Every finding on record at Harbor Healthcare of Ironton

Based on observations, record review, and staff interview, the facility failed to ensure a resident received assistance devices to prevent accidents. This affected one resident (#31) of three residents reviewed for falls. The facility census was 115. Findings include:Review of the record for Resident #31 revealed a re-admission date of 01/22/26 and diagnoses including dementia, Alzheimer's disease, and hypertension. A fall risk assessment completed 01/22/26 indicated the resident was at high risk for falls. Review of the plan of care for Resident #31 initiated 11/30/25 (during prior admission) revealed he was at high risk for injury and falls. The goal was for management of risk factors for falling. Interventions included 11/30/25 frequently used items in reach and 02/23/26 call before you fall sign in room. A Minimum Data Set (MDS) assessment completed 04/30/26 documented a brief interview for mental status score of 10, indicating moderately impaired cognition. It stated he was dependent upon staff for transfers. Review of nursing progress notes revealed the following:05/23/26 2:02 P.M.: IDT met to discuss unwitnessed fall that occurred on 05/22/26 at 3:30 A.M. in resident's bedroom. Resident was last observed by staff at approximately 2:30 A.M. asleep in bed. Resident later found on floor beside bed. Resident remains at high risk for falls related to history of previous falls. Intervention initiated for medical provider/pharmacy medication review related to sleep pattern disruption and potential medication contribution to nighttime wakefulness/fall risk. 05/27/26 3:49 P.M.: IDT met to discuss unwitnessed fall on 05/27/26 at 3:30 A.M. in resident's room. Resident was observed to be lying on the floor next to his bed. He was clean and dry. Call light not on. IDT determined resident likely slid out of bed. Replace non-skid material to right side of bed.05/28/26 3:21 P.M.: IDT met to discuss unwitnessed fall on 05/27/26 at 5:15 P.M. in resident's room. Resident was observed lying on the floor next to his bed. IDT determined resident likely slid out of bed. Fall mat to right side of bed added. 06/22/26 7:55 P.M. IDT met to discuss unwitnessed fall on 06/20/26 at 10:00 P.M. in resident's room. Resident was observed to be lying on the floor next to his bed. IDT determined resident likely slid out of bed. Intervention: offer to get up when restless. 06/22/26 8:05 P.M. IDT met to discuss unwitnessed fall on 06/21/26 at 7:00 P.M. in resident's room. Resident was observed to be lying on the floor next to his bed. Resident was last seen sitting in his wheelchair in the hallway. IDT determined resident likely slid out of wheelchair. Intervention: nonskid material to top and bottom of position change alarm. 06/23/26 3:19 P.M. IDT met to discuss witnessed fall on 06/22/26 at 12:10 P.M. in resident's room. Resident was observed to be transferring unassisted. As the nurse approached resident, resident sat himself in the floor before laying back onto the floor in a very slow, controlled, and intentional manner. IDT determined resident sat in the floor when he noticed staff approaching him to provide assistance.06/23/26 3:24 P.M. IDT met to discuss witnessed fall on 06/22/26 at 3:22 P.M. in resident's room. Resident was observed to be transferring unassisted. As social services was alerting nursing for assistance, resident sat himself on the floor. IDT determined resident sat on the floor when he noticed social services requesting assistance with transfer. Resident to be added to restorative for transfers.Observations on 07/21/26 at 2:40 P.M. revealed Resident #31 to be up in a wheelchair in his room. There was a sign on the wall that said: Call before you fall. The resident's call light was tied to the side rail on the other side of the bed from where the resident was sitting (not in reach). On 07/22/26 at 9:13 A.M. and 1:00 P.M. revealed Resident #31 to be in bed. The call light was observed on the floor (not in reach). Interview with Registered Nurse (RN) #198 on 07/22/26 at 1:01 P.M. revealed Resident #31 is able to use his call light to summon assistance from staff. Interview with RN #256 on 07/22/26 at 1:02 P.M. confirmed Resident #31's call light was on the floor beside his bed and was not within reach. She confirmed he had a sign on the wall to call before you fall. Interview with Unit Manager Licensed Practical Nurse #194 on 07/23/26 at 1:45 P.M. confirmed Resident #31 would need to have his call light in reach to call for assistance from staff as stated in the sign to: call before you fall. This deficiency represents non-compliance investigated under Complaint Number 3071922.

Based on observations, record review, staff interview, and policy review, the facility failed to provide pharmacy services to assure the accurate acquiring and administering of all drugs to meet the needs of each resident. This affected two residents (#3, #116) of 11 sampled residents. The facility census was 115. Findings include:1a. Review of the closed medical record for Resident #116 revealed an admission date of 03/19/26 and diagnoses including diabetes, status post fractured left femur, morbid obesity, and acute and chronic respiratory failure. Review of physician's orders revealed an order dated 03/20/26 for Degludec insulin 60 units daily (scheduled for 8:00 A.M.) for diabetes. The resident also had a physician's order 03/27/26 for Oxycodone-Acetaminophen (narcotic pain medication) 10-325 milligrams one tablet every six hours (scheduled at 6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 A.M.) for fractured left femur. Review of nursing progress notes dated 05/16/26 by Licensed Practical Nurse (LPN) #279 revealed the resident was currently out of the Degludec insulin. Review of the medication administration record revealed the Degludec insulin was not given on 05/16/26 at 8:00 A.M. (blood sugar documented as 184 at 8:00 A.M.)However, interview with the Director of Nursing on 07/23/26 at 8:30 A.M. and review of a pharmacy proof of delivery form revealed the Degludec insulin had been delivered by the pharmacy on 05/15/26. The Director of Nursing stated the Decludec insulin should have been available for administration on 05/16/26. Interview with LPN #279 on 07/23/26 at 9:05 A.M. confirmed the Degludec insulin was not available and not given on 05/16/26. She stated the pharmacy had stated it was on back order. 1b. In addition, review of nursing progress notes revealed on 05/18/26 at 5:48 A.M. LPN #212 documented that the Oxycodone pain medication was out of stock. It stated the pharmacy was closed and unavailable to dispense a code for a single dose (from emergency stock). Awaiting arrival from pharmacy or pharmacy to open. Review of the medication administration record for May 2026 revealed the Oxycodone was not given on 05/18/26 at 6:00 A.M. Interview with the Director of Nursing on 07/23/26 at 8:30 A.M. revealed the pharmacy never closes and the nurse should have been able to contact the pharmacy at 6:00 A.M. for a code to get a dose of Oxycodone from the emergency box. She stated she did not know why the facility ran out of the Oxycodone and they should not have ran out. Interview with LPN #212 on 07/23/26 at 9:00 A.M. confirmed there was no Oxycodone available for Resident #116 on 05/18/26 at 6:00 A.M. (last one given at 12:00 A.M. prior). He stated he did not know why the facility ran out of the Oxycodone. He stated he made multiple attempts to call the pharmacy but the number was not working. He stated the resident was not complaining of severe pain at 6:00 A.M. He stated she had a pain level of 1-2 at most. Interview with LPN #279 on 07/23/26 at 9:05 A.M. revealed she came on duty at 6:00 A.M. and replaced LPN #212 on 05/18/26. She stated Resident #116 woke up around 8:00 A.M. and was complaining of pain. She stated she gave the resident her regularly scheduled medication which included gabapentin and aspirin. She stated she then called the pharmacy and the nurse practitioner and was able to give Resident #116 a dose of Oxycodone around 9:00 A.M. The resident then got back on her schedule at 12:00 P.M. She stated the facility should not have ran out of the pain medication. She stated the pharmacy does not contact the facility when a narcotic is re-ordered and there are none left on the prescription. (new prescription would be needed from the physician). She also stated that sometimes when medications are re-ordered, it takes the pharmacy two days to get it to the facility. She also stated there is a delay in getting medications from the pharmacy on weekends. 2. Review of the medical record for Resident #3 revealed an admission date of 03/01/23 and diagnoses including acute and chronic respiratory failure. Review of physician's orders revealed 07/02/26 Acetylcysteine Inhalation solution 10% (a mucus thinning agent used for lung conditions)- 2 milliliters inhale orally in the morning (7:00 A.M.) for congestion related to acute and chronic respiratory failure. There was also an order 07/01/26 for Sodium Chloride inhalation Nebulization Solution 3%- 3 milliliters (used to loosen thick lung mucus) -inhale via nebulizer twice daily (7:00 A.M. and 7:00 P.M.). Observations on 07/22/26 at 8:25 A.M. revealed Registered Nurse #288 to administer medications to Resident #3. She stated that the Acetylcysteine and also the Sodium Chloride treatments were not available to give to Resident #3. She stated the medications had been reordered from the pharmacy 07/20/26 but had not been delivered yet. Review of the medication administration record revealed the Acetylcysteine and Sodium Chloride treatments were marked as not available on 07/22/26 at 7:00 A.M. Interview with the Director of Nursing on 07/23/26 at 10:02 A.M. revealed the pharmacy said they were having a hard time getting the medications but that they would be delivered on 07/23/26. Review of the facility policy dated 2001, revised April 2019, and titled Pharmacy Services Overview revealed the facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Pharmacy services are available to residents 24 hours a day, seven days a week. Residents have sufficient supply of their prescribed medications and receive medications in a timely manner. This deficiency represents non-compliance investigated under Complaint Number 3071922.

Based on observations, record review, staff interview, and policy review, the facility failed to ensure the medication error rate was not greater than 5%. The observed medication error rate was 9% (three errors in 32 opportunities for error). This affected two residents (#3, #92) of four residents observed for medication administration. The facility census was 115. Findings include:1. Observations on 07/22/26 at 8:25 A.M. revealed Registered Nurse (RN) #288 to administer medications to Resident #3. After the medications were given, RN #288 signed off on the medication administration record that Fluticasone (Flonase) nasal spray 50 micrograms was given. However, the observations had revealed that the Fluticasone was not administered with the other medications. Interview with RN #288 on 07/22/26 at 8:35 A.M. confirmed that she had signed off that the Fluticasone nasal spray was administered when it was not. Record review revealed a physician's order 07/02/26 for Fluticasone 50 micrograms one spray in each nostril daily (at 7:00 A.M.) for asthma.In addition, Resident #3 was not observed to receive Lamotrigine 400 milligrams which was scheduled to be given at 7:00 A.M. for Lennox-Gastaut Syndrome (a form of epilepsy). RN#288 stated that she had six pills in the cup to give Resident #3 that included B-complex, vitamin D, Pregabalin, Phenobarbital, diazepam, and Fycompa. Therefore, the Lamotragine could not have been given as documented. Review of the medication administration record revealed RN #288 documented that she had given the Lamotrigine at 7:00 A.M. Review of physician's orders revealed an order dated 07/01/26 for Lamotrigine 400 milligrams twice daily (7:00 A.M. and 7:00 P.M.) for Lennox-Gastaut Syndrome. 2. Observations on 07/22/26 at 8:38 A.M. revealed RN #288 to administer medications to Resident #92. RN #288 was observed to administer Vitamin B-6 50 milligrams. Cyanocobalamin (B12) 500 micrograms was not observed to be given. Record review revealed a physician's order 07/02/26 for Cyanocobalamin 500 micrograms daily at 7:00 A.M. for iron deficiency. There was no physician's order for Resident #92 for Vitamin B-6. Interview with the Director of Nursing on 07/23/26 at 10:05 A.M. confirmed Vitamin B-6 is not the same as Cyanocobalamin (B-12) and should not have been given. Review of the facility policy dated 2001, revised April 2019, and titled Administering Medications revealed medications are administered in accordance with prescriber orders. This deficiency represents non-compliance investigated under Complaint Number 3071922.

