Every finding on record at Hampton Woods Nursing Center, Inc

Based on record reviews, self-reported incident (SRI) review, facility policy review and interview, the facility failed to prevent the tampering with and possible diversion of resident liquid morphine. This failure had the potential to affect three residents (#18, #32, and #36) who were receiving morphine at the time of the incident of three residents reviewed for abuse, neglect and misappropriation. The facility census was 60.Findings include:1. A review of medical records for Resident #18 revealed a date of admission of 08/16/21. Significant diagnoses included senile degeneration of the brain and end stage heart failure. The resident was admitted to hospice care with a diagnosis of congestive heart failure (CHF) on 05/19/21. Resident #18 had physician's orders for Acetaminophen 650 milligrams (analgesic) by mouth every four hours as needed for pain, Morphine sulfate 20 milligrams per milliliter (opioid pain medication), give 0.5 milliliters by mouth every four hours as needed for pain and give 0.5 milliliters my mouth every four hours as needed for air hunger.A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating moderate cognitive impairment. Section J of the assessment revealed no scheduled or as needed pain medications had been administered in the previous seven day look back period.A care plan dated 03/19/26 revealed Resident #18 was at risk for increased pain. Interventions included pain medication per doctor's order. The care plan also revealed Resident #18 had a terminal diagnosis of end stage heart failure. Interventions included assessing pain and administering pain medication as ordered.Pain assessments that were completed daily on Resident #18 were reviewed from 02/01/26 through 04/06/28 and revealed scores of zero indicating no pain.A review of the medication administration record (MAR) from 02/01/26 through 04/06/26 revealed no morphine had been administered to Resident #18.2. A review of medical records for Resident #32 revealed a date of admission of 03/15/25. Significant diagnoses included cerebral infarction, dysphasia, and anxiety. The resident was admitted to hospice care on 04/01/2. Resident #32 had a physician's order for Morphine sulfate oral solution 20 milligrams per milliliter, give 0.25 milliliters by mouth every two hours as needed for shortness of breath or pain dated 12/05/25. A review of the quarterly MDS 3.0 assessment dated [DATE] revealed BIMS score of four out of 15, indicating severe cognitive impairment. Section J of the assessment revealed no scheduled pain medications or as needed pain medications were taken in the previous seven day look back. The assessment also indicated there was no pain present.A care plan dated 03/16/26 revealed Resident #32 had a terminal diagnosis of cerebral infarction. Interventions included assessing pain and administering pain medication as ordered.Pain assessments that were completed daily on Resident #32 were reviewed from 02/01/26 through 04/06/28 and revealed scores of zero indicating no pain.A review of the MAR from 02/01/26 through 04/06/26 revealed that one dose of morphine was administered to Resident #32 on 03/04/26 with good effect.3. A review of medical records for Resident #36 revealed the date of admission as 04/17/24. Significant diagnoses included arteriosclerosis of unspecified type of bypass graph of the extremities with gangrene, peripheral vascular disease, in chronic kidney disease (CKD) Stage IV. Resident #36 was admitted to hospice care on 12/12/25. Resident #36 had a physician's order for morphine sulfate oral solution 20 milligrams per milliliter, give 0.25 milliliters by mouth every two hours as needed for pain or shortness of breath. A quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of five out of 15, indicating severe cognitive impairment. The assessment also revealed no routine pain medications were given in the previous seven day look back. Pain was present with the timing listed as rare or not at all.A care plan dated 08 01/08/26 revealed Resident #36 had increased pain risk related to a wound. Interventions included pain medication per doctor's order. The care plan further revealed that Resident #36 had a terminal diagnosis of atherosclerosis with gangrene of the foot. Interventions included assessing pain and administering pain medication as ordered.Pain assessments that were completed daily on Resident #36 were reviewed from 02/01/26 through 04/06/28 and revealed scores of zero indicating no pain.A review of the MAR from 02/01/26 through 04/06/26 revealed no morphine was administered.A review of SRI tracking number 271955 dated 03/11/26 revealed on 03/07/26 at 7:00 P.M. the label on a bottle of morphine appeared to have the appearance of being wet with a smeared medication label. The medication and packaging were dry even though the packaging label looked wet. The bottle was sealed, and the controlled count was correct. On 03/08/26 at 7:00 A.M., the bottle of morphine was the same, and the controlled count was correct. The bottle of morphine remained sealed. On 03/08/26 at 7:00 P.M., the bottle of morphine remained the same; however, there was two to three milliliters of missing morphine from the bottle. The oncoming nurse (Registered Nurse (RN) #500) and the off going nurse (RN #702) signed off that the count as correct. Neither reported the discrepancy. On 03/09/26 at 7:00 A.M., Licensed Practical Nurse (LPN) #202 was the oncoming nurse, and RN #500 was the off going nurse. During the controlled substance count both noted the medication in question was wet, the packaging was wet, the label was smeared, and there was a two to three milliliter discrepancy. The sheet read 15 milliliters and should be in the sealed bottle, and there are only 12 milliliters in the sealed bottle. Both nurses notified administration as soon as possible. Administration secured the bottle and called the pharmacy. The pharmacy stated they would be out to check the bottle for manufacturer malfunction. On 03/10/26 at 7:00 P.M. an unopened bottle of morphine was noted to be unopened and sealed. The bottle was wet. The bottle was noted to contain 12 milliliters of morphine solution and should have contained a full 15 milliliters. The Director of Nursing (DON) was notified and instructed the nurses to place the bottle in sealed bag and place it in the medication room under double lock. On 03/11/26, the pharmacist came out and noted both bottles of morphine had a single puncture hole on the bottom. On 03/16/26 at 7:00 A.M. off going nurse (RN #500) and on coming nurse (LPN #212) discovered a one milliliter discrepancy on a bottle of liquid morphine. LPN #212 notified administration of the discrepancy. The DON and Assistant Director of Nursing (ADON) #112 secured the bottle of morphine into a double locked area. The pharmacist came to the facility and verified the missing one milliliter of morphine. The police were called, and all bottles of morphine were surrendered to the local police department.A review of an undated document titled; Absolute Pharmacy, Facility Theft or Loss Documentation revealed the tampered morphine bottles belonged to Resident #18 and Resident #36.On 04/06/26 at 3:38 P.M. an interview with Police Detective (PD) #702 revealed the three bottles of morphine were taken as evidence. PD #702 stated the bottles were definitely tampered with. PD #702 further stated the incident was an ongoing investigation.A review of the facility policy titled; Abuse, Alleged and/or Actual, Neglect and Misappropriation with the revision date of June 2025 revealed no employee, resident, consultant, staff, volunteer, agency serving the resident, family member, legal guardian, friend or any other individual shall knowingly abuse, mistreat, or neglect any resident of the facility or misuse the residence funds or personal property. The policy further revealed the definition of misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residence belongings or money without the residents' consent.This deficiency represents non-compliance investigated under Complaint Number 2805300.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #63 had an accurate advanced directive on file. This affected one resident (#63) of two residents reviewed for advanced directives. The facility census was 52.Findings include:Review of the medical record revealed Resident #63 was admitted [DATE] with diagnoses of acute kidney failure, muscle weakness, chronic diastolic congestive heart failure, and diabetes mellitus without complications. Review of the physician orders revealed Resident #63 had an order for do not resuscitate comfort care arrest (DNR CCA) which allowed for full medical treatment to be provided up until the point a patients' heart or breathing stops.Review of the Resident Care Card dated 03/04/26 revealed Resident #63 code status was DNR CCA.Further review of the electronic record revealed it did not contain a signed advanced directive, living will, or healthcare power of attorney determining the code status would be DNR CCA. Observation on 03/10/26 at 10:15 A.M. and 03/11/26 at 7:58 A.M. of the paper record at the nurses' station revealed the record did not contain a signed advanced directive, living will, or healthcare power of attorney. Interview on 03/11/25 at 9:39 A.M. with Licensed Practical Nurse (LPN) #436 revealed she was unable to locate any evidence of an advanced directive in Resident #63's record and stated she did ask the resident for his preference for code status, and the resident reported he wanted to be a full code meaning he wanted to receive all possible life-saving resuscitative measures performed if the heart or breathing stopped and would change the physician order to reflect that. Interview on 03/11/26 at 1:12 P.M. with Resident #63 and his daughter revealed Resident #63 had not decided on a code status, and there was no DNR CCA in place. The nurse then provided a DNR form to Resident #63 for review with the understanding he would remain a full code until the DNR form was completed. Review of the Advanced Medical Directives Policy, revised March 2022, revealed individuals had the right to make their own medical decisions.

Based on resident and family interview, staff interview, review of facility medication incident report, record review, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (Resident #9) out of four residents reviewed for medication administration. The facility census was 53.Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/23/25 with diagnoses including hypertension, hypothyroidism, hyperlipidemia, anemia, history of falls and history of fracture of right femur. Review of the facility document titled Medication Incident Report dated 07/14/25 at 10:45 A.M. revealed Registered Nurse (RN) #805 gave Resident #9 the wrong medications during their 9:00 A.M. medication pass. RN #805 did not verify she had the right resident and RN #805 administered the following wrong medications: Amlodipine (treats high blood pressure), Bupropion (antidepressant), Lisinopril (treats high blood pressure), Paxil (antidepressant) and Prednisone (corticosteroid). RN #805 stated in a written statement that she went into the residents' room and stated, I have your medicine and proceeded to give Resident #9 the medications. The statement additionally said when RN #805 attempted to give Resident #9 a Lovenox (blood thinner) shot, Resident #9 stated I have never been given a shot since I have been here, it was at that point RN #805 questioned herself and went out to check the medications and realized she was in the wrong room and administered Resident #9 the wrong medications. Review of Resident #9's progress notes dated 07/14/25 at 3:02 P.M. authored by the previous Director of Nursing #700 revealed at 11:00 A.M. she contacted the Nurse Practitioner and reviewed and discussed Resident #9's morning medications and received a new order to monitor her vital signs every two hours for 12 hours. Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, needed substantial to maximal assist for Activities of Daily Living (ADLs), was independent with eating and required staff assistance with medication administration. An interview on 01/29/26 at 9:20 A.M. with Resident #9 revealed she confirmed in July 2025 she was given the wrong medications. She stated the nurse, who she had never seen before and had not seen since this incident, came in her room and stated, I have your medicine. Resident #9 stated she took the medications, and then when the nurse attempted to give her a shot, she questioned the nurse stating, I have never been given a shot here. The nurse left the room and did not return. Resident #9 stated the DON at the time came in the room later in the afternoon and told her what happened and that she had been given the wrong medications. An interview on 01/29/26 at 12:22 P.M. with Resident #9's family revealed their mother called them in July and stated she was given the wrong medications. She stated this type of incident has not happened since July but was worried it could happen again. An interview on 01/29/26 at 1:10 P.M. with the current Director of Nursing #701 revealed she confirmed RN #805 did give Resident #9 the wrong medications. Review of the facility policy titled Medication Administration last revised July 2025 revealed the individual administering the medications were to verify the resident's identity before giving the resident his/her medications. This deficiency represents non-compliance investigated under Complaint Number 2580337.

