealed the following lab values outside of the normal limits: Sodium - 164 (normal 135-145), Chloride - 127 (normal 96-110), BUN - 61 (normal 1-24), Creatinine 1.8 (normal 0.6-1.3), Calcium - 11.1 (normal 8.4-10.2), Alkaline Phos - 142 (normal 34-136), AST - 54 (normal 4-40), and ALT - 97 (normal 4-55). The specimen was collected on Thursday, 01/24/13 at 4:40 A.M. and it was reported to the facility on [DATE] at 12:51 P.M. The lab report had a fax stamp which indicated the report was faxed to the physician on Friday 01/25/13 at 5:57 A.M. The nursing notes were silent as to when the physician actually received notice of the critical level lab values. The physician noted the labs and wrote on the lab sheet to repeat the labs on the following Monday (no date given) and to increase fluids. On 01/27/13 at 5:00 P.M. an order was received to start an IV now for one bag of fluid and one more as needed. On 01/27/13 at 6:00 P.M. a new order was received to send the resident to the hospital for evaluation and treatment. The resident was sent to the emergency roiagnom on [DATE]. The Chief Complaint was increased lethargy. Per the emergency room report the patient presented with a history of advanced dementia who was lethargic with blood in his mouth and foam coming out of his penis. An IV was placed in the patient and labs were drawn. The resident's BUN level was elevated at 61 (normal 1-24) and with an elevated Creatinine of 2.2 (normal 0.6-1.3). His sodium was critically high at 171 (normal 135-145) and his chloride was also critically high at 134 (normal 96-110) . The physician's impression was a urinary tract infection, severe [MEDICAL CONDITION] and dehydration. His assessment and plan was profound dehydration with [MEDICAL CONDITION]. His prognosis was "I have discussed the case with the patient's daughter. I have informed her that his prognosis is exceedingly poor at this point and he is not expected to survive the hospitalization ." Interviews with State tested Nursing Assistants (STNAs) #14 and #39 on 04/05/13 at 1:00 P.M., revealed they had not experienced difficulty giving fluids to the resident. The STNA's stated that the resident did not eat well but he usually did take fluids. An interview with the Diet Tech on 04/05/13 at 1:15 P.M., revealed she assessed the resident on 01/24/13 and noted the resident's intakes. At that time she recommended Med Pass, a supplement, to be started. She stated that she ordered the Med Pass because the nurses administered it and she could be sure he was receiving it. An interview with the Director of Nursing (DON) on 04/05/13 at 1:30 P.M. revealed she did not know if and when the Physician had been notified of the abnormal lab values received on 01/09/13 and on 01/24/13. At 5:00 P.M. she stated that there was no documentation that the Physician had been notified and she was unable to state that he had been notified.