Based on medical record review and staff interview, the facility failed to ensure the state Ombudsman's office was notified of resident discharge or transfer from the facility as required. This affected three (Resident #25, #76 and #99 ) of four residents reviewed. The facility census was 102. Findings include: 1. Review of the medical record for Resident #99, revealed an admitted [DATE] and readmitted [DATE]. Diagnoses included but were not limited to infectious gastroenteritis and colitis, difficulty walking, abnormal posture, cerebral infarction and fracture of unspecified part of neck of left femur. Review of the nursing progress notes and resident census record revealed Resident #99 was transferred to the local hospital on 10/05/24 and 11/28/24. Review of the medical record revealed no evidence the state Ombudsman was notified of Resident #99's transfers to the hospital. Interview on 01/28/25 at 1:23 P.M. with the Administrator revealed the Ombudsman was not notified in writing of the transfers to the hospital for the dates of 10/05/24 and 11/28/24 for Resident #99. 34299 2. Review of the medical record for Resident#25 revealed an admitted [DATE] with diagnoses including diabetes mellitus type two, hypertension, congestive heart failure, and liver disease. Review of the nursing progress notes and resident census revealed Resident # 25 was transferred to the local hospital on 09/21/24. Review of the medical record revealed no evidence the state Ombudsman was notified of Resident #25's transfer to the hospital on 09/21/24. Interview on 01/28/25 at 1:23 P.M. with the Administrator revealed the Ombudsman was not notified in writing of the transfer to the hospital on 09/21/24 for Resident #25. 3. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including basal cell carcinoma, peripheral vascular disease, respiratory failure with hypoxia, hepatitis A, kidney failure, and neoplasm of bladder and kidney. Review of the nursing progress notes and resident census revealed Resident #76 was transferred to the local hospital on 06/18/24, 07/22/24 and 07/28/24. Review of the medical record revealed no evidence the state Ombudsman was notified of Resident #76's transfers to the hospital on 06/18/24, 07/22/24 and 07/28/24. Interview on 01/28/25 at 1:23 P.M. with the Administrator revealed the Ombudsman was not notified in writing of the transfers to the hospital on 06/18/24, 07/22/24 and 07/28/24 for Resident #76.

Based on medical record review and staff interview, the facility failed to develop a care plan that addressed dementia care and specific symptoms for depression care. This affected two (Resident #4 and #47) of five reviewed for dementia and depression. Facility census was 102. Findings include: 1. Review of the medical record for Resident #4, revealed an admitted [DATE]. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic polyneuropathy, bipolar disorder, major depressive disorder, dementia, and unspecified dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe self, bed mobility, and transfers. This resident was also assessed to have non-Alzheimer's dementia, depression and bipolar disorder. Review of medical record revealed no plan of care for dementia care for Resident #4. Interview on 01/28/25 at 1:52 PM with Licensed Social Worker (LSW) #30 verified Resident #4 does not have a plan of care for dementia and the resident does have the diagnosis with moments of forgetfulness. 2. Review of the medical record for Resident #47, revealed an admitted [DATE]. Diagnoses included but were not limited to vascular dementia, adult failure to thrive, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 out of 15. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to have depression. Review of the plan of care revised on 02/28/23 revealed Resident #47 has an alteration in mood related to diagnosis of depression with no specific symptoms or behaviors noted. Review of the Patient Health Questionnaire (PHQ 9) dated 12/04/24, that is used to indicate a resident's severity of depression, revealed for Resident #47 to have answered yes to feeling tired or having little energy for a symptom presence. Interview on 01/28/25 at 2:46 P.M. with LSW #30 verified Resident #47 had indicated a symptom of depression of feeling tired or having little energy and it was not indicated on his care plan.