Based on record review and interview, the facility failed to timely notify the hospice provider of Resident #62's change in condition, resulting in an unwanted transfer to the Emergency Department (ED). This affected one resident (Resident #62) of three residents reviewed for falls. The facility census was 61. Findings include: Review of the medical record for Resident #62 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included Alzheimer's disease, muscle weakness, altered mental status, hypertension, and congestive heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was severely cognitively impaired. She required supervision for eating, partial to moderate assistance for oral and personal hygiene, substantial to maximum assistance for toileting, dressing, and was dependent for showering. She received hospice services. Review of the nurses' note dated 10/01/24 at 12:53 P.M. revealed Resident #62 was admitted to hospice services. The hospice nurse asked the facility to call hospice anytime the resident had a fall. Review of the nurse's note dated 11/01/24 at 11:15 P.M. revealed Resident #62 was found sitting on the floor just outside her bedroom door. She was assessed for injuries with none found at the time. She was assisted back to her wheelchair and returned to her bed. Resident #62's daughter and physician were notified within approximately 15 minutes of the fall. Review of the nurse's note dated 11/02/24 2:15 A.M. revealed Resident #62 was up in her wheelchair at the nurse's station when she began crying. Resident #62 reported having pain in her left hip. The physician was notified and ordered a transfer to the ED at 2:25 A.M. Resident #62's daughter was notified of the transfer to the ED on 11/02/24 at 3:02 A.M. and hospice was notified of the fall, change on condition, and transfer to the ED on 11/02/24 at 8:10 A.M. Resident #62 was admitted to the hospital for a left hip fracture. Review of the physician's orders for November 2024 revealed the family did not want Resident #62 sent to the ED for any reason, which began on 11/02/24. Interview on 12/03/24 at 1:11 P.M. with the Director of Nursing (DON) confirmed hospice was not notified of the fall or change in condition for Resident #62 in a timely manner. Interview on 12/03/24 at 1:23 P.M. with Hospice Executive Director #206 confirmed they should be notified immediately if a residents' needs changed, or a fall occurred. This deficiency represents noncompliance investigated under Master Complaint Number OH00159686.

Based on observation, staff and resident interviews, and review of facility mealtimes, the facility failed to ensure residents were offered a snack as required when there was greater than 14 hours between dinner and breakfast. This had the potential to affect all residents except for one resident (#44) identified by the facility as receiving nothing by mouth. The facility census was 60. Findings include: Interview on 10/08/24 at 11:52 A.M. with Resident #15 revealed the staff only bring snacks if you ask for them, and he gets hungry some nights. Interview on 10/08/24 at 11:54 A.M. with Resident #16 revealed she gets hungry at night, and the staff don't come around to ask if we want snacks. Observations during dinner time on 10/08/24 revealed Resident #6 received dinner at approximately 5:03 P.M. and breakfast on 10/09/24 at approximately 8:15 A.M., which was approximately 15 hours from dinner to breakfast, Review of undated facility document titled [NAME] Woods Mealtimes revealed there were 15 hours between dinner and breakfast as evidenced by: Breakfast 1. [NAME] unit (400 rooms) 7:30 A.M. 2. Montauk unit (300 room) unit 7:50 A.M. 3. Bridge unit (100 rooms) 8:10 A.M. 4. [NAME] unit (200 rooms) 8:30 A.M. Lunch 1. [NAME] unit 11:30 A.M. 2. Montauk unit 11:50 A.M. 3. Bridge unit 12:10 P.M. 4. [NAME] unit 12:30 P.M. Dinner 1. [NAME] unit 4:30 P.M. 2. Montauk unit 4:50 P.M. 3. Bridge unit 5:10 P.M. 4. [NAME] unit 5:30 P.M. Interview on 10/09/24 at 5:10 A.M. with State tested Nurse Aide (STNA) #703 revealed snacks were upon request. Interview on 10/09/24 at 5:16 A.M. with STNA #672 revealed snacks were upon request. Interview on 10/09/24 at 5:20 A.M. with STNA #703 and STNA #668 revealed snacks were provided upon request. Interview on 10/09/24 at 5:40 A.M. with STNA #705 revealed snacks were provided upon request. Interview on 10/09/24 at 10:12 A.M. with Dietitian #674 confirmed there was greater than 14 hours between dinner and lunch, and all residents were not being offered a substantial snack by staff. She confirmed the residents had not voted to have meals greater than 14 hours. She stated logistically with the kitchen also feeding the assisted living and the rehab unit, it was hard to feed everyone 14 hours or less between dinner and breakfast. She stated residents could receive snacks if they asked for them.

Based on record review and interview, the facility failed to ensure the Tuberculosis (TB) Risk Assessment was completed in an accurate manner. This had the potential to affect all residents who resided in the facility. The facility census was 60. Findings include: Review of the facility provided TB Risk Assessment revealed the assessment was completed on 01/2023. On 10/08/24 at 10:15 A.M. the Administrator was made aware that the TB Risk assessment provided was dated 01/2023 and was asked to provide an updated TB Risk Assessment. Review of updated facility provided TB Risk Assessment revealed a completion date of 01/2024. Interview on 10/08/24 at 11:45 A.M. with the Director of Nursing (DON) revealed the updated TB Risk Assessment was completed on 10/07/24. The DON further stated when she had gone through the state readiness binder to ensure everything was completed, she found that there was not an up-to-date TB Risk Assessment. The DON stated that was when she completed the TB Risk Assessment and dated it as completed 01/2024 when it was actually completed on 10/07/24.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #7 was fed in a dignified manner. This affected one resident (#7) out of five residents in the facility identified as needing physical assistance with meals. The facility census was 60. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Medical diagnoses included wedge compression fracture of unspecified thoracic vertebra, essential primary hypertension, moderate protein calorie malnutrition, malaise, major depressive disorder, and unspecified dementia. Review of the care plan dated 08/26/22 revealed Resident #7 was at risk for dehydration and weight loss related to dementia, malnutrition, mechanically altered diet, history of decreased appetite and not wanting supplements. Interventions included assisting with meals as needed, and encouraging completion of meals and fluids daily. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 required setup or clean up assistance with eating, and was dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, upper body and lower body dressing, and personal hygiene. Resident #7 had an indwelling urinary catheter and was frequently incontinent of bowel. Observation on 10/07/24 from 12:46 P.M. to 1:00 P.M. of the [NAME] Hall dining room revealed one large table with seven residents eating lunch. State tested Nurse Aide (STNA) #660 was observed standing at the table while feeding lunch which consisted of lasagna, green beans, and strawberries with whipped topping to Resident #7. An empty chair was observed behind the staff member against the wall. Interview on 10/07/24 at 1:01 P.M. with STNA #660 confirmed she was standing while feeding Resident #7 and stated she was busy getting other items for residents which was why she wasn't sitting while feeding the resident. Interview on 10/08/24 at 12:14 P.M. with Dietitian #674 confirmed staff should be sitting while feeding residents. Review of the undated facility policy Feeding a Dependent Resident revealed facility staff was to sit at the same level with the resident while assisting with feeding.

Based on record review and interviews, the facility failed to ensure resident Do Not Resuscitate forms were appropriately filled out for Residents #262 and #15. This finding affected two residents (#262 and #15) out of two residents reviewed for advanced directives. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE]. Medical diagnoses included acute kidney failure, calculus of kidney, obstructive and reflux uropathy, cognitive communication deficit, peripheral vascular disease, and occlusion and stenosis of bilateral carotid arteries. Review of Resident #262 physician orders revealed an order that stated Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 09/18/24. Review of Resident #262's care plan dated 09/19/24 revealed the care plan did not include advanced directives. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #262 was severely cognitively impaired. Resident #262 was independent with eating, required setup or clean-up assistance with oral hygiene, partial to moderate assistance with upper body dressing and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on and taking off footwear. Resident #262 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the DNR (Do Not Resuscitate) Comfort Care form with Licensed Practical Nurse (LPN) #644 on 10/08/24 at 2:19 P.M. revealed the form for Resident #262, which was signed by Nurse Practitioner #701 on 09/18/24, revealed neither the box for DNR Comfort Care-Arrest in which all providers would treat patient as any other without a DNR order until the point pf cardiac or respiratory arrest at which point all interventions would cease, and the DNR Comfort Care protocol would be implemented or the box for DNR Comfort Care in which following the DNR protocol would be effective immediately. Interview at the time of observation with LPN #644 confirmed neither box was checked, and she would have to look into the electronic medical record to determine if Resident #262 was a DNR Comfort Care Arrest or DNR Comfort Care. 46195 2. Review of medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included pulmonary embolism (blood clot in lung) without acute cor pulmonale (serious heart condition that develops as a complication of advanced lung disease) , presence of cardiac pacemaker, type two diabetes mellitus with ketoacidosis (complication from having very high blood sugars) without coma, hypo-osmolality (condition of having abnormally low osmolality in the body fluids), hyponatremia (concentration of sodium in blood is abnormally low) , acute ischemic heart disease, and conduction disorder. Review of the physician orders for Resident #15 revealed an order, dated 10/04/24, for DNR Comfort Care. Review of the DNR Comfort Care form for Resident #15, which was signed by the Nurse Practitioner #701 on 10/04/24, revealed neither the box for DNR Comfort Care-Arrest or DNR Comfort Care was checked. Review of the DNR Comfort Care form and interview on 10/08/24 at 2:19 P.M. with LPN #644 revealed LPN #644 confirmed neither box was checked and, she would have to look in the electronic medical record to determine if Resident #15 was a DNR Comfort Care Arrest or DNR Comfort Care.