Based on closed medical record review, review of an Against Medical Advice (AMA) form, hospital record review, review of the policy and procedure titled Discharging a Resident without a Physician's Approval policy and interviews with facility staff, Physician #399, a Patriot Emergency Medical Service representative, and an Amedysis Home Health representative, the facility failed to ensure a safe and orderly discharge for Resident #94, who had diagnoses including respiratory failure, protein-calorie malnutrition, osteomyelitis, cerebral infarction, sepsis, COVID-19 and dementia when the resident was discharged to an unsafe home environment on [DATE]. This resulted in Immediate Jeopardy on [DATE] at approximately 1:32 P.M., after the facility originally initiated and then allowed Resident #94 to discharge to a documented unsafe environment indicating the discharge was Against Medical Advice (AMA). Resident #94 had multiple medical conditions that required continual care including multiple skin tears, a Stage IV (full thickness skin loss extending through the fascia) pressure area to her coccyx, a Stage II (partial thickness skin loss) pressure area to her right heel, and antibiotic therapy for treatment of diagnosed cellulitis to her right upper extremity. In addition, Resident #94 was dependent on staff with a two-person, physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene and was dependent on staff with a one-person physical assist for eating and locomotion. The risk for actual harm, injury or death occurred on [DATE] as the facility lacked evidence to support a comprehensive and individualized discharge plan to meet the resident's total nursing and medical needs (i.e. antibiotic therapy, insulin therapy, wound care) at home or evidence the resident was requesting an AMA discharge. Resident #94 had no guardian or power of attorney (POA). The physician was unaware of the discharge at the time it occurred. The facility provided no discharge teaching or preparation for the discharge to the resident or family prior to the resident leaving. Resident #94 expired on [DATE] according to her obituary (published [DATE]). This affected one resident (#94) of three residents reviewed for transfer/discharge. The facility census was 92. On [DATE] at 4:50 P.M. the Administrator, the Director of Nursing (DON), Clinical Nurse Consultant (CNC) #999, and [NAME] President of Clinical Services #998 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide a safe and orderly discharge to home for Resident #94, who was picked up from the facility by medical transport arranged by family members. There was no evidence to support the resident's medical conditions, treatments, or upcoming appointments including any necessary provisions of care were coordinated to ensure the resident's total care needs were met after discharge. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: An AD-Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE]. Members at the meeting included the Administrator (CEO), Director of Nursing (DON), Regional Nurse Consultant, Assistant Director of Nursing, Medical Director via phone, Dietary Manager, Social Service Assistant, Medical Records, MDS Coordinator, Human Resources, Business Office Manager, Assistant Business Office Manager, Admissions Coordinator, Social Services Assistant, Staffing Coordinator, Assistant Dietary Director, Therapy Program Manager, and House Keeping Supervisor. The meeting was held to discuss and review abatement actions regarding the identified concern. On [DATE] the medical records of residents who discharged in the past year were reviewed to identify other residents who had been discharged against medical advice. This audit was completed by the Regional Nurse Consultant with no concerns identified. On [DATE] a new process, Discharge Against Medical Advice was developed and implemented through collaboration between the Administrator, DON, and Clinical Nurse Consultant to guide staff through a discharge Against Medical Advice. On [DATE] a new policy was implemented for Discharges Against Medical Advice. The policy includes: o Requirement to notify attending physician of a request by a resident or his/her representative, for discharge. o If the physician determines that the discharge is medically contraindicated, their determination will be discussed with the resident and/or representative. o If discharge is still desired after discussion, reasons for request, risks of leaving and possible alternatives will be discussed. o If discharge is still chosen, then a Release from Responsibility for Discharge Against Medical Advice form will be completed. o Document circumstances and actions taken in the clinical record. On [DATE] education regarding this policy and use of the accompanying form was initiated on with Licensed Nurses and provided by the Regional Nurse Consultant. Training is being continued with each oncoming shift prior to duty and provided by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or a Clinical Nurse Consultant. No licensed nurse will be permitted to work without training after [DATE]. On [DATE] there were 6 licensed nurses educated with completion of post-test, including 3 agency nurses. On [DATE], all remaining nurses, 14 facility nurses and 3 agency nurses, were educated with post testing completed with the exception of 2 licensed nurses that are currently on medical leave. They will be provided education prior to returning to active duty. All education on [DATE] was provided prior to the start of the nurse's shift. Education material will be added to the orientation process for licensed nurses. A new Discharge Checklist related to Safe Discharge was developed and implemented [DATE] through collaboration between the Administrator, DON, and CNC to guide nurses in completing all tasks associated with a safe discharge. The checklist includes: o Pre-Discharge tasks including o Obtain MD order for discharge. o Inform resident and representative of discharge. o Notify Social Service Director and Dietary Manager of order for discharge. o Obtain orders for home care. o Arrange for home care as ordered. o Schedule follow-up appointments o Notify pharmacy of upcoming discharge o Complete discharge instruction form o Initiate Discharge Summary form. o At Discharge tasks include: o Orders called in or written prescriptions / med list provided (if medications sent home) o Review Discharge instructions with Resident / Resident Representative o Complete Skin assessment and record findings o Obtain Vital Signs and record. o Discontinue IV's if indicated. o Remove wanderguards, Alarms or Safety equipment not accompanying resident at discharge. o Complete Personal Belongings Inventory and obtain signature. o Remove name band if used. o Assist resident to vehicle, if not transported via ambulance o Document in progress note condition at discharge, time left, how transported, who accompanied, instructions provided and any other pertinent discharge information. o Post Discharge Tasks: o Secure any non-electronic resident records, if any, for Medical Records to collect o Place any medications not sent with resident in designated location for return. o Narcotics to be removed from cart by designated individuals to be secured and destroyed in accordance with state guidance. o Pharmacy, Dietary, housekeeping to be notified of discharge o Equipment removed from room. o Name removed from door. o Discharge (D/C) Summary completed. On [DATE] education regarding this form was initiated on with Licensed Nurses and provided by the Regional Nurse Consultant. Training is being continued with each oncoming shift prior to duty and provided by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, or a Clinical Nurse Consultant. No licensed nurse will be permitted to work without training after [DATE]. On [DATE] there were 6 licensed nurses educated with completion of post-test, including 3 agency nurses. On [DATE], all remaining nurses, 14 facility nurses and 3 agency nurses, were educated with post testing completed except for 2 licensed nurses that are currently on medical leave. They will be provided education prior to returning to active duty. All education on [DATE] was provided prior to the start of the nurse's shift. Education material will be added to the orientation process for licensed nurses. A second QAPI meeting was held on [DATE] which included the Administrator (CEO), Director of Nursing, Regional Nurse Consultant, Assistant Director of Nursing, Dietary Manager, Social Service Assistant, Medical Records, MDS Coordinator, Human Resources, Business Office Manager, Assistant Business Office Manager, Admissions Coordinator, Social Services Assistant, Staffing Coordinator, Assistant Dietary Director, Therapy Program Manager, and House Keeping Supervisor, to discuss and review new processes put into place to prevent recurrence of alleged deficient practice. Medical Director participation was conducted via phone following the meeting with approval given for the plan and additional processes On [DATE] the facility conducted a root cause analysis and determined the Social Service Director did not follow established standards of practice. On [DATE] the Regional Nurse Consultant reviewed the medical records of all current residents who admitted for short term stays for information suggesting that the planned discharge location/conditions may be unsafe with no concerns identified. On [DATE] a form was developed to review with resident contemplating a discharge Against Medical Advice requiring review by the resident and or resident representative, acknowledging: o The risks of discharge o The benefits of remaining in the facility o Availability of other Health Care Providers o Release of responsibility for adverse effects resulting from the discharge; including the physician, the facility and its agents or employees The AMA Discharge Information Sheet includes: o Date of Discharge o Destination o Attending physician and phone number o Pharmacy to be used and phone number. o Discharge Medication list to include times, instructions and reason for use o Treatments being provided. o Assistive Devices being used. o Resident education provided o Community Agencies needed and contact numbers (if applicable) o Additional instructions The form was to be signed by the resident or Resident Representative, acknowledging review of information, and understanding. The form was to be signed by the nurse reviewing the information with the resident or Resident Representative. If the resident or resident representative refused to sign the form, after it had been reviewed, it should be noted that the information was provided and reviewed by witnesses. On [DATE] education was provided to the Social Service Director by the Administrator including expectations in the event information is conveyed regarding the appropriateness/safety of the discharge location. Expectations to include immediately communicating concerns to Administrator, any concerns with discharge that may be unsafe so that appropriate investigation and discharge planning can be conducted. Pre-discharge and At-Discharge Sections of the checklist will be reviewed by the nurse on duty to verify that all tasks have been completed prior to discharge. Monitoring of effectiveness of the new measures is achieved by initial completion of post-tests following education to assure comprehension of training, for all licensed nurses who were trained. Following initial education, retesting of 10% of the nurses weekly will be completed x 6 weeks. Testing will be completed by Unit Directors, Staff Development Coordinator, Assistant Director of Nursing, Director of Nursing or Clinical Nurse Consultant. Monitoring of completed checklist for review will be completed during the daily clinical meeting, Monday through Friday X 8 weeks and then 3 X week x 8 weeks, to assure that all tasks have been completed as indicated. This review will be completed by the Unit Directors, Staff Development Coordinator, Assistant Director of Nursing, Director of Nursing. Findings of the reviews will be reported to the facility's Quality Assurance and Assessment Committee. Any abnormalities or concerns identified will be immediately addressed and corrected with re-education as needed. On [DATE] from 11:00 A.M. to 11:20 A.M. interviews with Licensed Practical Nurse (LPN) #180, LPN #640 and LPN #890 revealed each employee had received training related to new policies on Admission, Transfers and Discharges along with proper AMA procedures. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of Resident #94's closed medical record revealed the resident was admitted to the facility on [DATE] and was transported home on [DATE] per emergency medical services. Resident #94 had diagnoses including respiratory failure, protein-calorie malnutrition, osteomyelitis, cerebral infarction, sepsis, COVID-19, arthropathy, gout, and dementia. Review of a hospital admission report, dated [DATE] revealed the resident was admitted with diagnoses including a weak cough, shortness of breath, and hypoxia. The resident was assessed to have bilateral leg contractures, bilateral hand contractures, and a Stage IV sacral wound that required daily dressing changes. The hospital report also noted the resident was alert to self, and unable to determine place or time. The resident was discharged from hospital for short-term (nursing home) placement. Review of the plan of care, dated [DATE] and updated [DATE] after resident's admission, revealed the resident had a discharge plan of care related to knowledge deficit for possible discharge home. Interventions included assistance with obtaining prescriptions, arranging transportation as needed, discuss with resident/representative the amount of assistance needed, evaluate resident's motivation to return to the community, make arrangements regarding community support, and provide contact numbers for community referrals. Review of Social History and Discharge Plan, dated [DATE] revealed the resident was oriented to self and able to answer some historical questions but does not seem aware of her condition or prognosis at the time of admission to the facility. Living arrangements noted the resident was living in her daughter's home, and also noted after this recent hospitalization , the daughter stated the resident has become more care than she can give. Review of a nursing assessment, dated [DATE] at 2:19 P.M. revealed the resident was alert and oriented to person and staff were unable to determine if the resident was alert to time or situation. The resident had short term memory impairment and impaired decision-making abilities. Review of the comprehensive 5-day Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #94 a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Resident # 94 was assessed to have short-term and long-term memory problems. The resident was also assessed to have the inability of identifying the current season, location of her room, staff names and faces, or that she was in a nursing home. The assessment indicated Resident #94 was dependent on two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of nursing assessment dated [DATE] at 1:48 P.M. revealed the resident was alert and oriented to person and staff were unable to determine if the resident was alert to time or situation. Resident responded to name but did not answer questions when asked. Review of a social service assessment, dated [DATE] at 2:54 P.M. revealed the resident was alert to self but refused to respond to multiple assessments. Additionally, the resident had a diagnosis of dementia so there was an assumption of both short-term and long-term memory loss. The resident was also documented as needing assistance with decision making. Review of a physician progress note, dated [DATE] revealed the resident was alert and pleasantly confused. A complete review of systems was limited due to dementia, and the resident was unable to provide a meaningful history at the time this assessment was conducted. Review of a social service (SS) note, dated [DATE] revealed Social Services Director #470 spoke with the daughter of Resident #94 on this date and discussed the possibility of palliative care. The daughter was also informed the resident's 20th day in the facility would be on [DATE]th, and that insurance would decrease payment to 80 percent of her bill with no source of secondary insurance. The note revealed the Social Service Director then explained they could apply for Ohio Medicaid, pay privately, or the resident could return home. The note indicated the daughter was to discuss the options with family members. Review of a social service note, dated [DATE] at 12:37 P.M. revealed the family wanted to take the resident home. However, the note also revealed a previous hospice provider was documented as refusing take the resident as a patient due to previous problems with the family and medication issues (at home). Another provider was suggested but was declined with the daughter stating she could not take care of her mom. The note revealed family was then agreeing to apply for Medicaid services with the resident staying at the facility. Review of a social service (SS) note, dated [DATE] at 12:44 P.M. revealed Social Service Director (SSD) #470 notified the Administrator and Director of Nursing Resident #94 was no longer discharging to her home. Review of a social service note, dated [DATE] at 2:56 P.M. revealed the family of Resident #94 had changed their mind and would be taking the resident home via voicemail received by the facility. The note indicated SSD #470 attempted to contact resident family members with no success and indicated the facility does not know how the resident will be transported home, and all discharge arrangements were canceled due to previous conversations with the resident planning to remain at the facility. The note revealed staff did not think this was a safe discharge, and that Hospice had declined to take the resident as they had indicated the resident's home situation was unsafe. The note revealed an AMA form was completed and ready for family to sign when they take the resident from the facility. Review of a social service (SS) note, dated [DATE] at 4:01 P.M. revealed SS was finally able to get in contact with resident's daughter. She confirmed her sister was going to pick up the resident and take her home (on this date) today. SS reminded the daughter that this was the last day the resident could reside in the facility without another payer source, and she stated she understood. The note indicated SS had talked to her (the daughter) about applying for Medicaid, which family declined to do. Social Service has made follow-up appointments for the resident's Primary Care Physician (PCP) and Wound Care and was waiting to see if home health would pick the resident up for their services. Review of a social service note, dated [DATE] at 8:12 A.M. revealed the resident was not picked up by her family last night as they stated they would. The resident was now remained in the facility without a payer source. Social Services had explained this to the resident's daughter multiple times. Social Service attempted to contact both daughters this morning and received a message that neither of their voice mail systems had been set up. The note indicated, will continue to contact them. Review of a physician note, dated [DATE] at 9:43 A.M. revealed the resident was seen and diagnosed with cellulitis to her right upper extremity, and received treatment with the antibiotic, Doxycycline 100 milligrams (mg) by mouth twice daily for seven days. The note revealed the resident's cognition remained at baseline per previous documentation. The resident was alert to person and place with abnormal memory and recall. Review of a physician's orders revealed an order, dated [DATE] for Doxycycline 100 mg by mouth twice daily for seven days. This was provided for a new diagnosis of right upper arm cellulitis. The resident was also documented as being septic when the antibiotic was prescribed. Review of a social service note, dated [DATE] at 3:30 P.M. revealed social service staff had continued to attempt to contact resident's daughters. SS was finally able to talk to daughter again, who stated she only had a moped and another family member had two flat tires on their vehicle. The daughter stated she would call back in 10 minutes, but SS still had not heard from her. SS talked to Administration about this and was told the facility should wait until Monday [DATE], and if family had not yet come to get Resident #94, then the facility should contact Adult Protective Services (APS) and the Ombudsman. The note revealed it was agreed this discharge would be Against Medical Advice (AMA). However, the note did not include any additional information as to how or why the discharge was an AMA discharge. Review of a nursing note, dated [DATE] at 1:32 P.M. revealed Resident #94 discharged home today and was transferred via stretcher per Patriot ambulance service. The resident was unable to sign AMA paperwork due to her bilateral hands being contracted. No family members were present to give discharge instructions to. The note indicated staff spoke with family via phone. Discharge medications and an instruction summary were sent with resident. The resident was to receive home health per Amedisys. Follow up appointments date, time, and phone number were sent to the family. All departments notified of discharge. Review of the Against Medical Advice form revealed the form was documented as being provided on [DATE] and was unsigned by the resident or family members. The signature block reflected the resident was transported by Patriot Ambulance Service and family was not present. The bottom of the form reflected Resident #94 was unable to sign the document due to bilateral hand contractures. No facility staff signature was evident on this form. Review of a social services note, dated [DATE] at 1:34 P.M. revealed Resident #94 was discharged to her home by ambulance on [DATE]. She was admitted to this facility on [DATE] from the hospital where she had presented to the emergency department with shortness of breath, a weak cough, and hypoxia. She came to this facility for post-hospitalization rehabilitation with plans to return to her home. While at this facility, she did not participate much with any of the therapy services and did not allow other departments to do a lot of the stuff they were required to do. On multiple occasions, the resident refused to allow SS to complete any of the assessments that were required. When her insurance cut her services, as was expected and had been explained to family, there was significant confusion between the daughters about whether or not Resident #94 was returning home or staying at the facility and applying for Medicaid. Staff had great difficulty in contacting family as they would not answer their phones, nor would they make decisions. On the day the resident was supposed to discharge, social services finally was able to contact the daughter, who stated she only had a moped to bring her mother home. She stated she would talk to family and call SS back in 10 minutes. SS never heard back from her. Over the weekend, family made arrangements for the resident to be taken home by ambulance. There was no one to sign the AMA paperwork. The note revealed staff did not feel this was a safe discharge and attempted to have AMA papers signed, but the resident was unable to do so and family was not present. Family had been informed this discharge would be AMA. Social Services contacted Kentucky Adult Protective Services and made a report of concern. Staff attempted to set up Community Hospice, but they would not admit the resident due to past experience with the resident's family and missing medications. SS was able to make a referral for Skilled Physical Therapy (PT) and Occupational Therapy (OT) and nursing with Amedysis Home Health. Durable Medical Equipment was ordered from WeCare Medical to be delivered to Resident #94's home. A follow up appointment was made with Physician #799. The note indicated social services staff would make a post discharge follow up phone call. Telephone Interview with Amedysis Representative #1000 on [DATE] at 03:16 P.M., revealed a referral was made by the facility on [DATE] and multiple calls were made to get into contact the family of the resident without success. The agency also attempted to complete a drive-by which was also not successful to make contact. Representative #1000 revealed their agency had received information the resident had expired on [DATE], and the case was closed out. Interview with Licensed Practical Nurse (LPN) #640 on [DATE] at 08:50 A.M. revealed Resident #94 was not in good shape when she left the facility. She stated the resident was alert but was not cognitively intact to make her own decisions upon discharge. LPN #640 revealed the resident had refused to participate in the BIMS assessment and had little interest in participating in anything. The resident had previously lived at home with her daughter prior to the hospitalization and her admission to the facility. The resident was discharged with Ashland Community Hospice, but the LPN did not know if a follow up was made by the Hospice provider after her discharge. She stated the resident did not have a POA, but her daughter was the next of kin. The LPN indicated the resident had admitted for a short term stay and did not have AMA paperwork. Guardianship or POA was not obtained prior to her leaving as the resident resided in Kentucky. She stated the physician made the determination make her AMA prior to her leaving the facility. The resident had Anthem insurance and was cut from services prior to her discharge. LPN #640 revealed the resident's family could not care of her upon her discharge and would not complete the required paperwork to apply for Medicaid services. She stated on [DATE], the family of the resident had called an EMS provider who came and picked up the resident to return her to the family home. She stated APS was called, along with Amedysis, who would be providing Home Health Services. The LPN believed instead of completing the required paperwork for long term care, the family of the resident had waited until a weekend when no administrative staff were present in the facility to remove the resident and take her home. She stated she had made several calls to the family home which went unanswered following the resident leaving the facility. Telephone interview with Physician #399 on [DATE] at 10:59 A.M. revealed he did not recall being contacted regarding Resident #94's discharge but believed the facility had done everything possible to complete a safe discharge. Physician #399 indicated he felt the facility's hands were tied due to the family dynamics, and the inability to reach them. Interview with PEMS Representative #499 on [DATE] at 11:40 A.M. revealed Resident #94 had required frequent service due to her condition and cognition. He stated the nurse who provided the resident information at the time of transport was Licensed Practical Nurse #700. The representative revealed he checked the transport logs, which did not reflect this transport was pre-arranged by the facility as nothing had been entered into the Google calendar for this resident for that date. He stated that was the system utilized for facilities to arrange transport. He verified the resident was transported to the family home in Flatwoods, Kentucky, where he was met by the daughter of the resident. Telephone interview with Licensed Practical Nurse #700 on [DATE] at 11:44 A.M. revealed the family of Resident #94 wanted her to come home on [DATE]. She stated the facility felt the resident needed more care than what the family could provide. She stated she was provided with discharge paperwork along with an AMA form which was given to the resident and EMS provider. She stated she did not call for the resident transport, as it had already been arranged. Interview with the Administrator on [DATE] at 1:59 P.M. revealed that neither she nor the facility viewed Resident #94's discharge as a safe discharge. She stated the resident's family members had set up transport for the date of [DATE], to be transported to the family member's home of residence. She stated none of the nurses working in the facility had called her on the day of the resident leaving the facility. She stated Social Services #530 had called her after the fact to discuss it. She stated the daughters were adamant the resident came home. She verified she did not consider this as a safe discharge due to the resident's wounds and present condition. Review of the Discharging a Resident without a Physician's Approval Policy revealed the physician would be notified immediately if a resident or their representative should request an immediate discharge. It also indicated if a resident or their representative insisted on being discharged , the resident and/or their representative must sign a release of responsibility form. If either party refused to sign the release, the refusal must be documented in the resident's medical record and witnessed by two staff members.