Based on record review, interview, and review of the facility policy the facility failed to ensure the physician was notified of daily weight gains of two or more pounds in a day or of blood sugar over 300 per physician order. This affected one resident (#23) of one resident reviewed for daily weights and had the potential to affect nine residents (#1, #4, #6, #13, #16, #20, #35, #43, and #47) who had orders for daily weights. This also affected one resident (#27) out of one resident reviewed for blood sugars and had the potential to affect 12 residents (#1, #2, #10, #16, #17, #21, #24, #27, #45, #47, #52, #164) who received blood glucose monitoring. The facility census was 60. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including diabetes, congestive heart failure, chronic kidney disease, and altered mental status. Review of the care plan dated 12/08/23 revealed Resident #27 had diabetes. Interventions included medication as ordered, blood sugar as ordered and monitor for signs of hypoglycemia and hyperglycemia sign and symptoms. Review of the pharmacy recommendation dated 05/16/24 revealed Consultant Pharmacist #900 recommended to change blood sugar notification to the following: if blood sugar was less than 70 or greater than 300 the nurse was to notify the physician and/or nurse practitioner (NP). NP #701 signed the pharmacy recommendation in agreement. Review of the physician orders for August 2024 and September 2024 revealed Resident #27 had the following order to check his blood sugar twice a day due to diabetes and if less than 70 or above 300 notify the physician and/ or NP. Review of the nursing notes dated from 08/01/24 to 09/20/24 revealed there was no documentation the physician or NP was notified regarding elevated blood sugars as ordered by the physician. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had impaired cognition. He received insulin. Review of the August 2024 Medication Administration Record (MAR) revealed there was a physician order that Resident #27's blood sugar was to be checked twice a day, and if the blood sugar was less than 70 and/or greater than 300 the facility was to notify the physician and/or NP. The following revealed the blood sugars were either below or above the recommended parameters and the physician or NP should have been notified: 08/01/24 at 4:00 P.M. it was 326, 08/02/24 at 4:00 P.M. it was 341, 08/03/24 at 6:00 A.M. it was 308, 08/06/24 at 4:00 P.M. it was 331, 08/07/24 at 4:00 P.M. it was 320, 08/08/24 at 4:00 P.M. it was 355, 08/11/24 at 4:00 P.M. it was 359. 08/12/24 at 6:00 A.M. it was 344, 08/12/24 at 4:00 P.M. it was 324, 08/13/24 at 4:00 P.M. it was 340, 08/14/24 at 4:00 P.M. it was 348, 08/15/24 at 4:00 P.M. it was 368, 08/17/24 at 4:00 P.M. it was 355, 08/18/24 at 4:00 P.M. it was 316, 08/19/24 at 4:00 P.M. it was 390, 08/20/24 at 4:00 P.M. it was 304, 08/22/24 at 4:00 P.M. it was 398. 08/25/24 at 4:00 P.M. it was 389, 08/28/24 at 4:00 P.M. it was 308, 08/29/24 at 4:00 P.M. 318, and 08/30/24 at 4:00 P.M. it was 364. Review of the September 2024 MAR revealed there was a physician order that Resident #27's blood sugar was to be checked twice a day and if the blood sugar was less than 70 and/or greater than 300 revealed the facility was to notify the physician and/or NP. The following revealed the blood sugars were either below or above the recommended parameters and the physician or NP should have been notified: 09/02/24 at 4:00 P.M. it was 319, 09/04/24 at 4:00 P.M. it was 360, 09/06/24 at 4:00 P.M. it was 415, 09/08/24 at 4:00 P.M. it was 422, 09/09/24 at 4:00 P.M. 335, 09/10/24 at 6:00 A.M. it was 320, 09/11/24 at 4:00 P.M. it was 320, 09/12/24 at 4:00 P.M. it was 399, 09/14/24 at 4:00 P.M. it was 312, 09/16/24 at 4:00 P.M. it was 380, 09/17/24 at 4:00 P.M. it was 366, and 09/20/24 at 4:00 P.M. it was 326. Interview on 10/08/24 at 2:45 P.M. and 4:20 P.M. with the Director of Nursing (DON) verified Resident #27 had an order to notify the physician and/or NP if his blood sugar was less than 70 or if his blood sugar was above 300. She verified that she had reviewed the August 2024 and September 2024 MARs and the nursing notes, and there was no documentation that the physician was notified when Resident #27's blood sugar was above 300. 47568 2. Review of the medical record revealed Resident #23 had an admitted [DATE]. Medical diagnoses included acute kidney failure, type two diabetes mellitus, essential atrial fibrillation, and acute on chronic systolic congestive heart failure. Review of quarterly MDS assessment 09/04/24 revealed Resident #23 was moderately cognitively impaired. Resident #23 required supervision or touching assistance with eating, substantial to maximal assistance with oral hygiene, and personal hygiene and was dependent on staff for toileting, upper and lower body dressing. Resident #23 was always incontinent of bowel and bladder. Review of the physician orders for Resident #23 revealed an order dated 07/14/24 for daily weights, notify the physician with a two-pound weight gain in one day or a three to five pound weight gain in one week. Review of the documented daily weights for Resident #23 from 07/14/24 to 10/09/24 revealed resident had a daily weight gain of 5.2 pounds (lbs) from 07/24/25 to 07/25/24, 11lb weight gain from 07/27/24 to 07/28/24, 8.4lbs weight gain from 07/30/24 to 07/31/24, 15.6lbs weight gain from 08/11/24 to 08/12/24, 7.7lbs weight gain from 08/18/24 to 08/19/24, 3.8lbs weight gain from 08/30/24 to 09/01/24 and a 4.2lbs weight gain from 09/11/24 to 09/12/24 with no documentation of physician notification. Interview on 10/09/24 at 12:45 P.M. with Registered Nurse (RN) Campus Director of Nursing #700 confirmed there was no documented evidence that the physician was notified of Resident #23's weight gains on 09/12/24, 09/01/24, 08/19/24, 08/11/24, 07/31/24, 07/28/24, and 07/25/24. Review of the facility policy Diagnostic Testing/Condition Change Reporting, Residents dated 11/22 revealed the physician, resident and/or responsible party are notified when the resident's physical, communicative, psychosocial or functional status changes unexpectedly, return of abnormal lab, radiology or other diagnostic test results, the resident is injured or if treatment is significantly altered.

Based on record review, review of the Internet Quality Improvement and Evaluation System (iQIES) Minimum Data Set (MDS) 3.0 Validation Report, staff interview, and facility policy review the facility failed to ensure Resident #19's MDS assessments were submitted in a timely manner. This affected one resident (#19) out of 23 residents reviewed for MDS submission. The facility census was 60. Findings include: Review of medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, depressive disorder, primary osteoarthritis, disorder of thyroid, anxiety disorder, essential hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Review of Resident #19's medical record revealed the 08/11/24 quarterly MDS 3.0 assessment had been completed, but there was no indication it had been submitted to the Centers for Medicare and Medicaid (CMS) as required. Review of the IQIES MDS Final Validation Report submitted on 10/08/24 at 3:49 P.M. revealed Resident #19's quarterly MDS assessment, dated 08/11/24, was submitted to CMS on 10/08/24, which was more than 14 days late. Review of the IQIES MDS Final Validation Report dated 10/08/24 and interview on 10/08/24 at 5:10 P.M. with MDS Coordinator/LPN #621 revealed Resident #19's 08/11/24 MDS assessment was submitted on 10/08/24 and confirmed it had not been submitted within 14 days after the assessment was completed as required. Review of the facility policy titled Minimum Data Set (MDS), dated [DATE], revealed the MDS coordinator would transmit all completed assessments to the appropriate state agency in a timely manner in compliance with federal regulations.

Based on record review, interview, and review of the facility policy, the facility failed to ensure comprehensive care plans reflected advanced directives and indwelling urinary catheter use for Resident #262 and advanced directives and fluid restriction for Resident #15. This affected two residents (#15 and #262) out of 22 residents reviewed for care plans. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE]. Medical diagnoses included acute kidney failure, calculus of kidney, obstructive and reflux uropathy, cognitive communication deficit, peripheral vascular disease, and occlusion and stenosis of bilateral carotid arteries. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #262 was severely cognitively impaired. Resident #262 was independent with eating, required setup or clean-up assistance with oral hygiene, partial to moderate assistance with upper body dressing and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on and taking off footwear. Resident #262 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of Resident #262 physician orders revealed an order that stated Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 09/18/24. Further review revealed an order dated 09/18/24 that revealed Resident #262 had an indwelling urinary (Foley) catheter to closed drain and ensure the Foley catheter bag cover was in place. Review of Resident #262's care plan dated 09/19/24 revealed care plan did not include advanced directives or the use of an indwelling urinary catheter. Interview on 10/10/24 at 8:42 A.M. with MDS Licensed Practical Nurse (LPN) #631 stated that they do not put code statuses in the resident's care plans, confirming Resident #262's care plan did not include his code status. MDS LPN #631 further stated that it was not the facility policy to include code statuses in care plans. Interview on 10/10/24 at 8:49 A.M. with Assistant Director of Nursing (ADON) #626 confirmed Resident #262's care plan did not reflect the use of an indwelling urinary catheter. Review of the facility policy Resident Care Plan dated 05/15 revealed the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consistent with the physician's plan of care. Topics included in care plans but were not limited to problems relating to diagnosis, problems following physician's orders, dietary and nutritional status problems, problems related to preventative care, refusal of care and treatment, problems related to physical deficits and advance directives. 46195 2. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included pulmonary embolism (blood clot in lung)without acute cor pulmonale (serious heart condition that develops as a complication of advanced lung disease), presence of cardiac pacemaker, type two diabetes mellitus with ketoacidosis (complication from having very high blood sugars) without coma, hypo-osmolality (condition of having abnormally low osmolality in the body fluids) and hyponatremia (concentration of sodium in blood is abnormally low), acute ischemic heart disease, and conduction disorder. Review of the physician progress note dated 05/13/24 revealed during Resident #15's hospitalization , she was found to have likely chronic obstructive pulmonary disease (COPD), hyponatremia, and concerns for syndrome of inappropriate antidiuretic hormone (SIADH), a condition where the body makes too much antidiuretic hormone which causes water retention, low sodium levels, and fluid overload which is usually treated with a fluid restriction. Review of Resident #15's physician orders revealed an order dated 05/21/24 for fluid restriction 1,200 milliliters (ml) every day and an order dated 10/04/24 for DNR Comfort Care. Review of Resident #15's quarterly Nutrition assessment dated [DATE] revealed the resident continued on a 1200 ml fluid restriction with no identification on how fluids would be dispersed or tracked. Review of the care plan initiated on 05/13/24 revealed Resident #15's code status was not addressed in the care plan. Review of the nutrition care plan created on 05/13/24 revealed Resident #15 was at risk due to having diagnoses of SIADH and fluid overload, being on a diuretic, a mechanically altered diet, and history of weight loss. Interventions listed did not address the fluid restriction. Interview on 10/09/24 at 10:12 A.M. with Dietitian #674 confirmed Resident #15's care plan did not have an intervention addressing the fluid restriction. Interview on 10/10/24 at 8:42 A.M. with MDS Coordinator/LPN #621 confirmed Resident #15's care plan did not address the resident's code status since the facility did not put code status in the care plan. Review of the facility policy Resident Care Plan dated 05/15 revealed the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consistent with the physician's plan of care. Topics included in care plan but were not limited to problems relating to diagnosis, problems following physician's orders, dietary and nutritional status problems, problems related to preventative care, refusal of care and treatment, problems related to physical deficits and advance directives.

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure Resident #16's medication was not left at bedside unsecured. This affected one resident (#16) out of five residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included local infection of the skin and subcutaneous (under the skin) tissue, atherosclerotic heart disease, type two diabetes, chronic (congestive) heart failure (CHF), chronic kidney disease, permanent atrial fibrillation (irregular heart rhythm), schizoaffective disorder depressive type (involves both schizophrenia and a mood disorder). Review of Resident #16's physician orders reveal an order dated 09/10/24 for Potassium Chloride Extended Release 20 milliequivalent (mEq) give two tablets by mouth three times a day for health maintenance. Observation and Interview on 10/07/24 at 11:13 A.M. revealed there was a medicine cup with a one white pill sitting on Resident #16's overbed table. Interview at the time of observation with Resident #16 revealed the pill in her cup was her potassium. At the time of observation, Licensed Practical Nurse (LPN) #638 was observed at the medication cart in the common area and was asked to come into the resident's room. Observation and interview on 10/07/24 at 11:13 A.M. with LPN #638 confirmed the potassium pill was left at bedside. She stated due to the commotion of trying to find a multivitamin that had fallen and the resident asking to go to the restroom, she forgot to stay to ensure the medication was taken by the resident. Review of the facility policy titled Medication Administration, dated February 2022, revealed all medications would be administered safely and appropriately and medications would be administered only by licensed nursing personnel or by nursing students under the direct supervision of a licensed nursing instructor and or specific unit nurse.

Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to track fluids consumed for Resident #15 as ordered by the physician. This affected one resident (#15) out of one resident reviewed for fluid restriction. The facility identified three residents (#15, #17, and #214) with physician's orders for fluid restrictions. The facility census was 60. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included other pulmonary embolism (blood clot in lung) without acute cor pulmonale (serious heart condition that develops as a complication of advanced lung disease), presence of cardiac pacemaker, type two diabetes mellitus with ketoacidosis (complication from having very high blood sugars) without coma, hypo-osmolality (condition of having abnormally low osmolality in the body fluids) and hyponatremia (concentration of sodium in blood is abnormally low), acute ischemic heart disease, and conduction disorder. Review of the physician progress note dated 05/13/24 revealed during Resident #15's hospitalization she was found to have likely chronic obstructive pulmonary disease (COPD), hyponatremia, and concerns for syndrome of inappropriate antidiuretic hormone (SIADH), a condition where the body makes too much antidiuretic hormone which causes water retention, low sodium levels, and fluid overload which is usually treated with a fluid restriction. Review of the nutrition care plan created on 05/13/24 revealed Resident #15 was at risk due to having diagnoses of SIADH and fluid overload, being on a diuretic, a mechanically altered diet, and history of weight loss. Interventions listed did not address the fluid restriction. Review of Resident #15's physician orders revealed an order dated 05/21/24 for fluid restriction 1,200 milliliters (ml) every day. Review of Resident #15's quarterly nutrition assessment, dated 08/27/24, revealed the resident continued a 1200 ml fluid restriction with no identification on how fluids would be dispersed or tracked. Review of the September 2024 and October 2024 Medication Administration Record (MAR) revealed nurses were acknowledging Resident #15 was on a 1200 ml fluid restriction, but there was documentation in the MAR on how the fluids were being dispersed or how much fluid the resident was consuming daily. Observation on 10/08/24 at 5:41 P.M. revealed Resident #15 received orange Jello with whipped topping for dessert. Interview on 10/08/24 at 5:43 P.M. with Registered Nurse (RN) #640 confirmed Resident #15 received the Jello and stated she shouldn't have received the Jello since she was on a fluid restriction. Interview on 10/09/24 at 9:18 A.M. with State tested Nursing Assistant (STNA) #653 revealed she has never been told what residents are allowed to have while on a fluid restriction, but she would only give one drink with a meal. She stated for residents that had a physician's order for a fluid restriction, it would depend on the type of soup if they were allowed soup, but she knew they couldn't have Jello. She stated she had never been told how much fluid a resident could have with a meal when they were on a fluid restriction. Interview on 10/09/24 at 9:20 A.M. with STNA #655 revealed a paper comes up with the beverage cart tells them what residents were on a fluid restriction and the amount of fluids allowed in a 24 hour period. She stated she was never told how much fluid a resident was allowed when they were on a fluid restriction, but she stated one cup was 800 (ml) (one cup is 240 ml). Interview and observation on 10/09/24 at 10:02 A.M. with Registered Nurse (RN) #640 revealed the fluid restriction was broken down on a form kept on the nurse's cart. The form stated how the fluids would be dispersed when a resident was on a fluid restriction. There was a separate form for each resident on a fluid restriction. Observation of the notebook on the nurse's cart with RN #640, where the fluid restriction forms were kept, revealed there was no form for Resident #15's fluid restriction. Interview at the time of observation with RN #640 confirmed there was no form in the notebook on how fluids would be dispersed for the resident's 1200 ml fluid restriction. He confirmed there was no documentation in the medical record on how much the resident was consuming, and he had no way of knowing how much fluid the resident was consuming. Interview on 10/09/24 at 10:12 A.M. with Dietitian #674 stated there was supposed to be a fluid restriction breakdown on the nurse's cart but confirmed there was no documentation in the medical record on how much fluid was to be consumed for residents on a fluid restriction. Interview on 10/09/24 at 12:00 P.M. with Resident #15 revealed she had never been educated on the fluid restriction. She stated all she knows is that she is allowed to have one drink per meal and some water with her pills. She didn't know how much water she was allowed, and she didn't know what else she should be limiting while being on a fluid restriction. Review of the facility policy titled Fluid Restriction Policy, updated 04/12/16, revealed the purpose of the fluid restriction was to prevent fluid overload in patients at risk and to manage symptoms and improve overall health outcomes. The dietitian or designee would provide breakdown of fluids at med passes and meals. Nursing would then place the breakdown in the treatment book, track daily, and document if not being followed.

Based on observation, record review, and review of the facility policy, the facility failed to ensure masks or pipes for the nebulizer (a machine that turns liquid medication into a fine mist) were covered when not in use for Resident #16 and #35. This affected two residents (#16 and #35) out of three residents reviewed for respiratory care. The facility identified 16 residents (#3, # 9, #10, #16, #20, #35, #39, #42, #44, #45, #50, #163, #164, #214, #215, #263) who used nebulizers. The facility census was 60. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included chronic diastolic (congestive) heart failure (CHF), schizoaffective disorder-depressive type, other disorders of the lung, and depression. Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, required partial/moderate assistance from staff for most activities of daily living, including transfers, and supervision or touch assistance from staff for wheelchair mobility. Review of Resident #16's physician orders revealed an order dated 08/17/24 for one application of albuterol sulfate (a bronchodilator which helps to relax the muscles around the lungs to help improve breathing function) inhalation nebulization solution (2.5 milligram (mg)/three milliliters (ml)) 0.083 percent to be inhaled orally via nebulizer every six hours as needed for shortness of breath. Review of the October 2024 Medication Administration Record (MAR) revealed Resident #16 hadn't received any as needed albuterol sulfate treatments for shortness of breath. Review of the care plan initiated on 09/08/23 revealed Resident #16 had altered respiratory function related to CHF and history of pneumonia. Interventions included oxygen per physician orders, aerosol treatment per physician orders, monitor and report any significant changes to the physician, monitor and report to nurse/physician any signs or symptoms or respiratory distress, changes in breathing, respiratory rate, restlessness, chills, or fever, promote comfortable sleeping position by elevating head of bed as needed. Observation and interview on 10/09/24 at 2:35 P.M. with Registered Nurse (RN) #640 confirmed Resident #16's nebulizer pipe was uncovered and was sitting on the resident's bedside table. He stated it should be covered when not in use and could not answer why it was not covered. 2. Review of the medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, congestive diastolic (congestive) heart failure (CHF), chronic obstructive pulmonary disease (COPD), anxiety disorder, depression, and bipolar disorder. Review of Resident #35's physician orders revealed an order dated 09/24/24 for three ml to be inhaled four times a day for shortness of breath or wheezing of Ipratropium-Albuterol Inhalation Solution (respiratory inhalant combination) 0.5-2.5(3) mg/3 ml. Review of the October 2024 MAR for Resident #35 revealed Resident #35 received Ipratropium-Albuterol inhalation solution via a nebulizer machine three to four times a day. Review of the quarterly MDS dated [DATE] revealed Resident #35 was moderately impaired cognitively, required substantial/maximum staff assistance for personal hygiene, chair to bed transfer, and mobility of her wheelchair, was dependent on staff for toileting hygiene, shower/bathe self, and shower transfers. Review of the care plan initiated on 09/08/23 which indicated Resident #35 had altered respiratory function related to CHF and COPD. Interventions included oxygen per physician orders, aerosol treatment per physician orders, monitor and report any significant changes to the physician, monitor and report to nurse/physician any signs or symptoms or respiratory distress, changes in breathing, respiratory rate, restlessness, chills, or fever, promote comfortable sleeping position by elevating head of bed as needed. Observation and interview on 10/09/24 at 2:35 P.M. with RN #640 confirmed Resident #35's nebulizer mask was uncovered and was sitting on the resident's bedside table. He stated it should be covered when not in use and could not answer why it was not covered. Interview on 10/09/24 at 2:41 P.M. with Admission/Infection Control RN #627 confirmed nebulizer pipes and masks should be rinsed, air dried after use, and then covered. Review of the facility policy titled Oral and Nasal Inhalations Administration Procedure effective dated 06/02/15 revealed before the next treatment, dissemble and clean the medicine chamber, adapter, mouthpiece or mask, and lid with soap and water, rinse thoroughly. Lay all pieces on a towel: cover with towel and air dry. Store in a clean plastic bag.

Based on interviews, observation, record review, review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during high contact resident care. This affected three residents (#54, #164, and #262) out of five residents observed for EBP. This had the potential to affect 22 residents (#1, #2, #3, #4, #7, #16, #21, #22, #27, #33, #37, #42, #44, #46, #54, #162, #164, #212, #214, #213, #262, and #264) who had orders for enhanced barriers. The facility census was 60. Findings included: 1. Review of the medical record for Resident #164 revealed an admitted [DATE] with diagnoses including hypertension, neoplasm of the kidney, hydronephrosis (swelling of one or both kidneys due to urine build up), diabetes, neuromuscular dysfunction of the bladder, presence of nephrostomy and percutaneous endoscopic gastrostomy (PEG) tube. Review of the undated care plan revealed Resident #164 had a self-care deficit with activities of daily living (ADL) related to decreased mobility, weakness, and amputation. Interventions included assistance with all bed mobility/transfers and anticipate the resident's needs in a timely manner. Review of the undated care plan revealed Resident #164 was incontinent of bowel and had an indwelling urinary catheter due to neurogenic bladder. Interventions included catheter care per the policy, assess and report any signs of impaired catheter integrity, and monitor and report any signs of infection. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #164 had impaired cognition and was dependent on staff for ADL including: toileting hygiene, dressing, rolling left and right (bed mobility), and transfers. She was always incontinent of bowel and bladder. Review of the October 2024 physician orders revealed Resident #164 had an order to cleanse around her nephrostomy tube insertion site and apply abdominal (ABD) pad with tape every day shift and as needed, hospice care, cleanse around PEG tube with normal saline and apply split sponge gauze every shift, EBP due to PEG tube, and EBP due to nephrostomy tube. Observation on 10/08/24 at 9:51 A.M. revealed Registered Nurse (RN) #800 entered Resident #164's room with her morning medications to administer orally as ordered. There was no signage on Resident #164's door that she was on EBP. After administering her medications, Hospice RN #801 entered the room and they both (RN #800 and Hospice RN #801) donned gloves but no other enhanced barriers including gowns and proceeded to provide high contact care including: rolling Resident #164 left and right as Resident #164 was dependent on staff on bed mobility, provided incontinence care as she was incontinent of bowel movement, and changed her nephrostomy tube dressing to her right lower back. Interview on 10/08/24 at 11:30 A.M. with RN #800 was asked how she determined which residents were on EBP due to no signage on the entry of the doors revealed if a resident had a urinary catheter or open area requiring a dressing then they needed to wear enhanced barriers. She revealed staff went by a purple magnet in the upper corner of the door frame as she pointed to the presence of the magnet to Resident 164's door frame that indicated she was on EBP. She verified she had not donned a gown during Resident #164's high contact care including bed mobility, incontinence care, and changing of her nephrostomy tube dressing because she forgot to. Interview on 10/08/24 at 11:30 A.M. with Hospice RN #801 revealed that when she entered facilities, there was usually a sign on the entry door that indicated they were on any special precautions but verified Resident #164 was to be on EBP, and they should have worn a gown during her care. 2. Review of the medical record for Resident #54 revealed she had an admitted [DATE] with diagnoses including Alzheimer's disease, urinary retention, acute cystitis with hematuria (blood in urine), and rheumatoid arthritis. Review of Medicare five-day MDS assessment dated [DATE] revealed Resident #54 had impaired cognition. She was dependent on staff for ADL, including toileting hygiene, dressing, rolling left and right (bed mobility), and transfers. She was always incontinent with bowel and bladder. Review of the October 2024 physician orders revealed Resident #54 had an order dated 10/07/24 for EBP, indwelling urinary catheter due to obstructive and reflux uropathy and indwelling urinary catheter care twice a day. Review of the care plan dated 10/07/24 revealed Resident #54 had an indwelling urinary catheter due to urinary retention and she was frequently incontinent of bowel. Interventions included catheter care per policy, assess and report any signs of impaired catheter integrity, and monitor and report any signs of infection. Observation on 10/08/24 at 3:51 P.M. of Certified Nursing Assistant (CNA) #649 and CNA #661 revealed they entered Resident #54's room to provide care. There was no signage on the outside of her room that indicated Resident #54 was on EBP. Both performed hand hygiene and donned gloves but no other personal protective equipment (PPE) such as a gown. They proceeded to provide high contact care including indwelling urinary catheter care, turning in bed as she was totally dependent on staff rolling left and right, provided incontinence care as she was incontinent of bowel movement, and assisting Resident #54 out of bed with the use of a mechanical lift to her wheelchair. Interview on 10/08/24 at 4:05 P.M. with CNA #649 and CNA #661 verified they had not worn appropriate PPE including gowns during the above care. CNA #661 stated, oh my goodness, I completely forgot as she revealed there was no sign on the outside of the door to remind staff that a resident was on EBP. CNA #649 revealed staff were to go by the small purple magnet in the corner of the doorframe indicating a resident was on EBP as he pointed to the magnet to the top corner of Resident #54's doorframe. CNA #649 revealed often they get caught up in providing care and forget to look. They verified Resident #54 was to be on EBP as she had an indwelling urinary catheter, and they should have worn gowns during her care. Interview on 10/09/24 at 2:30 P.M. with Admission/ RN/ Infection Control #627 revealed EBP were required for any high contact care including for residents with wounds, indwelling catheter, nephrostomy tubes, intravenous catheters besides peripheral access, and PEG tubes. She revealed all residents on EBP were identified with a purple magnet to the upper corner of the doorframe as the facility was trying to provide dignity and not call attention to residents on EBP as often then there is a stigma as to what was wrong with that person. She verified in the incidents observed that staff should have worn appropriate PPE, including gowns when providing high contact care especially with indwelling urinary catheter care, and nephrostomy tube dressing change. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed EBP were indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). The effective date for implementation of EBP under the guidelines was 04/01/24. Review of the facility policy labeled, Enhanced Barrier Precautions (EBP) dated April 2024 revealed the purpose of the policy was to follow the most current recommendation of the center of the disease control (CDC) and the prevention of transmitting MDRO from one resident to another. The policy revealed EBP would be followed to prevent the transfer of MDRO during high contact care activities for residents. This was applicable to include people with indwelling medical devices including urinary catheters, central vascular lines, tracheostomies, enteral feeding tubes, wound drains, and persons with chronic wounds. 47568 3. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE]. Medical diagnoses included acute kidney failure, calculus of kidney, obstructive and reflux uropathy, cognitive communication deficit, peripheral vascular disease, and occlusion and stenosis of bilateral carotid arteries. Review of the Medicare Five Day MDS assessment dated [DATE] revealed Resident #262 was severely cognitively impaired. Resident #262 was independent with eating, required setup or clean-up assistance with oral hygiene, partial to moderate assistance with upper body dressing and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on and taking off footwear. Resident #262 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of Resident #262's physician orders revealed an order dated 09/19/24 for EBP due to indwelling urinary (Foley) catheter and deep tissue injury (DTI) to the left heel (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). Observation on 10/07/24 at 12:01 P.M. of Resident #262 room revealed no evidence of an EBP sign indicating the need to wear PPE during hands on care. Observation on 10/09/24 1:12 P.M. of indwelling urinary catheter care for Resident #262 revealed State tested Nurse Aide (STNA) #654 and STNA #666 knocked on door, entered resident room, performed hand hygiene and put on clean gloves. STNA #654 and STNA #666 started providing catheter care for Resident #262 with gloves being the only PPE that was worn. Once catheter care was completed, STNA #654 and STNA #666 removed their soiled gloves and performed hand hygiene. Interview on 10/09/24 at 1:20 P.M. with STNA #654 and STNA #666 confirmed the only PPE they used during catheter care was gloves. STNA #654 and STNA #666 confirmed that Resident #262 was in EBP and that they should have also worn gowns during catheter care. Interview on 10/09/24 at 2:30 P.M. with Infection Control Registered Nurse (RN) #627 stated residents who have PEG tubes, surgical wounds, Foley catheters, and peripherally inserted central catheter (PICC) were placed in EBP. Those residents identified as needing EBP get a small purple magnet above their door that identifies that they are in EBP. During care such as catheter care, wound care, turning and repositioning staff would wear designated PPE.