Based on record review, staff interviews, review of facilities fall investigation and facility policy review, the facility failed to ensure adequate assistance and safety interventions were in place to prevent falls during resident ambulation. This affected one resident (#27) of four residents reviewed for falls. Actual harm occurred on 02/20/23 when Resident #27, who required extensive assistance from one staff for ambulation sustained a fall resulting in a subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), posterior head laceration and traumatic closed displaced fracture of shaft of right femur requiring surgical repair. At the time of the fall, State tested Nursing Assistant (STNA) #560 failed to utilize a gait belt while ambulating the resident. Additionally, the facility failed to comprehensively investigate the fall and implement individualized interventions to prevent further falls for Resident #27. The facility census was 92. Findings Include: Review of the medical record for Resident #27 revealed an initial admitted [DATE] with the latest readmission of 03/09/23 with diagnoses including traumatic subarachnoid hemorrhage, fracture of shaft of right femur, respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), asthma, diabetes mellitus, obesity, atrial fibrillation, depression, sleep apnea, heart failure, dysphagia, hypertension, generalized muscle weakness, difficulty, constipation, hypothyroidism, gastro-esophageal reflux disease, hyperlipidemia, chronic pain syndrome, benign prostatic hyperplasia with lower urinary tract symptoms, folate deficiency anemia and dependence on renal dialysis. Review of the fall risk assessment dated [DATE] revealed a score of 60 indicating the resident was at high risk for falls. Review of the plan of care dated 01/25/22 revealed the resident was at risk for injury, falls related to medications. Interventions included frequently used items within reach, medications/treatments as ordered, observe for unsteady balance or gait and assist as needed and therapy screens as needed. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had no cognitive impairment. The resident required extensive assistance of one staff for bed mobility, transfers and ambulation. Review of the progress note dated 02/20/23 at 5:45 P.M., revealed the aide toileting the resident reported the resident lost his balance and fell backwards onto the ground. The resident complained of right hip/leg pain and was unable to straighten his leg out and yelled out in pain. The resident sustained a laceration to the back of his head with a knot. 911 was called and the resident was transported to the local emergency room . Review of the progress note dated 02/20/23 at 10:57 P.M., revealed Resident #27 was admitted to the local hospital with a brain bleed and fractured skull. Review of the incident report dated 02/20/22 revealed the nurse was called to the resident's room per STNA #560 where the resident was lying on the floor. The resident stated he fell backwards while walking back from the bathroom with assistance. The nurse completed a head-to-toe assessment and called 911. The incident report documented the resident had a posterior head laceration. STNA #560 stated the resident said his knees were going to give out and she attempted to move the wheelchair behind him, but he fell before the wheelchair could be placed underneath him. Review of the facility investigation dated 02/20/23 revealed on 02/21/23 the interdisciplinary team (IDT) reviewed the resident's witnessed fall on 02/20/23. The note documented the resident was being assisted back from the toilet by two aides (STNA #560 and unknown aide) when the resident stated his legs were going to give out. The STNA attempted to place the wheelchair under the resident, but he sustained a fall before he could be assisted into the wheelchair. The STNA was re-educated on proper gait belt use and lowering resident to the ground. Following the incident, on 02/20/23 the resident's plan of care was updated to reflect staff were educated on using gait belt safely, Review of a hospital discharge continuity form, dated 03/09/23 revealed the resident was treated for subarachnoid hemorrhage and traumatic closed displaced fracture of shaft of right femur which required the surgical procedure open reduction and internal fixation of the right femur. On 03/28/23 at 11:26 A.M., an interview with Resident #27 revealed STNA #560 was assisting him to the bathroom, and he told her his knees were getting weak and the STNA told him to take a step. Resident #27 revealed when he took a step he fell , and his knee hit the wall. He revealed the STNA did not have a gait belt in use when ambulating him to the bathroom. He revealed there was only one STNA assisting him at the time of fall. He further revealed only the therapy staff utilized a gait belt. On 04/05/23 at 9:06 A.M., interview with Clinical Nurse Consultant (CNC) #999 verified STNA #560 was not utilizing a gait belt while ambulating Resident #27 to the bathroom. On 04/05/23 at 9:16 A.M., interview with Physical Therapy Assistant (PTA) #800 revealed all residents had a gait belt in their room for use. She revealed each resident was given a gait belt for use until discharge and the gait belt was then sent to laundry. She revealed all residents in therapy had a gait belt in place during the session in case of loss of balance. She revealed any resident who required extensive (staff) assistance should have a gait belt in place and the STNA staff should use the gait belt for transfers and ambulation. Review of the facility policy titled, Safe Lifting and Movement of Residents, dated 07/2017 revealed in order to promote the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care would be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lift devices. This deficiency represents non-compliance investigated under Complaint Number OH00141044.

Based on observation, record review and staff interviews, the facility failed to ensure five residents (#46, #52, #57, #85 and #195) Minimum Data Set (MDS) were accurate in the area of diagnoses, contracture's and psychotropic medications. This affected five of 26 sampled residents. The census was 92. Findings Include: 1. Review of the medical record for Resident #52 revealed an initial admitted [DATE] with the latest readmission of 03/23/23. Diagnoses included quadriplegia, cervical disc disorder, acute transverse myelitis in demyelinating disease of central nervous system, polyosteoarthritis, hypothyroidism, anemia, chronic viral hepatitis C, stiffness of unspecified joint, resistance to multiple antibiotics, major depressive disorder, hereditary and idiopathic neuropathy, contracture of unspecified joint, osteoporosis, gastro-esophageal reflux disease, neuromuscular dysfunction of bladder and bipolar disorder. Review of the nursing admission screening/history dated 08/16/21 revealed the resident had contracture's to the left hand, right hand, had foot drop and wears brace/boot for prevention and had foot drop to the left foot. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had no cognitive deficit. The resident required extensive assist of two staff for bed mobility, dependent on two staff for transfers and toileting use. The assessment indicated the resident had no function impairment to upper extremities and functional impairment to both lower extremities. Review of the plan of care revealed no care plan addressing the resident's foot drop or contracture's to bilateral hands. On 03/27/23 at 2:16 P.M., observation of Resident #52 revealed the resident was observed with contracture to right hand/fingers. Resident #52 was not able to open her hand fully when asked if she was able to open her hand. The resident stated, her hand had gotten worse since being admitted to the facility. On 03/29/23 at 10:17 A.M., interview with Clinical Nurse Consultant (CNC) #999 verified the MDS for Resident # 52 was coded inaccurately. On 03/29/23 at 1:25 P.M., interview with Physical Therapy Assistant (PTA) #800 verified the resident's right had was contracted. 2. Review of the medical record for Resident #57 revealed an initial date of 07/23/20 with the latest readmission of 02/05/22 with the admitting diagnoses including congestive heart failure, acute and chronic respiratory failure, sleep apnea, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, diabetes mellitus, diverticulitis arthropathy, schizophrenia, dysphagia, history of COVID-19, benign prostatic hyperplasia, chronic embolism and thrombosis, anxiety disorder, hyperlipidemia, hypertension, constipation, unilateral inguinal hernia, adult failure to thrive and major depressive disorder. Review of the psychiatry initial consult dated 05/18/22 revealed the resident was being seen following a readmission from the hospital. The progress noted revealed the resident has an active diagnosis of Schizoaffective disorder and was currently receiving Risperdal two milligrams (mg) by mouth twice daily. The assessment and plan was schizoaffective disorder continue Risperdal, Buspar, Cymbalta and Depakote. The resident was diagnosed with Schizophrenia and Insomnia. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a BIMS score of 15 out of 15 indicating the resident had no cognitive deficit. The assessment indicated schizophrenia was not an active diagnosis. On 03/29/23 at 10:17 A.M., interview with CNC #999 verified the active diagnosis of schizophrenia was not coded on the MDS. 34299 3. Review of the medical record for Resident #85 revealed an admitted [DATE] with diagnoses including sepsis, cellulitis of bilateral lower extremities, moderate protein calorie malnutrition, peripheral vascular disease, and Methicillin resistant Staphylococcus aureus (MRSA) of nasal passage, colonized. Review of the comprehensive Medicare five day MDS dated [DATE] indicated Resident #85 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Resident #85 was coded as having an active Multi-Drug Resistant Organism (MDRO). Review of the physician orders for March 2023 revealed Resident #85 was not prescribed an antibiotic and did not have an order for contact precautions. Review of the nursing progress notes revealed Resident #85 received a prescribed antibiotic for diagnosis of sepsis for 10 days; 02/05/23 through 02/13/23. Review of the plan of care dated 02/27/23 revealed Resident #85 had an acute infection with risk for complications related to sepsis and cellulitis of bilateral lower extremities. Interventions included diagnostics as ordered, medications and treatments as ordered and standard precautions. Review of the plan of care dated 02/27/23 revealed Resident #85 had MDRO colonization with a risk for acute infection related to history of MRSA. Interventions included diagnostics as ordered, medications and treatments as ordered and observe for efficacy and adverse effects of medications. Observations on 03/29/23 at 10:05 A.M., on 03/30/23 at 8:55 A.M., on 03/30/23 at 3:10 P.M. and on 04/03/23 at 10:20 A.M. of Resident #85 revealed no sign posted on door related to infection control or isolation precautions. An interview on 03/30/23 at 8:55 A.M. with Resident #85 revealed he was not aware of having any contagious infection. An interview on 04/03/23 at 2:14 P.M. with Certified Nursing Assistant (CNA) #195 revealed Resident #85 was not on any infection control precautions other than standard precautions. An interview on 04/03/23 at 2:26 P.M. with Director of Nursing (DON) confirmed Resident #85 was not on infection control precautions. An interview on 04/03/23 at 3:30 P.M. with MDS nurse #255 revealed and confirmed Resident #85 did not have an active diagnosis of MDRO in wounds. The MDS nurse stated Resident #85 hospital history and physical revealed Resident #85 had colonized MRSA in his nasal passages. The MDS nurse confirmed the comprehensive assessment was coded incorrectly. 4. Review of the medical record for Resident #195 revealed an admitted [DATE] with diagnoses of acute osteomyelitis of the left foot, MRSA, cerebral infarct, type two diabetes mellitus, and hemiplegia of left side. Review of the comprehensive Medicare five day MDS dated [DATE] revealed Resident #195 was cognitively intact as evidenced by a BIMS score of 14 out of 15. Resident #195 was admitted with a surgical wound with treatment, intravenous antibiotics and active diagnosis of MDRO. Review of the physician orders for March 2023 revealed Resident #195 received Vancomycin Hydrochloride 750 milligrams (mg) intravenously once daily, and Meropenem intravenous solution reconstituted one gram intravenously two times daily for osteomyelitis of left foot. There were no orders for isolation, or contact precautions. Review of nursing progress notes revealed Resident #195 received intravenous antibiotic as ordered. Review of the plan of care dated 03/14/23 revealed Resident #195 had infection risk related to wound. Interventions included diagnostics as ordered, medications and treatments as ordered, standard precautions, and observe for resolution or worsening. Review of the plan of care dated 03/14/23 revealed Resident #195 had MDRO colonization with a risk for acute infection related to history of MDRO. Interventions included diagnostics as ordered and notify the physician as needed, follow standard precautions or specific precautions for type of infection, mediations and treatments as ordered, see Medication Administration Record and Treatment Administration Record for specific instructions, and observe for efficacy and adverse effects. Observations of Resident #195 on 03/28/23 at 2:29 P.M., 03/30/23 at 8:30 A.M., and at 2:30 P.M. revealed no sign posted on door related to infection control or isolation precautions. An interview on 03/28/23 at 2:29 P.M. with Resident #195 revealed she had osteomyelitis in her left foot. An interview on 04/03/23 at 2:14 P.M. with Certified Nursing Assistant (CNA) #195 revealed Resident #195 was not on any infection control precautions other than standard precautions. An interview on 04/04/23 at 11:02 A.M. with MDS nurse #255 revealed and confirmed Resident #195 did not have an active diagnosis of MDRO in wounds. The MDS nurse stated Resident #195 hospital history and physical and discharge instructions revealed Resident #195 did not have an active diagnosis of MDRO. The MDS nurse confirmed the comprehensive assessment was coded incorrectly. 07316 5. Review of the medical record for Resident #46 revealed an admitted [DATE]. The resident had diagnoses including Parkinson's disease, malignant neoplasm of the breast, lymphedema, and hypertension. Review of physician's orders revealed an order for an antipsychotic medication (Quetiapine 50 milligrams at bedtime) since admission on 07/02/22. Review of a Minimum Data Set (MDS) assessment completed 07/25/22 revealed it indicated the resident received an antipsychotic medication and had a gradual dose reduction on 07/15/22. There was no evidence the resident had a gradual dose reduction of the medication. Review of a quarterly MDS assessment completed 01/19/23 revealed it indicated the resident had received an antianxiety medication for seven of the last seven days. There was no evidence in the record the resident was receiving any antianxiety medication in December 2022, January 2023 or currently. Interview with Clinical Nurse Consultant #999 on 04/04/23 at 3:18 P.M. confirmed the MDS assessments on 07/25/22 and 01/19/23 were inaccurate. She confirmed Resident #46 had not had a gradual dose reduction on 07/15/22 and had not received the antianxiety medication as indicated on the quarterly MDS of 01/19/23.

Based on observations, medical record review and staff interview, the facility failed to develop comprehensive care plans for four residents (#2, #4, #52, and #79) of 23 sampled residents. The facility census was 92. Findings include: 1. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnosis of respiratory failure with hypoxia, chronic obstructive pulmonary disorder (COPD), unspecified severe protein calorie deficiency, congestive heart failure, debility and shortness of breath. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #79 was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) exam of 15 out 15. Resident #79 had active diagnoses of respiratory failure with hypoxia, risk of malnutrition, chronic obstructive respiratory failure and shortness of breath. Resident #79 was documented as having shortness of breath when lying flat and received oxygen. Review of the Medication Administration Record (MAR) for March 2023 revealed Resident #79 received Ipratropium-Albuterol solution 0.5/2.5 milligrams/3 milliliters orally via nebulizer every four hours for shortness of breath, wheezing, COPD,and asthma. Nurse to record pre treatment breath sounds such as rhonci, crackles or normal breath sounds, pulse and respiratory rate. Resident received oxygen at two liters per min via nasal cannula and documented oxygen saturations. Review of the plan of care dated 01/26/23 revealed Resident #79 had impaired respiratory status with risk for gas exchange related to COPD, oxygen dependent, and respiratory failure. Interventions included diagnostics as ordered, notify physician as needed, medications and treatments as ordered and observe for efficacy and adverse effects. The plan of care did not include use of oxygen or respiratory assessment. Observations on 03/28/23 at 3:07 P.M., 03/29/23 at 1:10 P.M. and on 04/03/23 at 1:15 P.M. revealed Resident #79 noted to have a moist deep cough. Resident #79 was wearing oxygen at two liters per minute via nasal cannula. An interview on 03/28/23 at 3:07 P.M. with Resident #79 revealed she had pneumonia before and knew what it felt like. Resident #79 stated the doctor ordered an x-ray. An interview on 03/29/23 at 1:20 P.M. with Licensed Practical Nurse (LPN) #101 revealed the LPN was agency staffing and had not worked with Resident #79 prior. LPN #101 stated Resident #79 had a horrible cough and just finished her Medrol dose pack for chronic bronchitis. LPN stated oxygen saturation was obtained and documented on the MAR. An interview on 04/04/23 at 4:00 P.M. with the Director of Nursing (DON) confirmed the plan of care for Resident #79 was not comprehensive and updated related to respiratory care and needs including oxygen therapy and respiratory assessment. 33023 2. Record Review of Resident #4 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: diabetes mellitis type II, chronic obstructive pulmonary disease, hypertension, chronic kidney disease stage 3, osteoarthritis, bipolar disorder, congestive heart failure, anxiety, depression, dementia, COVID-19, and muscle weakness. Review of the MDS assessment dated [DATE] revealed resident was alert and oriented to person, place, and time and able to make her needs known and revealed resident is always incontinent of both bowel and bladder. Resident is also an extensive, two-person assist for activities of daily living including bed mobility, toileting, and transfers. Review of Resident-Centered Care Plan revealed this resident had a Urinary Incontinence Care Plan in place, effective 02/19/23 and an intervention to observe for incontinence every two hours and as needed. The facility was unable to provide any type of Bowel Incontinence Care Plan. Interview with Resident #4 on 03/28/23 at 08:26 A.M. stated that sometimes she doesn't get cleaned up appropriately following a bowel movement. Interview with the Administrator on 04/04/23 at 2:22 P.M. verified this resident does not have an active care plan for bowel incontinence. 32654 3. Review of the medical record for Resident #52 revealed an initial admitted [DATE] with the latest readmission of 03/23/23. Diagnoses included quadriplegia, cervical disc disorder, acute transverse myelitis in demyelinating disease of central nervous system, polyosteoarthritis, hypothyroidism, anemia, chronic viral hepatitis C, stiffness of unspecified joint, resistance to multiple antibiotics, major depressive disorder, hereditary and idiopathic neuropathy, contracture of unspecified joint, osteoporosis, gastro-esophageal reflux disease, neuromuscular dysfunction of bladder and bipolar disorder. Review of the nursing admission screening/history dated 08/16/21 revealed the resident had contracture's to the left hand, right hand, had foot drop and wears brace/boot for prevention and had foot drop to the left foot. Review of the MDS dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a BIMS score of 15 out of 15 indicating the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required extensive assist of two staff for bed mobility, dependent on two staff for transfers and toileting use. The assessment indicated the resident had no functional impairment to upper extremities and functional impairment to both lower extremities. Review of the monthly physician's orders identified orders dated 12/15/21 contracture boot right foot drop every shift. Review of the plan of care revealed no care plan addressing the resident's foot drop or contracture's to hands. On 03/27/23 at 2:16 P.M., observation of Resident #52 revealed the resident was observed with contracture to right hand/fingers. Resident #52 was not able to open her hand fully when asked if she was able to open her hand. The resident stated, her hand had gotten worse since being admitted to the facility. Further observation revealed the resident had foot drop to right and left foot. On 03/29/23 at 1:25 P.M., interview with Physical Therapy Assistant (PTA) #800 verified the resident's right had was contracted. On 04/04/23 at 10:46 A.M., interview with Clinical Nurse Consultant #999 verified the resident had no plan of care addressing the resident's contracture's or foot drop. 42728 4. Record review for Resident #2 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia, Bell's Palsy, and contracture. Review of the annual MDS assessment, dated 03/02/23, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility, transfers, and toileting and to be dependent upon one staff member for eating. This resident was assessed to have functional limitation in range of motion to bilateral upper and lower extremities. Review of the active care plans for this resident revealed no evidence of a plan of care for limited range of motion or contracture's. Observation on 03/28/23 at 4:10 P.M. revealed this resident was observed to have contracture's present to both hands and feet. Interview with the DON and Clinical Nurse Consultant #999 on 04/04/23 at 9:45 A.M. verified there was not a plan of care in place to address care of contracture's or limited range of motion for Resident #2. Review of the facility titled Resident Mobility and Range of Motion, revised 07/2017, revealed the care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. Documentation of the residents progress towards these goals and objectives will include attempts to address any changes or decline in the residents condition or needs.

Based on record reviews, staff interviews, and review of facility policy, the facility failed to ensure appropriate antibiotic therapy was prescribed for the treatment of residents urinary tract infections. This affected four residents (#1, #19, #28, and #67) who were reviewed for prescribed antibiotic therapy during the annual survey. The facility census 92. Findings include: 1. Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease, hypertension, and dementia. Review of the results of urine culture, dated 03/19/23, revealed 10,000 - 100.000 colony formulating units per milliliter (cfu/ml) of the bacteria Escherichia coli (E-coli) was present. Review of the physicians order, dated 03/20/23 and discontinued on 03/21/23, revealed an order to administer 500 milligrams (mg) of Keflex (a broad spectrum antibiotic) three times a day for seven days for the treatment of a urinary tract infection. Review of the results of the sensitivity testing, dated 03/21/23, revealed no documentation of susceptibility of E-coli present to the medication Keflex. Review of the physicians order, dated 03/21/23, revealed an order to begin the administration of Macrobid (an antibiotic medication) for the treatment of the residents urinary tract infection. Interview with Infection Control Preventionist (ICP) #790 on 04/04/23 at 9:10 A.M. verified the physician had ordered Keflex for the treatment of Resident #1's urinary tract infection before the results of sensitivity testing had come back which indicated the medication Macrobid was more appropriate. 2. Record review for Resident #19 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, epilepsy, and anxiety. Review of the results of the urine culture, dated 03/07/23, revealed over 100,000 cfu/ml of the bacteria E-coli was present. Review of the results of the sensitivity testing, dated 03/08/23, revealed no documentation of susceptibility of E-coli present to the medication Keflex. Review of the physicians order, dated 03/08/23, revealed an order to begin administration of Keflex three times a day for seven days for the treatment of a urinary tract infection. Interview with ICP #790 on 04/04/23 at 9:10 A.M. verified the sensitivity testing did not indicate Keflex was appropriate for the treatment of Resident #19's urinary tract infection. 3. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, overactive bladder, and hypertension. Review of the results of the urine culture and sensitivity testing, dated 03/13/23, revealed over 100,000 cfu/ml of the bacteria E-coli was present. There was no documentation of the susceptibility of E-coli present to the medication Keflex. Review of the physicians order, dated 03/13/23, revealed an order to begin administration of Keflex three times a day for seven days for the treatment of a urinary tract infection. Interview with ICP #790 on 04/04/23 at 9:10 A.M. verified the sensitivity testing did not indicate Keflex was appropriate for the treatment of Resident #28's urinary tract infection. 07316 4. Review of the medical record for Resident #67 revealed an admitted [DATE] and a diagnosis of benign prostatic hypertrophy (enlarged prostate). The resident had an indwelling catheter. Review of hospital records revealed on 01/11/23 the resident presented to the emergency department for evaluation of dysuria (painful or difficult urination). Patient has a visible Foley catheter with cloudy urine present in the tubing. He also reports discomfort to the suprapubic region of abdomen. A urinalysis was completed on 01/11/23 which showed 2+ blood and a large amount of leucocytes. Resident #67 was diagnosed with a urinary tract infection and an antibiotic (Levoquin 750 milligrams) was ordered daily for 14 days. The resident returned to the facility. Record review revealed Resident #67 received the Levoquin daily at the facility from 01/12/23 to 01/25/23. (14 days). Review of additional hospital records revealed on 01/12/23 it was noted by the hospital that the colony count showed three or more organisms, indicating a poor specimen. A repeat collection was suggested. There was no evidence a repeat urine culture was obtained to determine if the resident actually had a urinary tract infection or if the antibiotic the resident was taking was effective against the type of bacteria that might be present. Interview with the Director of Nursing on 04/05/23 at 9:42 A.M. confirmed the hospital records indicated the urine specimen was poor and a repeat urine culture was not done. Review of the facility policy titled Antibiotic Stewardship revised December 2016 revealed it stated when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued

Based on review of Medicare Notice of Non-Coverage forms, medical record review, facility policy review, and staff interview, the facility failed to provide accurate and timely notification of Medicare non-coverage. This affected one (Resident #149) of three residents reviewed for Medicare non-coverage. The facility census was 92. Findings include: Review of the medical record for Resident #149 revealed an admitted [DATE]. Review of a physical therapy evaluation on 11/28/22 revealed the resident presented for therapy after hospitalization from [DATE] to 11/25/22 for pneumonia, hypotension, and septic shock. It stated she demonstrated unsteadiness on feet, gait impairments, and instability during standing. It stated she would be going to live with her daughter upon discharge. Review of a social history and discharge plan dated 11/28/22 revealed the resident lived with family prior to placement. A section for plans for length of stay stated short term with a question mark. It further stated her daughter wanted her to live with her upon discharge. A Minimum Data Set assessment completed 12/02/22 documented a brief interview for mental status score of 15 out of 15, indicating intact cognition. It indicated the resident required limited assistance from one staff with bed mobility, transfers, walking, dressing, toileting, and hygiene. A care conference summary on 12/07/22 stated the discharge goal was to go home with care giver, being daughter. No time frame was documented and no further discharge planning documented in the medical record. Review of a Notice of Medicare Non-Coverage form revealed Resident #149 was notified on 01/03/23 that her Medicare coverage would end on 01/04/23 (notified only one day prior to services ending). It was documented on the form that the resident decided to go home. Review of physical therapy notes revealed that, although the resident was notified that her Medicare coverage was ending on 01/04/23, she was provided with physical therapy on 01/05/23. Review of nurses progress notes on 01/05/23 at 6:24 P.M. revealed Licensed Practical Nurse #320 documented Resident #149 left the facility at this time with family. No further information was documented (when she would be back). A physical therapy discharge summary on 01/06/23 stated the resident was discharged from therapy on 01/05/23. It further stated the patient was undecided of where to return to on discharge; will discharge to a family members home. It also stated the patient went to overnight visit with family at this time. The resident did not return to the facility after leaving on 01/05/23 at 6:24 P.M. Interview with Assistant Business Office Manager #250 on 04/04/23 at 9:34 A.M. confirmed Resident #149 was notified on 01/03/23 that she was being cut from Medicare on 01/04/23. (only one day notice). She stated therapy tells her when residents are cut from Medicare. She stated she was not sure if the resident was really cut from Medicare on 01/04/23 but was told by someone (did not know who) to have the resident sign the Medicare Notice of Non-Coverage form since she was planning to go home. Interview with Therapy Director #800 on 04/04/23 at 9:45 A.M. revealed she thought the resident was cut from Medicare on 01/05/23 and confirmed the resident received therapy on 01/05/23, even though her notice of non-coverage stated she was cut on 01/04/23. She said there must have been a communication error amongst the staff. Interview with Social Service Director #470 on 04/04/23 at 10:00 A.M. revealed that Resident #149 was not to be cut from Medicare until 01/10/23. She confirmed the Notice of Non-Coverage of Medicare Form was signed by the resident on 01/03/23 and it stated coverage ended 01/04/23. She confirmed the resident did not return to the facility after leaving with her family on 01/05/23 (after being discharged from physical therapy). Interview with the Administrator on 04/04/23 at 1:24 P.M. revealed the resident wanted to go home so that is why the facility had her sign the Notice of Medicare Non-Coverage Form on 01/03/23. She was unsure if the resident was actually cut from Medicare or not. Review of the facility policy titled Medicare Advanced Beneficiary Notice dated April 2021 revealed if a resident's Medicare Part A benefits are terminating for coverage reasons, the Notice of Medicare Non-Coverage form will be issued to the resident at least two calendar days before Medicare covered services end. The notice informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination.

Based on medical record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASRR) document after a significant change occurred. This affected one (Resident #57) of nine PASRR documents reviewed. The census was 92. Findings Include: Review of the medical record for Resident #57 revealed an initial date of 07/23/20 with the latest readmission of 02/05/22 with the admitting diagnoses including congestive heart failure, acute and chronic respiratory failure, sleep apnea, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, diabetes mellitus, diverticulitis arthropathy, schizophrenia, dysphagia, history of COVID-19, benign prostatic hyperplasia, chronic embolism and thrombosis, anxiety disorder, hyperlipidemia, hypertension, constipation, unilateral inguinal hernia, adult failure to thrive and major depressive disorder. Review of Resident #57's PASRR document, dated 07/22/20, revealed under Section D: Indications of Serious Mental Health, the resident had no mental health diagnosis listed. But in review of his current face sheet/diagnosis list, he had the following diagnoses and dates of onset: schizophrenia (05/18/22). There was no documentation to support a PASRR document was completed after the one submitted on 07/22/20. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had no cognitive deficit. The assessment indicated schizophrenia was not an active diagnosis. On 03/29/23 at 10:17 A.M., interview with Clinical Nurse Consultant (CNC) #999 verified a significant change PASRR was not completed following the addition of the diagnoses of schizophrenia on 05/18/22.

Based on review of Medicare Notice of Non-Coverage forms, medical record review, and staff interview, the facility failed to develop and implement an effective discharge plan for a resident who was notified their Medicare coverage ended. This affected one (Resident #149) of three residents reviewed for Medicare non-coverage. The facility census was 92. Findings include: Review of the medical record for Resident #149 revealed an admitted [DATE]. Review of a physical therapy evaluation on 11/28/22 revealed the resident presented for therapy after hospitalization from [DATE] to 11/25/22 for pneumonia, hypotension, and septic shock. It stated she demonstrated unsteadiness on feet, gait impairments, and instability during standing. It stated she would be going to live with her daughter upon discharge. Review of a social history and discharge plan dated 11/28/22 revealed the resident lived with family prior to placement. A section for plans for length of stay stated short term with a question mark. It further stated her daughter wanted her to live with her upon discharge. A plan of care dated 11/28/22 stated the resident had a risk for knowledge deficit related to possible discharge home. Interventions included assist with arranging transportation as needed, contact applicable home health agency as needed prior to discharge, discuss with resident/family amount of support available to resident upon discharge. The discharge plan was not updated after 11/28/22. A Minimum Data Set (MDS) assessment completed 12/02/22 documented a brief interview for mental status score of 15 out of 15, indicating intact cognition. It indicated the resident required limited assistance from one staff with bed mobility, transfers, walking, dressing, toileting, and hygiene. It indicated the resident had an unstageable pressure ulcer. A care conference summary on 12/07/22 stated the discharge goal was to go home with care giver, being daughter. No time frame was documented and no further discharge planning was documented in the medical record. Review of a Notice of Medicare Non-Coverage form revealed Resident #149 was notified on 01/03/23 that her Medicare coverage would end on 01/04/23 (notified only one day prior to services ending). It was documented on the form that the resident decided to go home. Review of physical therapy notes revealed that, although the resident was notified that her Medicare coverage was ending on 01/04/23, she was provided with physical therapy on 01/05/23. Review of nurses progress notes on 01/05/23 at 6:24 P.M. revealed Licensed Practical Nurse #320 documented Resident #149 left the facility at this time with family. No further information was documented (when she would be back). Interview with Licensed Practical Nurse #320 on 04/04/23 at 8:40 A.M. revealed Resident #149's daughter (not the one identified as who she would live with) took her out on 01/05/23. He said he did not remember where the resident was going or any other details about her leaving. A physical therapy discharge summary on 01/06/23 stated the resident was discharged from therapy on 01/05/23. It further stated the patient was undecided of where to return to on discharge; will discharge to a family members home. It also stated the patient went to overnight visit with family at this time. The resident did not return to the facility after leaving on 01/05/23 at 6:24 P.M. A progress note by Social Service Director (SSD) #470 on 01/06/23 at 9:30 A.M. revealed it was reported Resident #149 had left the building overnight with a family member. Since she was Medicare, she is not able to go for overnight stay and was discharged from services here at the nursing home. SSD #470 contacted her first emergency contact, which was her sister, and was told Resident #149 was not there. She contacted the resident's daughter (identified as the one the resident was going to discharge home with) and she did not know that her mother had left the facility. She stated she must have gone with another daughter. SSD explained about Medicare and overnight visits. Told her that therapy says she has met all of her goals and was going to be discharged from their services on 01/10/23 anyway. Told her facility would make a referral for therapy services and make follow up appointment with physician, and will send her home with 5 days worth of medications (resident already gone at this point). Also talked about making referral for Passport services. It was not determined in the notes where the resident actually was at that time. It was noted the resident had been marked as discharged . On 01/06/23 at 1:09 P.M. a nurses note stated family members here. Medication list and prescriptions given to family. There was no evidence the family was provided with any education on providing care for pressure ulcers to the hips that the resident was receiving treatment for. The resident had a physician's order for a thin layer of santyl and cover with gauze and dressing twice daily to the left hip and paint right hip with betadine daily for a suspected deep tissue injury. The resident weighed 89 pounds. There was no evidence of any education regarding diet or nutrition. A progress note by SSD #470 on 01/06/23 at 3:33 P.M. stated she spoke to Resident #149's sister and another daughter (not the one she spoke to earlier and not the one identified to discharge home with). Explained post discharge services facility would provide. Note stated the resident will be staying at her sister's home. Follow up physician's appointment provided. Interview with Assistant Business Office Manager #250 on 04/04/23 at 9:34 A.M. confirmed Resident #149 was notified on 01/03/23 that she was being cut from Medicare on 01/04/23. (only one day notice). She stated therapy tells her when residents are cut from Medicare. She stated she was not sure if the resident was really cut from Medicare on 01/04/23 but was told by someone (did not know who) to have the resident sign the Medicare notice of non-coverage since she was planning to go home. Interview with Therapy Director #800 on 04/04/23 at 9:45 A.M. revealed she thought the resident was cut from Medicare on 01/05/23 and confirmed the resident received therapy on 01/05/23, even though her notice of non-coverage stated she was cut on 01/04/23. She said there must have been a communication error amongst the staff. Interview with Social Service Director #470 on 04/04/23 at 10:00 A.M. revealed that Resident #149 was not to be cut from Medicare until 01/10/23. She confirmed the notice of non-coverage of Medicare was signed by the resident on 01/03/23 and it stated coverage ended 01/04/23. She confirmed the resident did not return to the facility after leaving with her family on 01/05/23 (after being discharged from physical therapy). She confirmed there was no evidence of any discharge planning being done even though the resident was notified she was cut from Medicare and it had not been decided where the resident was going to go. She stated when the family returned for the resident's belongings on 01/06/23, the resident was at her sister's house (even though when she called there earlier, she was told the resident was not there). She confirmed the resident did not return with family to get her belongings and was not seen again after she left on 01/05/23 at 6:24 P.M. Interview with the Administrator on 04/04/23 at 10:15 A.M. revealed a discharge plan should have been developed when staff knew the resident wanted to go home and when she was notified she was being cut from Medicare. The facility provided the surveyor with a Discharge Instruction Summary that stated discharge was on 01/05/23 at 3:00 P.M. (even though resident left with family on 01/05/23 at 6:24 P.M. and the nurse did not know she was being discharged ). It stated she was discharged to Home and was escorted to nursing home exit by staff. The instructions did not include medications or hip pressure ulcer treatments. It was not signed by the resident or family. Interview with the Administrator on 04/04/23 at 1:40 P.M. revealed the form was dated 01/05/23 because the resident left on 01/05/23 but the discharge instruction summary was actually given to the family on 01/06/23 when they came to pick up her belongings. She confirmed the form was not signed by resident or family. She stated the normal procedure was to have them sign that they received the form. She stated the facility did not actually know the resident was being discharged on [DATE] even though the form indicated it. She confirmed the resident was not discharged on [DATE] at 3:00 P.M. and was not helped out of the facility by staff even though the form indicated that. Interview with the Director of Nursing on 04/05/23 at 9:25 A.M. confirmed there was no evidence any instructions on pressure ulcer care was provided to the resident or family on discharge. Interview with Resident #149's daughter on 04/04/23 at 9:10 A.M. (the daughter who the resident had indicated she would live with on discharge) revealed she was not aware her other sister was taking the resident out of the facility on 01/05/23. She said the resident did return to the resident's sisters house after discharge and remained there about a week before she required hospitalization again. She stated the resident is now in another nursing home.