Based on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) review, and facility investigation review the facility failed to prevent an incident of neglect when Resident #42 was not properly assisted with activities of daily living (ADL) including bed mobility, bathing, and incontinence care according to the resident care card to prevent an injury. Actual Harm occurred on 10/27/23 during the 7:00 P.M. to 7:00 A.M. shift when Resident #42, who was dependent on staff for ADLs, including two-person assistance for bed mobility, bathing, and toileting, was found with significant bruising including deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye. The injuries were determined by the facility to be the result of Agency State tested Nursing Assistant (STNA) #611 providing care without another staff member assisting on 10/27/23 during the 7:00 P.M. to 7:00 A.M. shift for the resident including a bed bath, changing all of the resident's bed linen while she was in bed, and providing incontinence care. The resident's injuries were assessed to be consistent with the resident's face being hit against the half side rail of the bed with no other explanation of the injuries provided. This affected one resident (#42) of three residents who were dependent on two staff for their ADL care, including bed mobility. The facility identified 28 residents (#1, #3, #4, #5, #7, #11, #12, #14, #17, #18, #24, #26, #31, #34, #36, #37, #39, #41, #42, #44, #46, #52, #55, #56, #57, #58, #60, and #61) who were dependent on two-staff assistance with bed mobility. The facility census was 62. Findings Include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, psychotic disturbance, and diabetes. Review of the care plan dated 03/10/16 revealed Resident #42 had an ADL self-care performance deficit related to weakness, decreased mobility, and alteration in cognition. Interventions included bed mobility and transfer with staff assistance (refer to resident care card). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Resident #42 rejected care one to three days during the seven-day assessment reference period. She was dependent on staff for ADL, including rolling left and right, transfers, and toileting. She was always incontinent of bowel and bladder. Review of the resident care card dated 10/23/23 revealed Resident #42 was oriented to self only. She required a turn schedule with two-staff assistance with bed mobility, a mechanical lift (a machine that transfers a resident from surface such as wheelchair to bed) with two-staff assistance for transfers, and two-staff assistance with toileting. She was unable to ambulate. She was incontinent of bowel and bladder and was to be checked and changed every two hours. Review of the nursing note dated 10/28/23 at 10:08 A.M. and completed by Registered Nurse (RN) #607 revealed he was notified by staff that Resident #42 had bruising to her facial area. She was assessed and had deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye. She was confused when asked how it happened and stated, it happened outside the school. Nurse Practitioner (NP) #902 was notified and ordered the resident to be sent to the emergency room (ER) for an evaluation. The Administrator and Resident #42's Power of Attorney (POA) were notified. Review of the After Visit Summary dated 10/28/23 revealed Resident #42 was seen by ER Physician #701 due to fall and closed head injury. The summary report revealed a computed tomography (CT) scan was completed of her cervical spine, facial bones, head, and left hip. She also had a chest and pelvis x-ray. All testing was essentially negative, and he recommended no new orders. Review of the nursing note dated 10/28/23 at 11:08 A.M. and completed by RN #607 revealed he received a call from the hospital, and Resident #42 would be returning to the facility as all x-rays and CT scans were negative. Review of the facility SRI tracking number 240643, dated 10/29/23 revealed the Administrator reported (to the State agency) an injury of unknown source for Resident #42. The report indicated on 10/28/23 at 8:40 A.M. STNA #608 and Agency STNA #609 notified RN #607 that Resident #42 had bruising to her face. RN #607 assessed and noted purple/red bruising to her forehead, under both eyes, and surrounding tissue of her left eye. When interviewed, Resident #42 stated, it happened outside of the school. NP #902 was notified and ordered her to be sent to the hospital for evaluation. The SRI revealed all staff were interviewed that worked from 10/27/23 7:00 A.M. to 10/28/23 at 8:40 A.M. The investigation revealed STNA #700 was assigned to Resident #42 on 10/27/23 from 7:00 A.M. to 7:00 P.M. and had not noticed any bruising. The investigation revealed the Administrator interviewed Agency STNA #611, and she had stated she noticed a bump on Resident #42's forehead and her right eye was purple when she provided her with a bed bath on 10/27/23 at 8:20 P.M. without any other staff assistance. Agency STNA #611 revealed STNA #613 was providing Resident #11 (Resident #42's roommate) a bed bath at the same time, but she had not reported the bruising to STNA #613 or RN #612 (nurse on duty) as she stated, I assumed everyone knew. Agency STNA #611 revealed she checked and changed Resident #42 throughout the rest of the night providing her care without any other staff assistance. The facility investigation concluded that it appeared the resident was turned and repositioned by Agency STNA #611 and hit her face on the half upper side rail. The SRI was substantiated, and Agency STNA #611 was not to return to the facility. As an intervention, the facility padded the residents side rails. Observation on 11/16/23 at 8:57 A.M. revealed Resident #42 had bruising of all different colors (yellow, green, blue, light purple, and dark purple) in the middle of her forehead, under and above her bilateral eyes, and on the outside (temple region) of her left eye. Attempts to interview Resident #42 were unsuccessful due to cognitive ability as she was unable to provide any details regarding how the bruises occurred. She denied pain. Interview on 11/16/23 at 2:20 P.M. with RN #607 revealed on 10/28/23 around breakfast time STNA #609 stated Resident #42 had bruising to her face. He revealed he went and assessed, and she had raccoon eyes as she had bright red to dark red to purple bruising to her bilateral eyes, forehead, and on the outside of her left eye (temple region). He stated he felt they were fresh new bruises by the appearance. He revealed he had not received anything in the report and/or seen anything in her medical record regarding the bruising. He contacted NP #902 who ordered the resident to be sent to the emergency room . He revealed there was no way the resident fell as she would have been unable to get back up unless two staff assisted with a mechanical lift as she was heavy as well as dead weight. He revealed the resident was fully dependent on two staff for her ADL care, including bed mobility, bathing, and toileting as she was difficult to roll over. He revealed he did not feel one person could safely provide ADL care to the resident. Interview on 11/16/23 at 2:38 P.M. with STNA #608 revealed she remembered collecting breakfast trays on 10/28/23 with STNA #609 and noticed Resident #42 had two huge black eyes. She revealed she had purple and black bruises all around both eyes (under and above) and on her forehead. She revealed Resident #42 required two-person assistance with her ADL care as she did not assist with rolling over. Interview on 11/16/23 at 2:49 P.M. with Agency STNA #609 revealed on 10/28/23 at approximately 8:40 A.M. when she went in with STNA #608 to change Resident #42, she noticed the resident had bruising all over her face: both eyes, bridge of her nose, and forehead. She stated she asked Resident #42 what had happened, and she stated she fell going to school but was unable to provide any other information. She stated she reported the bruises to RN #607. She revealed she did not believe the resident fell as two staff would have had to assist her up with a mechanical lift as she does not bear any weight. She stated she required two staff to assist with bed mobility and provide incontinence care as she does not roll herself and would be very hard to do alone. Interview on 11/16/23 at 5:26 P.M. with Agency STNA #611 revealed on 10/27/23 she worked 7:00 P.M. to 7:00 A.M. and the aide she was working with (STNA # 613) stated that Resident #42 and her roommate, Resident #11, were scheduled for bed baths. She stated between 7:00 P.M. and 9:00 P.M. they both went into the room at the same time. She stated STNA #613 completed the bed bath for Resident #11, and she completed the bed bath and incontinence care for Resident #42. She revealed the resident required a complete linen change during the bed bath. She verified she did not ask STNA #613 for assistance in providing the care as she completed it by herself. She stated she had never received information in report that Resident #42 required two staff assist with her ADL care and was not aware of the facility had resident care cards indicating the type of care the residents required. She stated during Resident #42's bed bath she had noticed a bruise to the middle of her forehead and underneath one of her eyes (was not sure which eye). She revealed she asked Resident #42 what happened, and she stated, she rolled out of bed. She revealed STNA #613 was on the other side of the room, and she told her about the bruise and what Resident #42 said. She revealed she told a nurse but was not sure of the nurse's name. She revealed the next day a man from the facility (unsure who) contacted her, and she told him that Resident #42 stated she rolled out of bed. She revealed throughout the night she checked and changed Resident #42, and each time she did not have any assistance. Interview on 11/16/23 at 3:33 P.M. with RN #612 revealed she worked on 10/27/23 from 7:00 A.M. to 11:30 P.M. and completed several assessments approximately every four hours on Residents #42 as she had COVID-19. She revealed she last checked her at approximately 9:30 P.M. and that Resident #42 did not have any bruising to her face. She stated Agency STNA #611 never reported to her that Resident #42 had bruising to her forehead and/or her eye. She also never reported that Resident #42 stated that she rolled out of bed. Interview on 11/16/23 at 4:50 P.M. with STNA #613 revealed on 10/27/23 from 4:00 P.M. to 10:00 P.M. Resident #42 and her roommate (Resident #11) were scheduled for bed baths. She stated she and Agency STNA #611 went into the room together, and Agency STNA #611 gave Resident #42 a bed bath at the same time she gave Resident #11 a bed bath. She stated she had not seen Resident #42 as the curtain was pulled, but she did not hear anything that appeared unusual. She stated she did not assist Agency STNA #611 with the bed bath, changing of linens, incontinence care, and/or turning Resident #42. She revealed Agency STNA #611 never told her anything about Resident #42 having bruising to her face and/or the resident stating that she rolled out of bed. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing (DON) verified Resident #42 required two-person assistance with bed mobility, incontinence care, and bed baths. They stated staff were to check the resident care cards for what assistance a resident needed and verified Resident #42's care card stated she required two-staff assistance for the above ADL. They stated through the investigation it was determined beginning the evening of 10/27/23 Agency STNA #611 provided Resident #42 a bed bath, changed her linen, and provided incontinence care without any other staff assistance. They revealed that was the reason they concluded that the bruising to Resident #42's face most likely occurred; from Agency STNA #611 turning the resident into the side rail. They revealed as an intervention they padded the resident's half side rails. They revealed they did not feel Resident #42 fell as she was pretty heavy (her weight was 160 pounds), and she required a mechanical lift with two persons assist to transfer her. They also revealed they believed if she had fallen, she would have had bruises and/or injuries on other parts of her body, not only on her face. They stated Agency STNA #611 also verified throughout the rest of the night that she checked and changed Resident #42 also using only one person assist. Observation on 11/19/23 at 9:25 P.M. revealed Licensed Practical Nurse (LPN) #615 and STNA #617 transferred Resident #42 with a mechanical lift from her wheelchair to her bed to provide incontinence care. Resident #42 was totally dependent on the staff to roll her side to side as she did not assist. They both confirmed that they would not be able to complete her care by themselves as they stated, she was very heavy and fully dependent on care. Interview on 11/19/23 at 10:40 A.M. with Administrator revealed he had contacted Agency STNA #611 on 10/28/23 at approximately 1:00 P.M. as part of the investigation and Agency STNA #611 had stated during the bed bath she had noticed bruising to Resident #42 forehead and small purple mark by her right eye. He revealed he asked her if she reported the bruising, and she stated she had not stating, she assumed everyone knew. He revealed Agency STNA #611 had never told him that Resident #42 had stated she rolled out of bed. Interview on 11/19/23 at 12:58 P.M. with Resident #11 (Resident #42's roommate) revealed she did not know what happened to Resident #42 as she just knew one day her face was all bruised up. She denied seeing or hearing anything. Review of the facility policy labeled Activities of Daily Living, dated June 2015, revealed the purpose of the policy was to provide assistance as necessary. The policy revealed all resident functional status would be assessed and supervised as needed to assist in achieving and maintaining maximum functional ability. Review of the facility policy labeled Abuse, Alleged and/ or Actual, Neglect and Misappropriation, dated September 2016, revealed the purpose of the policy was to assure residents right to be free of verbal, physical, sexual, and mistreatment. The policy stated no employee and/or agency serving the residents would knowing abuse, mistreat, or neglect any resident of the facility. The policy revealed neglect was the reckless failing to provide a resident with treatment, care, goods, or services necessary to maintain the health and safety of the resident when the failure results in serious physical harm to the resident. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00147913.

Based on observation, record review, review of the facility policy and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #14. Actual Harm occurred on 10/03/23 when Resident #14, who was totally dependent on staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his left gluteal (buttock) area. There was no documented evidence of adequate intervention(s) or monitoring to prevent the development of this wound or to ensure the pressure ulcer was identified prior to being unstageable. This affected one resident (#14) of two residents reviewed for pressure ulcers. The facility census was 62. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including osteomyelitis of vertebra sacral region, cerebral infarction, congestive heart failure, and diabetes. Review of the care plan dated 06/29/23 revealed Resident #14 had the potential for and/or actual skin breakdown related to decreased mobility, incontinence, friction, and diabetes. Interventions included keeping the resident's skin clean and dry, positioning him properly using devices such as pillows as needed, pressure reducing device to bed and wheelchair, and preventing skin to skin contact as much as possible. Review of the care plan dated 07/05/23 revealed Resident #14 had a self-care deficit in ADL related to weakness, decreased mobility, and cerebral vascular accident. Interventions included assisting with all transfers, assisting with bed mobility, and anticipating and meeting all needs in a timely manner. Review of the Braden scale for predicting pressure sore risk dated 09/14/23 and completed by Licensed Practical Nurse (LPN) #620 revealed Resident #14 was at risk for developing pressure ulcers because he was chair fast, very limited with mobility, and had a problem with friction and shearing. Review of the resident care card dated 09/14/23 revealed Resident #14 required two-staff assistance and was on a turn schedule for bed mobility, two-staff assistance with a mechanical lift for transfers, and two-staff assistance with toileting. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition. He was totally dependent on two staff with bed mobility, transfers, and toileting. He was unable to ambulate. He was at risk for pressure ulcers. Review of the weekly skin assessment dated [DATE] and completed by Assistant Director of Nursing (ADON)/ LPN/ Wound Nurse #620 revealed no new areas of concern, including Resident #14's left gluteal area. Review of nursing note dated 10/02/23 at 8:03 P.M. and completed by LPN #615 revealed he found a new area on Resident #15's left buttock and compromised tissue on his hip. The note revealed new orders were in place. There was no other description of the wound including stage and/or measurements. Review of the provider consultation dated 10/03/23 revealed Wound Nurse Practitioner (NP) #901 consulted, and Resident #14 had a new pressure wound to his left gluteal area which was in-house acquired. The wound was classified as unstageable and measured 7.0 centimeters (cm) in length by and 11.0 cm in width. The wound had a moderate amount of serosanguinous (thin and watery fluid that is pink in color due to the presence of small amounts of blood) drainage. The wound contained 20 percent (%) slough and 10 percent deep tissue injury (an injury to the soft tissue under the skin due to pressure and was usually over a boney prominence). She ordered a treatment for the area. Review of the skin grid dated 10/03/23 and completed by ADON/ LPN/ Wound Nurse #620 revealed Resident #14's left gluteal area originated as a facility acquired unstageable pressure ulcer on 10/03/23. The wound measured 7.0 cm in length by 11.0 cm in width, and the wound contained slough. Review of the November 2023 physician's orders revealed Resident #14 had an order dated 10/03/23 to cleanse the lower left buttock wound with normal saline, apply Medihoney (promotes a moist wound environment that aids and supports autolytic debridement), calcium alginate (dressing for moderately to heavily draining wounds), and cover with a dressing twice a day and as needed. Review of the skin grid dated 11/14/23 and completed by ADON/ LPN/ Wound Nurse #620 revealed Resident #14's left gluteal unstageable pressure ulcer continued and measured one cm in length, 7.5 cm in width and 0.1 cm in depth. The wound bed contained slough. Review of the provider consultation dated 11/14/23 revealed Wound NP #901 consulted, and the unstageable pressure ulcer was now classified as a Stage three (involved full-thickness skin loss potentially extending into the subcutaneous tissue layer) and measured a 1.0 cm in length by 7.5 cm in width by 0.1 cm in depth. The wound continued to have moderate serosanguinous drainage with 10% percent slough. The wound was debrided to remove the slough at the bedside, and Resident #14 tolerated the procedure well. Interview on 11/19/23 at 10:30 A.M. with the Director of Nursing (DON) and ADON/ LPN/ Wound Nurse #620 revealed Resident #14's wound to his left gluteal area was noted per nursing notes on 10/02/23 by LPN #615 but there was no description including stage and/or measurements of the wound. They verified the first measurements and staging of the wound was on 10/03/23 identified as facility acquired unstageable pressure ulcer that contained 20% slough per Wound NP #901's assessment on 10/03/23. They verified Resident #14 required total dependence from staff for his ADL, including for bed mobility, transfers, and toileting. Observation of the wound care on 11/19/23 at 1:06 P.M. completed by LPN #601 and LPN #615 revealed Resident #14 continued to have a pressure ulcer to his left gluteal area. LPN #615 described the wound as having small amount of white slough to the center of the wound bed with blanchable healthy skin surrounding the wound. The treatment was completed as ordered. Interview on 11/19/23 at 1:29 P.M. with LPN #615 as he was the nurse who first found the wound on 10/02/23 revealed he had to be honest stating, it had been a hot minute since the wound was found and could not recall and/or describe how the wound looked when he found it. He verified he did not include a description, and/or measurements in the nursing notes and/or on another assessment form. Review of the facility policy labeled Pressure Ulcers identification and Suggested Treatment Protocols, dated June 2015, revealed pressure ulcers would be identified and treatments would be ordered for proper healing of the wound. Review of the facility policy labeled Pressure Ulcers, Prevention and Care of, dated June 2015, revealed the purpose of the policy was to prevent impairment in the skin integrity. The protocol would be followed when a resident had a decubitus ulcer or was at high risk for developing an ulcer including care to prevent the alteration in skin integrity in all residents. This deficiency represents non-compliance investigated under Complaint Number OH00147676.