Based on review of Medicare Notice of Non-Coverage forms, medical record review, and staff interview, the facility failed to have a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of medications, and a post-discharge plan of care developed with the resident/resident representative for a resident who was notified their Medicare coverage ended and left the facility. This affected one (Resident #149) of three residents reviewed for Medicare non-coverage. The facility census was 92. Findings include: Review of the medical record for Resident #149 revealed an admitted [DATE]. Review of a physical therapy evaluation on 11/28/22 revealed the resident presented for therapy after hospitalization from [DATE] to 11/25/22 for pneumonia, hypotension, and septic shock. It stated she demonstrated unsteadiness on feet, gait impairments, and instability during standing. It stated she would be going to live with her daughter upon discharge. Review of a social history and discharge plan dated 11/28/22 revealed the resident lived with family prior to placement. A section for plans for length of stay stated short term with a question mark. It further stated her daughter wanted her to live with her upon discharge. A plan of care dated 11/28/22 stated the resident had a risk for knowledge deficit related to possible discharge home. Interventions included assist with arranging transportation as needed, contact applicable home health agency as needed prior to discharge, discuss with resident/family amount of support available to resident upon discharge. The discharge plan was not updated after 11/28/22. A Minimum Data Set (MDS) assessment completed 12/02/22 documented a brief interview for mental status score of 15 out of 15, indicating intact cognition. It indicated the resident required limited assistance from one staff with bed mobility, transfers, walking, dressing, toileting, and hygiene. It indicated the resident had an unstageable pressure ulcer. A care conference summary on 12/07/22 stated the discharge goal was to go home with care giver, being daughter. No time frame was documented and no further discharge planning was documented in the medical record. Review of a Notice of Medicare Non-coverage form revealed Resident #149 was notified on 01/03/23 that her Medicare coverage would end on 01/04/23 (notified only one day prior to services ending). It was documented on the form that the resident decided to go home. Review of physical therapy notes revealed that, although the resident was notified that her Medicare coverage was ending on 01/04/23, she was provided with physical therapy on 01/05/23. Review of nurses progress notes on 01/05/23 at 6:24 P.M. revealed Licensed Practical Nurse #320 documented Resident #149 left the facility at this time with family. No further information was documented (when she would be back). Interview with Licensed Practical Nurse #320 on 04/4/23 at 8:40 A.M. revealed Resident #149's daughter (not the one identified as who she would live with) took her out on 01/05/23. He said he did not remember where the resident was going or any other details about her leaving. A physical therapy discharge summary on 01/06/23 stated the resident was discharged from therapy on 01/05/23. It further stated the patient was undecided of where to return to on discharge; will discharge to a family members home. It also stated the patient went to overnight visit with family at this time. The resident did not return to the facility after leaving on 01/05/23 at 6:24 P.M. A progress note by Social Service Director (SSD) #470 on 01/06/23 at 9:30 A.M. revealed it was reported Resident #149 had left the building overnight with a family member. Since she was Medicare, she is not able to go for overnight stay and was discharged from services here at the nursing home. SSD #470 contacted her first emergency contact, which was her sister, and was told Resident #149 was not there. She contacted the resident's daughter (identified as the one the resident was going to discharge home with) and she did not know that her mother had left the facility. She stated she must have gone with another daughter. SSD explained about Medicare and overnight visits. Told her that therapy says she has met all of her goals and was going to be discharged from their services on 01/10/23 anyway. Told her facility would make a referral for therapy services and make follow up appointment with physician, and will send her home with 5 days worth of medications (resident already gone at this point). Also talked about making referral for Passport services. It was not determined in the notes where the resident actually was at that time. It was noted the resident had been marked as discharged . On 01/06/23 at 1:09 P.M. a nurses note stated family members here. Medication list and prescriptions given to family. A progress note by SSD #470 on 01/06/23 at 3:33 P.M. stated she spoke to Resident #149's sister and another daughter (not the one she spoke to earlier and not the one identified to discharge home with). Explained post discharge services facility would provide. Note stated the resident will be staying at her sister's home. Follow up physician's appointment provided. Interview with Assistant Business Office Manager #250 on 04/04/23 at 9:34 A.M. confirmed Resident #149 was notified on 01/03/23 that she was being cut from Medicare on 01/04/23. (only one day notice). She stated therapy tells her when residents are cut from Medicare. She stated she was not sure if the resident was really cut from Medicare on 01/04/23 but was told by someone (did not know who) to have the resident sign the Medicare notice of non-coverage since she was planning to go home. Interview with Therapy Director #800 on 04/04/23 at 9:45 A.M. revealed she thought the resident was cut from Medicare on 01/05/23 and confirmed the resident received therapy on 01/05/23, even though her notice of non-coverage stated she was cut on 01/04/23. She said there must have been a communication error amongst the staff. Interview with Social Service Director #470 on 04/04/23 at 10:00 A.M. revealed that Resident #149 was not to be cut from Medicare until 01/10/23. She confirmed the notice of non-coverage of Medicare was signed by the resident on 01/03/23 and it stated coverage ended 01/04/23. She confirmed the resident did not return to the facility after leaving with her family on 01/05/23 (after being discharged from physical therapy). She confirmed there was no evidence of any discharge planning being done even though the resident was notified she was cut from Medicare and it had not been decided where the resident was going to go. She stated when the family returned for the resident's belongings on 01/06/23, the resident was at her sister's house (even though when she called there earlier, she was told the resident was not there). She confirmed the resident did not return with family to get her belongings and was not seen again after she left on 01/05/23 at 6:24 P.M. Interview with the Director of Nursing on 04/05/23 at 9:25 A.M. confirmed there was no evidence of a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of medications, or a post-discharge plan of care. Interview with Resident #149's daughter on 04/04/23 at 9:10 A.M. (the daughter who the resident had indicated she would live with on discharge) revealed she was not aware her other sister was taking the resident out of the facility on 01/05/23. She said the resident did return to the resident's sisters house after discharge and remained there about a week before she required hospitalization again. She stated the resident is now in another nursing home.

Based on observations, medical record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming. This affected one ( Resident #41) of four residents reviewed for activities of daily living. The facility census was 92. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] and diagnoses including vascular dementia, chronic kidney disease, and chronic obstructive pulmonary disease. Review of Minimum Data Set assessment completed 01/05/23 indicated cognitive impairment. It further indicated the resident required extensive assistance from two staff for transfers and extensive assistance from one staff for personal hygiene, bathing, dressing, and locomotion. A plan of care dated 11/01/19 stated the resident had a self care deficit and will be dressed and groomed appropriately. It indicated the resident would receive assistance from staff. Observations on 03/27/23 at 4:52 P.M., 03/28/23 at 3:04 P.M., and 03/29/23 at 8:10 A.M. revealed Resident #41 to have white hairs present on her chin and upper lip. Review of the medical record did not reveal any evidence of refusal of personal hygiene in the past three months. Interview with Licensed Practical Nurse #890 on 03/29/23 at 9:35 A.M. revealed staff are to shave female residents with facial hair weekly or as needed. She confirmed Resident #41 required assistance from staff with hygiene. She confirmed the resident had hair on her chin and upper lip. She stated she would have staff provide care for this.

Based on observation, record review, interview, the facility failed to identify, assess and monitor skin conditions for Resident #57 and failed to ensure Resident #85's physician ordered wound dressings were in place. This affected two residents ( #57 and #85) of five residents review for skin conditions. The facility census was 92. Findings Include: 1. Review of the medical record for Resident #57 revealed an initial date of 07/23/20 with the latest readmission of 02/05/22 with the admitting diagnoses including congestive heart failure, acute and chronic respiratory failure, sleep apnea, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, diabetes mellitus, diverticulitis arthropathy, schizophrenia, dysphagia, history of COVID-19, benign prostatic hyperplasia, chronic embolism and thrombosis, anxiety disorder, hyperlipidemia, hypertension, constipation, unilateral inguinal hernia, adult failure to thrive and major depressive disorder. Review of the plan of care dated 07/22/20 revealed the resident was at risk for alteration in skin integrity related to diabetes, mobility status, nutritional status. Interventions included assist with incontinence care approximately every two hours and as needed, encourage mobility as tolerated, encourage to offload heels as much as resident will comply, encourage/assist to turn and reposition approximately every two hours as much as resident will comply, medications/supplements as ordered, pressure redistribution mattress for bed as needed, Registered Dietician (RD) consult as needed and treatments as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had no cognitive deficit. The resident required extensive assistance of two for bed mobility, dependent on two staff for transfers, toileting and was non-ambulatory. The resident was always incontinent of both bowel and bladder. The assessment indicated the resident had no skin issues. Review of the monthly physician orders for April 2023 identified an order dated 05/16/22 for weekly skin assessments every Thursday night. On 03/27/23 at 1:11 P.M., observation of the resident revealed multiple scabbed areas to right lower leg with a Band-Aid covering an area with active bleeding. Review of the medical record revealed no documented evidence the scabbed areas were assessed or monitored. On 03/29/23 at 4:30 P.M., interview with Clinical Nurse Consultant (CNC) #999 verified the scabbed areas was not identified, assessed or monitored. 34299 2. Review of the medical record for Resident #85 revealed an admitted [DATE] with diagnoses including sepsis, cellulitis of bilateral lower extremities, moderate protein calorie malnutrition, peripheral vascular disease, and hypertension. Review of the nursing progress notes revealed a note dated 02/04/23 at 2:00 A.M. The nurse assessed Resident #85 skin and wounds to bilateral lower extremities. The nurse removed ace wrap, Kerlix, and four by four gauze pads. The wounds were cleansed, measured and re dressed. There was notable bleeding and drainage noted to wounds. The wounds on the right lower extremity was noted to be necrotic. Review of the comprehensive Medicare five day MDS assessment dated [DATE] revealed Resident #85 was cognitively intact with a BIMS score of 15 out of 15. Resident #85 required assistance with activities of daily living. Resident #85 was coded with six venous/arterial ulcers with infection and treatment. Review of the plan of care dated 02/27/23 indicated Resident #85 had impaired skin integrity related to mixed vascular wounds to bilateral legs and feet. Interventions included administer medications and treatments as ordered, encourage resident to allow evaluation of bilateral lower extremities, encourage resident to ask for assistance to prevent trauma to wounds, observe for signs and symptoms of infection or worsening of wounds and notify the physician as needed. Review of the physician orders for March 2023 revealed Resident #85 had orders to cleanse bilateral lower legs with wound cleanser, apply Xeroform to wounds, cover with dressings (four by four gauze pads), and wrap in Kerlix daily. Review of the medication administration record for 03/20/23 revealed Resident #85 received wound care daily on day shift. There was no documentation of wound care as needed. Review of the weekly wound assessments dated 03/08/23, 03/15/23, 03/23/23 and 03/28/23 revealed Resident #85 wounds to bilateral lower extremities were healing. An observation on 03/29/23 at 10:05 A.M. revealed Resident #85 was lying in bed. Resident #85 was lying on his left side, and the outer Kerlix dressing was missing from right lower extremity exposing the venous ulcers. An observation on 04/03/23 at 10:20 A.M. revealed Resident #85 was seated in wheelchair in his room. The outer Kerlix dressing was missing from his right lower extremity, and was hanging loose and bunched at the ankle of left lower extremity. Resident #85 bilateral lower extremities were red and purple in color, had edema and no drainage was noted. The small pieces of Xeroform were noted to be covering the wound beds. An interview on 04/03/23 at 10:20 A.M. with Resident #85 revealed the dressing to his bilateral lower extremities had been off since last night and that it happened a lot. An interview on 03/29/23 at 10:07 A.M. with Licensed Practical Nurse (LPN) #255 confirmed by observation that Resident #85 wounds to bilateral lower extremities were not covered. An interview on 03/29/23 at 10:30 A.M. with the Director of Nursing (DON) confirmed by observation that Resident #85 wounds to bilateral lower extremities were not covered.