Based on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) review, and facility investigation review the facility failed to ensure an injury of unknown origin resulting in serious bodily injury for Resident #42 was timely reported to the State agency, within two hours and failed to ensure law enforcement was notified. This affected one resident (#42) of one resident reviewed for abuse. The facility census was 62. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, psychotic disturbance, and diabetes. Review of the care plan dated 03/10/16 revealed Resident #42 had an activities of daily living (ADL) self-care performance deficit related to weakness, decreased mobility, and alteration in cognition. Interventions included bed mobility and transfer with staff assistance (refer to resident care card). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Resident #42 rejected care one to three days during the seven-day assessment reference period. She was dependent on staff ADL including rolling left and right, transfers, and toileting. She was always incontinent of bowel and bladder. Review of the resident care card dated 10/23/23 revealed Resident #42 was oriented to self only. She required a turn schedule with two-staff assistance for bed mobility, a mechanical lift with two-staff assistance for transfers, and two-staff assistance with toileting. She was unable to ambulate. She was incontinent of bowel and bladder and was to be checked and changed every two hours. Review of the nursing note dated 10/28/23 at 10:08 A.M. and completed by Registered Nurse (RN) #607 revealed he was notified by staff that Resident #42 had bruising to her facial area. She was assessed and had deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye (temple area). She was confused, and when asked how it happened, she stated, it happened outside the school. Nurse Practitioner (NP) #902 was notified and ordered the resident to be sent to the emergency room (ER) for an evaluation. The Administrator and Resident #42's Power of Attorney (POA) were notified. Review of the after-visit summary from the ER dated 10/28/23 revealed Resident #42 was seen by ER Physician #701 due to fall and closed head injury. The summary report revealed a computed tomography (CT) scan was completed of her cervical spine, facial bones, head, and left hip. She also had a chest and pelvis x-ray. All testing was essentially negative, and he recommended no new orders. Review of facility SRI tracking number 240643 as created on 10/29/23 at 6:05 A.M. for injury of unknown source and submitted by the Administrator revealed on 10/28/23 at 8:40 A.M. State tested Nurse Aide (STNA) #608 and Agency STNA #609 notified RN #607 Resident #42 had bruising to her face. RN #607 assessed the resident and noted purple/red bruising to her forehead, under both eyes, and surrounding tissue of her left eye. When interviewed, Resident #42 stated, it happened outside of the school. NP #902 was notified and ordered her to be sent to the hospital for evaluation. The SRI revealed all staff were interviewed who worked from 10/27/23 7:00 A.M. to 10/28/23 at 8:40 A.M. The investigation revealed STNA #700 was assigned to Resident #42 on 10/27/23 from 7:00 A.M. to 7:00 P.M. and had not noticed any bruising. The investigation revealed the Administrator interviewed Agency STNA #611, and she had stated she noticed a bump on Resident #42's forehead and her right eye was purple when she provided her with a bed bath on 10/27/23 at 8:20 P.M. without any other staff assistance. Agency STNA #611 revealed STNA #613 was providing a bed bath at the same time to Resident #11 (Resident #42's roommate) but had not reported the bruising to STNA #613 or RN #612 (nurse on duty) as she stated, I assumed everyone knew. Agency STNA #611 revealed she checked and changed Resident #42 throughout the rest of the night providing her care without any other staff assistance. The facility investigation concluded that it appeared the resident was turned and repositioned by Agency STNA #611 and hit her face on the half upper side rail. The SRI was substantiated, and Agency STNA #611 was not to return to the facility. As an intervention, Resident #42's top half side rails were padded. The SRI indicated that law enforcement was not notified. Observation on 11/16/23 at 8:57 A.M. revealed Resident #42 had bruising of all different colors (yellow, green, blue, light purple, and dark purple) in the middle of her forehead, under and above her bilateral eyes and on the outside (temple region) of her left eye. Attempts to interview Resident #42 were unsuccessful due to the resident's cognitive ability as she was unable to provide any details regarding how the bruises occurred. She denied pain. Interview on 11/16/23 at 2:20 P.M. with RN #607 revealed on 10/28/23 around breakfast time STNA #609 stated Resident #42 had bruising to her face. He revealed he went and assessed, and she had raccoon eyes as she had bright red to dark red to purple bruising to her bilateral eyes, forehead, and on the outside of her left eye (temple region). He stated he felt they were fresh new bruises by the appearance. He revealed he had not received anything in the report and/or seen anything in her medical record regarding the bruising. He contacted NP #902 who ordered the resident to be sent to the emergency room . He revealed there was no way that she fell as she would have been unable to get back up unless two staff assisted with a mechanical lift as she was heavy as well as dead weight. He revealed she was fully dependent on two staff for her ADL, including bed mobility, bathing, and toileting as she was difficult to roll over. He revealed he did not feel one person could safely provide her ADL. Interview on 11/16/23 at 2:38 P.M. with STNA #608 revealed she remembered collecting breakfast trays on 10/28/23 with STNA #609 and noticed Resident #42 had two huge black eyes. She revealed she had purple and black bruises all around both eyes (under and above) and on her forehead. She revealed Resident #42 required two-person assistance with her ADL as she does not assist with rolling over. Interview on 11/16/23 at 2:49 P.M. with Agency STNA #609 revealed on 10/28/23 at approximately 8:40 A.M. when she went in with STNA #608 to change Resident #42, she noticed the resident had bruising all over her face: both eyes, bridge of her nose, and forehead. She stated she asked Resident #42 what had happened, and she stated she fell going to school but was unable to provide any other information. She stated she reported the bruises to RN #607. She revealed she did not believe she fell as two staff would have had to assist her up with a mechanical lift as she does not bear any weight. She stated she required two staff to assist with bed mobility and provide incontinence care as she does not roll herself and would be very hard to do alone. Interview on 11/16/23 at 5:26 P.M. with Agency STNA #611 revealed on 10/27/23 she worked 7:00 P.M. to 7:00 A.M. and the aide she was working with (STNA # 613) stated that Resident #42 and her roommate, Resident #11, were scheduled for bed baths. She stated at between 7:00 P.M. and 9:00 P.M. they both went into the room at the same time. She stated STNA #613 completed the bed bath for Resident #11, and she completed the bed bath and incontinence care for Resident #42's. She revealed she required a complete linen change during the bed bath. She verified that she did not ask STNA #613 for assistance in providing the care as she completed it by herself. She stated she had never received information in report that Resident #42 required two staff assist with her ADL and was not aware of the facility had resident care cards indicating the type of care the residents required. She stated during Resident #42's bed bath she had noticed a bruise to the middle of her forehead and underneath one of her eyes (was not sure which eye). She revealed she asked Resident #42 what happened, and she stated, she rolled out of bed. She revealed STNA #613 was on the other side of the room, and she told her about the bruise and what Resident #42 said. She revealed she told a nurse but was not sure of the nurse's name. She revealed the next day a man from the facility (unsure who) contacted her, and she told him that Resident #42 stated she rolled out of bed. She revealed throughout the night she checked and changed Resident #42, and each time she did not have any assistance. She denied at any time Resident #42 bumping her head on the side rail during her care. Interview on 11/16/23 at 3:33 P.M. with RN #612 revealed she worked on 10/27/23 from 7:00 A.M. to 11:30 P.M. and completed several assessments approximately every four hours on Residents #42 as she had COVID-19. She revealed she last checked her at approximately 9:30 P.M. and that Resident #42 did not have any bruising to her face. She stated Agency STNA #611 never reported to her that Resident #42 had bruising to her forehead and/or her eye. She also never reported that Resident #42 stated that she rolled out of bed. Interview on 11/16/23 at 4:50 P.M. with STNA #613 revealed on 10/27/23 from 4:00 P.M. to 10:00 P.M. Resident #42 and her roommate (Resident #11) were scheduled for bed baths. She stated she and Agency STNA #611 went into the room together, and Agency STNA #611 gave Resident #42 a bed bath at the same time she gave Resident #11 a bed bath. She stated she had not seen Resident #42 as the curtain was pulled, but she did not hear anything that appeared unusual. She stated she did not assist Agency STNA #611 with the bed bath, changing of linens, incontinence care, and/or turning Resident #42. She revealed Agency STNA #611 never told her anything about Resident #42 having bruising to her face and/or the resident stating that she rolled out of bed. Interview on 11/19/23 at 10:40 A.M. with Administrator revealed he had contacted Agency STNA #611 on 10/28/23 at approximately 1:00 P.M. as part of the investigation and that Agency STNA #611 had stated during the bed bath she had noticed bruising to Resident #42 forehead and small purple mark by her right eye. He revealed he asked her if she reported the bruising and she had stated she had not and she stated she, assumed everyone knew. He revealed Agency STNA #611 had never told him that Resident #42 had stated she rolled out of bed. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing (DON) verified Resident #42 required two-person assistance with bed mobility, incontinence care, and bed baths. They stated staff were to check the resident care cards for what assistance a resident needed and verified Resident #42's care card stated she required two-staff assistance for the above ADL. They stated through the investigation it was determined the evening of 10/27/23 Agency STNA #611 provided Resident #42 a bed bath, changed her linen, and provided incontinence care without any assistance. They revealed that was the reason they concluded that the bruising to Resident #42's face most likely occurred from Agency STNA #611 turning her into the side rail. They revealed as an intervention they padded her half side rails. They revealed they did not feel Resident #42 fell as she was pretty heavy as her weight was 160 pounds, and she required a mechanical lift with two persons assist to transfer her. They also revealed they believed if she had fallen, she would have had bruises and/ or injuries on other parts of her body, not only on her face. They stated Agency STNA #611 also verified throughout the rest of the night that she checked and changed Resident #42 also using only one person assist. They verified they had not reported the incident to the local law enforcement and/or submitted the SRI to the State agency within two hours. Interview on 11/19/23 at 12:58 P.M. with Resident #11 (Resident #42's roommate) revealed she did not know what happened to Resident #42 as she just knew one day her face was all bruised up. She denied seeing or hearing anything. Review of the facility policy labeled Abuse, Alleged and/ or Actual, Neglect and Misappropriation, dated September 2016, revealed the purpose of the policy was to assure residents right to be free of verbal, physical, sexual, and mistreatment. The policy revealed the facility would report to proper authorities as per policy. The policy revealed any injury of unknown origin involving any resident would be investigated as possible abuse. The policy did not include to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury. The policy also did not include instances where an alleged violation of abuse, neglect, misappropriation of resident property and exploitation would be reasonable suspicion of a crime. The policy also did not include in these cases, the facility was obligated to report the reasonable suspicion of a crime to the local law enforcement. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00147913.

Based on interview, record review, and review of the facility policy the facility failed to obtain daily weights as ordered. This affected two residents (#39 and #58) out of three residents reviewed for daily weights. This had the potential to affect eight residents (#7, #13, #16, #19, #25, #39, #48, and #58) who had orders for daily weights. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including congestive heart failure (CHF), diabetes, hypertension, and acute kidney failure. Review of the care plan dated 07/21/23 revealed Resident #39 had an alteration in nutrition related to CHF. Interventions included obtaining a daily weight, monitoring her appetite and weight, and diet as ordered. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition. Her weight was 194 pounds with no weight loss. Review of the October 2023 and November 2023 physician's orders revealed Resident #39 had an order for a daily weight to be completed every night shift due to acute CHF. Review of the October 2023 Treatment Administration Record (TAR) revealed Resident #39 had an order dated 08/31/23 to have a daily weight in the morning and to call the cardiac clinic if there was a five-pound weight gain in one week. The TAR was blank from 10/10/23 to 10/19/23. Review of the weight summary dated from 10/10/23 to 10/19/23 revealed on 10/10/23 Resident #39's weight was 189 pounds and on 10/19/23 her weight was also 189.9 pounds. There were no weights recorded from 10/11/23 to 10/18/23. Review of the nutritional risk assessment dated [DATE] and completed by Dietitian #606 revealed Resident #39 had a diagnosis of CHF and was recently diuresed (an increased excretion of urine by means at times of medication) at the hospital. She was to be weighed daily. Interview on 11/19/23 at 11:35 A.M. with the Director of Nursing (DON) verified Resident #39 had an order for a daily weight to be completed, and there was no documented evidence daily weights were completed from 10/11/23 to 10/18/23. 2. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including atherosclerotic heart disease, hypertension, cerebral infarction, and presence of coronary bypass graft. Review of the after-visit summary from the hospital dated 11/08/23 revealed Resident #58's discharge instructions after open heart surgery included obtain a weight every morning and call the surgeon if a weight gain of three or more pounds overnight or five pounds in a week as this may be a sign of fluid retention. Review of the November 2023 Physician orders revealed Resident #58 had an order dated 11/09/23 for a daily weight to be completed in the morning and notify the physician if weight gain of three pounds in one day. Review of the November 2023 TAR revealed on 11/09/23 Resident #58 had an order to have a daily weight completed in the morning and notify the physician of weight gain of three or more pounds in a day. The TAR revealed on 11/09/23, 11/10/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, and 11/18/23 the TAR was blank. The TAR revealed on 11/10/23 and 11/14/23 the TAR was signed off, but no weight was recorded. The only two weights recorded on the MAR from 11/09/23 to 11/19/23 were on 11/17/23 and his weight was 191.2 and on 11/19/23 his weight was 191.4. Review of the care plan dated 11/09/23 revealed Resident #58 had an alteration in nutrition with diagnoses of coronary artery bypass graft (CABG) (a surgical procedure used to treat coronary heart disease by diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart), and hypertension. Interventions included daily weight, diet as ordered, monitor appetite, and weight and notify physician of significant problems. Review of the nutritional risk assessment dated [DATE] and completed by Dietitian Tech #621 revealed Resident #58 was status post CABG surgical procedure and had an order for a daily weight to be monitored. Review of the weight summary dated from 11/09/23 to 11/19/23 revealed Resident #58 had the following weights completed: 11/09/23 his weight was 189 pounds, 11/14/23 his weight was 191.6, 11/17/23 his weight was 191.2 pounds, and on 11/19/23 his weight was 191.4. He was missing daily weights for 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, and 11/18/23. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #58 had intact cognition. Interview on 11/19/23 at 12:14 P.M. with Resident #58 revealed that he was to be weighed daily due to having recent heart surgery, but sometimes it did not happen as the staff just did not obtain it. Interview on 11/19/23 at 11:35 A.M. with the DON verified Resident #58's weight was not completed daily as ordered as there was no weight completed on the following days: 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, and 11/18/23. Interview on 11/16/23 at 11:28 A.M. with Dietitian #606 revealed that it had been an issue at the facility with daily weights being completed. She stated residents, including Resident #39 and Resident #58, who had orders for daily weights were not obtained as ordered. Review of the undated facility policy labeled Weight and Height Measurements revealed residents were to be weighted on admission and monthly unless otherwise ordered by nursing order or the attending physician when the following conditions existed including renal failure and onset of CHF. This deficiency represents non-compliance investigated under Complaint Number OH0000147676.

Based on interview, observation, record review, and facility policy review the facility failed to ensure Resident #39 was free from significant medication errors. This affected one resident (#39) out of two residents reviewed for insulin administration. This had the potential to affect 15 residents (#12, #13, #14, #16, #17, #23, #27, #29, #31, #35, #39, #43, #46, #48, and #52) with orders for insulin. In addition, the facility did not ensure Resident #39 was not administered two glucagon kits (a subcutaneous injection that worked by triggering the liver to release stored sugar to raise the blood sugar) without a physician order affecting one resident (#39) out of three residents reviewed for medication administration. The facility census was 62. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including diabetes, acute kidney failure, and congestive heart failure (CHF). Review of the care plan dated 07/21/23 revealed Resident #39 had alteration in nutrition due to diabetes. Interventions included diet per order and encourage completion of meals. There was nothing in her care plan related to checking her blood sugars and/or administering her insulin. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition and received seven days of insulin injections. Review of the November 2023 physician's orders revealed Resident #39 had an order for Insulin lispro (a fast-acting insulin that should be given 15 minutes before a meal) 100 units per milliliter (ml) inject six units subcutaneously (SQ) with meals and insulin lispro injection solution inject per sliding scale SQ with meals due to diabetes. Observation on 11/16/23 at 9:04 A.M. revealed Resident #39's breakfast tray was on her bedside table off to the side of the room with a clothing protector over it appearing as she had completed her breakfast. Interview on 11/16/23 at 9:04 A.M. with Private Caregiver #603 in Resident #39's room revealed she comes in every Tuesday and Thursday from 8:00 A.M. to 3:00 P.M. to assist in caring for Resident #39. She revealed Resident #39 received her breakfast tray approximately between 8:30 A.M. to 8:45 A.M. and was finished. She revealed a nurse had not been in to check her blood sugar and/or administer her insulin while she was there. She revealed rarely do the nurses administer her insulin before and/or when she received her tray as this had been a concern as they always come in after she was finished with her meal. Observation of medication administration on 11/16/23 at 9:13 A.M. of Licensed Practical Nurse (LPN) #604 revealed she had taken Resident #39's blood sugar at approximately 8:20 A.M. and it was 220 requiring sliding scale coverage. She revealed she did not administer her insulin (lispro) routine or sliding scale order as the insulin was on the other side in another medication cart and that she needed to retrieve it. She retrieved the insulin and administered insulin lispro six units SQ per her routine order that was scheduled for 8:00 A.M. as well as her insulin lispro per her sliding scale to administer three units for blood sugar between 201 and 225 that was also scheduled at 8:00 A.M. with meals. She administered a total of nine units of lispro insulin to the right side of her abdomen on 11/16/23 at 9:47 A.M. LPN #604 then proceeded to sign off the other medication that she had administered and verified that she had already signed off the lispro insulin as given previously when she had obtained the blood sugar but had not given the insulin. She verified that she had documented a blood sugar check of 207 not 220 as she had previously told this surveyor. She revealed she had obtained her blood sugar twice, once at 8:15 A.M. that was 207 and then she took it again at approximately 8:45 A.M. and at that time her blood sugar was 220. She verified she should not have signed off her insulin as given until after it was given. She also verified that the lispro insulin was given at 9:47 A.M. and that the order was scheduled for 8:00 A.M. and was to be given with meals. She verified she had already completed her breakfast when she administered her insulin. Interview on 11/16/23 at 10:59 A.M. with the Director of Nursing (DON) revealed LPN #604 told her that she had signed off the insulin as being given when she obtained her blood sugar but had not given the insulin. She verified the expectation of the nurse was not to sign off a medication until after the medication was administered. She also verified that Resident #39's insulin lispro was scheduled to be given with meals and this morning was scheduled for 8:00 A.M. She verified that giving the insulin at 9:47 A.M. was not following the physician's order. 2. Review of medical record for Resident #39 revealed an admitted [DATE] with diagnoses including diabetes, acute kidney failure, and CHF. Review of the October 2023 physician's orders and Medication Administration Record (MAR) for October 2023 revealed Resident #39 had an order dated 08/04/23 for glucose oral gel 40 percent give 15 grams by mouth as needed for hypoglycemia. The MAR revealed on 10/27/23 that the glucose oral gel was not signed off as administered as noted as given per the medication incident report and nursing notes. There was no order for Resident #39 to receive a glucagon kit (glucagon injection requiring a physician's order). Review of nursing note dated 10/27/23 at 10:41 P.M. completed by Registered Nurse (RN) #612 revealed Primary Care Physician (PCP) #900 was in to see Resident #39 and requested Resident #39 be sent to the hospital because her blood sugar was 58 despite soda with sugar, orange juice, peanut butter crackers, and the oral glycogen gel was ineffective. There was no mention in the nursing notes that glucagon kits were administered times two. Review of the medication incident report dated 10/27/23 at 10:39 P.M. revealed RN #612 administered glucose oral gel times one dose and when that was ineffective, she administered glucagon kit times two with no order for the doses. She borrowed the glucagon kits from other residents that they were prescribed for. The report revealed RN #612 stated when the glucose oral gel was ineffective, she made an emergency decision to give two glucagon kits despite knowing there was no physician order for the medication. The report revealed PCP #900 was in the facility at the time, but that RN #612 never bothered to get the orders from him to use the glucagon kits. The report revealed the final disposition of the facility investigation was RN #612 was given disciplinary action for working outside her scope of practice and was terminated from her employment. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing revealed on 10/27/23 RN #612 administered Resident #39 two glucagon kits without a physician order. They revealed she used kits that belonged to other residents for Resident #39 and verified she failed to get a physician order despite PCP #900 being in the facility. They verified they terminated her employment as they felt RN #612 worked outside her scope of practice and even if they felt a resident could benefit from a certain medication, they were to call the physician for the order and/or if an emergency ask another nurse for assistance to call. Review of the undated policy labeled Medication Administration revealed the purpose of the policy was to ensure all medications were administered safely. The policy revealed whenever medications were administered the mode, frequency, timing, and route of administration was consistent with the prescription or order. Review of the facility policy labeled Insulin Injection Administration Procedures, dated 06/02/15, revealed the procedure to be followed included: check prescribers' order, compare medication label with medication administration record including medication expiration date, and documented the administration on the MAR including site of administration and dosage given if using sliding scale. This deficiency represents non-compliance investigated under Complaint Number OH00147676.

Based on interview and record review, the facility failed to ensure interventions to prevent falls were in place for Resident #60. Actual harm occurred when the resident sustained [REDACTED]. This affected one of three residents reviewed for falls. The facility census was 59. Findings include. Resident #60 was admitted [DATE] with [DIAGNOSES REDACTED]. The Mayo Clinic defines progressive supranuclear ophthalmoplegia as an uncommon brain disorder that causes serious problems with walking, balance and eye movements. The disorder results from deterioration of cells in areas of the brain that control body movement and thinking. Review of a Minimum Data Set assessment dated [DATE] revealed Resident #60 was unable to walk, required extensive assistance of two staff for bed mobility and transferring, and extensive assistance on and off the toilet. Resident #60 was non-verbal and a Brief Interview for Mental Status (BIMS) was unable to be completed due to cognitive impairment. Review of a Fall Risk assessment dated [DATE] revealed Resident #60 had intermittent confusion. Review of an Investigation Report Record dated 09/15/18 revealed Resident #60 was found on the floor of the dining room. Resident #60 sustained a small abrasion to her forehead. An intervention to add a non-slip fabric to the resident's wheelchair was implemented. Review of an Investigation Report Record dated 09/25/18 revealed Resident #60 was found on her hands and knees on the floor of her bathroom. Resident #60 revealed she was trying to take herself to the bathroom. Resident #60 was on a toileting program at the time of the second fall and able to self propel her wheelchair. Therefore, a new intervention for a clip alarm to her wheelchair was implemented to alert staff of any unassisted transfers. Review of an Investigation Report Record dated 10/10/18 at 8:30 A.M., revealed Resident #60 had a third fall. The investigation revealed State tested Nurse Aide (STNA) #81 assisted Resident #60 into the bathroom and onto the toilet. The same investigation revealed STNA #81 left the resident on the toilet but kept checking on her. When STNA #81 returned, Resident #60 was found lying on her left side on the bathroom floor. Resident #60 sustained a laceration to her left forehead. Resident #60 was transported to the emergency room and received six stitches. An interview was completed with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) / Licensed Practical nurse (LPN) #80, on 11/13/18 at 11:48 A.M. The DON and LPN #80 verified STNA #81 should not have left Resident #60 alone in the bathroom. Review of an Investigation Report Record dated 10/23/18 at 1:00 A.M., revealed Resident #60 had a fourth fall. The investigation revealed Resident #60 was self-propelling her wheelchair into the bathroom. STNA #82 was behind the wheelchair. Resident #60 was having difficulty getting her wheelchair over the threshold to the bathroom. STNA #82 assisted Resident #60. However, STNA #82 did not apply the footrests to the wheelchair prior to putting the wheelchair in motion. Resident #60 dropped her feet causing the chair to halt. Resident #60 fell forward and onto the floor. Resident #60 sustained a bloody nose, laceration to her lip and a laceration to her right eyebrow. Resident #60 was transported to the emergency room and received stitches to her lip and right eyebrow. An interview was completed with the DON and ADON/LPN #80, on 11/13/18 at 11:48 A.M. The DON and LPN #80 verified STNA #82 should have put the footrests on the resident's wheelchair prior to propelling the wheelchair. A policy and procedure to prevent falls was requested. The DON provided a procedure dated 10/2015 to document a resident fall. The DON verified the facility did not have a policy and procedure addressing fall prevention. This deficiency substantiates Complaint Number OH 919.