Based on observations, staff interviews, review of medical records, and review of facility policy, the facility failed to ensure adequate care and services were provided to prevent worsening of contracture's. This affected two residents (#2 and #52) out of two residents reviewed for limited range of motion. The facility census was 92. Findings include: 1. Record review for Resident #2 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia, Bell's Palsy, and contracture. Review of the annual Minimum Data Set (MDS) assessment, dated 03/02/23, revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility, transfers, and toileting and to be dependent upon one staff member for eating. This resident was assessed to have functional limitation in range of motion to bilateral upper and lower extremities. This resident was assessed to not have any recorded minutes of physical therapy, occupational therapy, or passive or active range of motion during the look-back period. Review of the active care plans for this resident revealed no evidence of a plan of care addressing contracture's or limited range of motion. Review of the active physicians orders for this resident revealed no orders for range of motion exercises, splints, or other devices to prevent the development or worsening of contracture's. Review of the Occupational Therapy Evaluation and Plan of Treatment, dated 03/30/23, revealed reason of referral to be resident presents with reported decline by staff resulting in need for skilled therapy to address decline in range of motion. Observation on 03/28/23 at 4:10 P.M. revealed Resident #2 was lying in bed and had contracture's present to both hands and feet. No splints or other devices were observed to be used. Interview with Certified Nurse Aide (CNA) #350 on 03/28/23 at 4:20 P.M. verified Resident #2 had contracture's to both hands and both feet and did not have any splints or devices ordered to be in place. CNA #350 stated the facility did not have a restorative program and there was no schedule for range of motion exercises to be performed for residents. Interview with the Administrator on 03/29/23 at 9:50 A.M. verified the facility did not currently have a restorative program in place. Interview with Licensed Practical Nurse (LPN) #890 on 03/29/23 at 12:10 P.M. revealed Resident #2 did not have any orders for splints, other devices, or range of motion exercises to be performed. Interview with Occupation Therapist (OT) #801 on 03/30/23 at 10:45 A.M. revealed Resident #2 was evaluated and was going to begin treatment with Occupational Therapy which included passive range of motion and stretching exercises and also a trial with a soft splint/palm guard to both contracted hands. OT #801 could not verify there had been a decline in the contracture's for Resident #2. Interview with CNA #135 on 04/03/23 at 3:35 P.M. revealed the employee was unsure if residents were supposed to receive passive range of motion during care and did not know where to look to find out. CNA #135 verified range of motion exercises were not being performed on Resident #2 during care. 32654 2. Review of the medical record for Resident #52 revealed an initial admitted [DATE] with the latest readmission of 03/23/23. Diagnoses included quadriplegia, cervical disc disorder, acute transverse myelitis in demyelinating disease of central nervous system, polyosteoarthritis, hypothyroidism, anemia, chronic viral hepatitis C, stiffness of unspecified joint, resistance to multiple antibiotics, major depressive disorder, hereditary and idiopathic neuropathy, contracture of unspecified joint, osteoporosis, gastro-esophageal reflux disease, neuromuscular dysfunction of bladder and bipolar disorder. Review of the nursing admission screening/history dated 08/16/21 revealed the resident had contracture's to the left hand, right hand, had foot drop and wears brace/boot for prevention and had foot drop to the left foot. Review of the OT evaluation and plan of treatment dated 08/17/21 revealed the resident right and left hand where within functional limits. Review of the OT evaluation and plan of treatment dated 11/15/22 revealed the resident's right and left hand were within functional limits. Review of the OT discharge summary dated 12/15/22 revealed a restorative or maintenance program was not indicated at that time. The summary indicated the resident's prognosis to maintain current level of function was good with consistent staff follow through. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had clear speech, understood others, makes herself understood and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had no cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required extensive assist of two staff for bed mobility, dependent on two staff for transfers and toileting use. The assessment indicated the resident had no function impairment to upper extremities and functional impairment to both lower extremities. Review of the monthly physician's orders for April 2023 identified an order dated 12/15/21 contracture boot right foot drop every shift. Review of the plan of care revealed no care plan addressing the resident's foot drop or contracture's to hands. Review of the OT evaluation and plan of treatment dated 03/30/23 revealed the resident's right thumb, index finger, middle finger, ring finger, little finger were now impaired. The evaluation indicated the functional limitations were from contracture. The evaluation documented the resident refuses resting hand splint. OT recommendations included passive range of motion (PROM) stretching and increasing tolerance for use of resident hand splint for right hand and PIP (proximal interphalangeal) joints. On 03/27/23 at 2:16 P.M., observation of Resident #52 revealed the resident was observed with contracture to right hand/fingers. Resident #52 was not able to open her hand fully when asked if she was able to open her hand. The resident stated, her hand had gotten worse since being admitted to the facility. Further observation revealed the resident had foot drop to right and left foot. On 3/29/23 at 9:50 A.M., interview with the Administrator revealed the facility currently had no restorative program in place. On 3/29/23 at 12:10 P.M., interview with Licensed Practical Nurse (LPN) #860 revealed the nursing staff did not do ROM with resident and was unsure how the facility monitored for worsening of contracture's. On 03/29/23 at 1:25 P.M., interview with Physical Therapy Assistant (PTA) #800 verified the resident's right had was contracted but the resident refused splints to both the right hand and the contracture boot to the right foot. On 04/04/23 at 10:46 A.M., interview with Clinical Nurse Consultant (CNC) #999 verified the resident had no program in place to prevent further decline in the resident's contracture's. On 04/04/23 at 09:43 AM interview with OT #800 revealed she had worked with the resident on multiple occasions. She revealed they code range of motion in two different categories. She said within normal limits (WNL), the resident had full function and within functional limits (WFL), the resident has impairments but is still able to function. She revealed the resident's impairments now prevent her to complete certain tasks. She revealed the facility currently had no restorative program and the ROM should be completed with activities of daily living (ADL) care by the floor staff. On 04/04/23 at 10:46 AM interview with CNC #999 confirmed the facility had no interventions in place to maintain the resident's ROM. Review of the facility titled Resident Mobility and Range of Motion, revised 07/2017, revealed residents will not experience an avoidable reduction in range of motion. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.

Based on observations, staff interviews, record reviews, and review of facility policy, the facility failed to ensure physician orders were in place for the administration of oxygen and failed to ensure oxygen was administered as ordered by the physician. This affected two residents (#1 and #345) out of the four residents reviewed for respiratory care. The facility census was 92. Findings include: 1. Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, chronic kidney disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/21/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to be independent with setup help only for eating. This resident was assessed to use oxygen while a resident of the facility. Review of the care plan, dated 07/28/22, revealed this resident had actual/at risk for impaired gas exchange. Interventions included to auscultate breath sounds as ordered, diagnostics as ordered, and medications/treatments as ordered. Review of the active physicians order, dated 08/08/22, revealed this resident had orders for the administration of oxygen at two liters per minute by nasal cannula as needed. Observation on 03/27/23 at 12:40 P.M. revealed Resident #1 was sitting in a wheelchair in her room and had oxygen being administered by nasal cannula at a rate of five liters per minute by nasal cannula. Observation on 03/28/23 at 8:08 A.M. revealed Resident #1 was lying in bed and had oxygen being administered by nasal cannula at a rate of five liters per minute by nasal cannula. Observation on 03/29/23 at 9:25 A.M. revealed Resident #1 was sitting up in a wheelchair in her room with oxygen being administered at a rate of five liters per minute by nasal cannula. Observation and interview with Licensed Practical Nurse (LPN) #890 on 03/29/23 at 11:20 AM verified Resident #1 was receiving oxygen at a rate of five liters per minute when the physicians order indicated two liters per minute of oxygen to be administered. LPN #890 immediately changed the administration of the oxygen to two liters per minute. 2. Record review for Resident #345 revealed this resident was admitted to the facility on [DATE] and had diagnoses including abnormal finding of the lung field and dependence on supplemental oxygen. Review of the care plan, dated 03/24/23, revealed this resident had actual/risk for impaired gas exchange related to oxygen dependence. Interventions included medications/treatments as ordered - see Medication Administration Record (MAR)/Treatment Administration Record (TAR) for specific instructions. Review of the active physicians orders for Resident #345 revealed no order for the administration of oxygen therapy. Observation on 03/28/23 at 8:12 A.M. revealed Resident #345 was lying in bed with oxygen being administered at a rate of two liters per minute by nasal cannula. Observation on 03/29/23 at 9:00 A.M. revealed Resident #345 was lying in bed with oxygen being administered at a rate of two liters per minute by nasal cannula. Observation and interview with LPN #890 on 03/29/23 at 10:40 A.M. verified Resident #345 was being administered oxygen at a rate of two liters per minute by nasal cannula without a physicians order. LPN #890 verified there should be an order in place for the administration of oxygen to a resident. Review of the facility policy titled Oxygen Administration, revised 10/2010, revealed in preparation to review the physician's orders or facility protocol for oxygen administration. Adjust the oxygen flow device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, staff interview, medical record review, the facility failed to provide Resident #2 a prescribed medication. This affected one resident (#2) of four residents reviewed for medication administration. The facility census was 92. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including hemiplegia, Bell's Palsy and contracture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed this resident was rarely/never understood. This resident was assessed to be dependent upon two staff members for bed mobility, transfers, and toileting and to be dependent upon one staff member for eating. Review of the physician orders dated March 2023 revealed Resident #2 was ordered Reglan 5 milligram (mg) tablets, give two tablets to equal 10 mg, via gastrointestinal tube four time daily at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. Review of the Medication Administration Record (MAR) dated March 2023 revealed Resident #2 did not receive the medication Reglan as ordered on 03/29/23 at 12:00 P.M. An observation on 03/29/23 at 12:10 P.M. of medication administration for Resident #2 with Licensed Practical Nurse (LPN) #890 revealed the medication Reglan was not available for administration. An interview on 03/29/23 at 3:05 P.M. with LPN #890 confirmed there was not any Reglan available for administration to Resident #2. The LPN stated she called the pharmacy for re order and delivery.

Based on medical record review, staff interview, and policy review, the facility failed to ensure irregularities identified by the pharmacist were reported to the physician and acted upon timely. This affected two (Residents #27 and #46) of five residents reviewed for unnecessary medications. The facility census was 92. Findings include: 1. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including Parkinson's disease, malignant neoplasm of the breast, lymphedema, hypertension, and [NAME] Body Dementia. The resident had received an antipsychotic medication (Quetiapine 50 milligrams at bedtime) since admission. Review of monthly pharmacy reviews since admission revealed the pharmacist indicated to see report for irregularities on 11/15/22, 12/30/22, and 02/24/23. Review of the pharmacy report for 11/15/22 revealed it stated the resident received an antipsychotic (Quetiapine) but did not have an A1C or fasting lipids documented as being done in the previous 12 months. It was recommended that the lab testing be completed as antipsychotic drugs have been associated with metabolic abnormalities, including increased waist circumference, weight gain, hyperglycemia, insulin resistance, and dyslipidemia. On 11/22/22 the nurse practitioner signed that she agreed with the recommendation and to implement the plan to obtain lab on next convenient lab day and at least annually thereafter. Review of the medical record did not reveal any evidence that the fasting lipid blood test had been completed as recommended. In addition, the pharmacy recommendations for 12/30/22 and 02/24/23 were not available in the medical record. Interview with the Director of Nursing on 04/05/23 at 9:30 A.M. confirmed the fasting lipids were not completed for Resident #46 as recommended by the pharmacist and the nurse practitioner on 11/22/22. She further stated the facility was unable to find the pharmacy recommendations from 12/30/22 or 02/24/23. 32654 2. Review of the medical record for Resident #27 revealed an initial admitted [DATE] with the latest readmission of 03/09/23 with the admitting diagnoses including traumatic subarachnoid hemorrhage, fracture of shaft of right femur, respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), asthma, diabetes mellitus, obesity, atrial fibrillation, depression, sleep apnea, heart failure, dysphagia, hypertension, generalized muscle weakness, difficulty, constipation, hypothyroidism, gastro-esophageal reflux disease, hyperlipidemia, chronic pain syndrome, benign prostatic hyperplasia with lower urinary tract symptoms, folate deficiency anemia and dependence on renal dialysis. Review of the plan of care dated 01/23/23 revealed the resident was at risk for complications from cardiac disease related to congestive heart failure, cerebrovascular disease, coronary artery disease, hypertension, history of myocardial infarct, hyperlipidemia and atrial fibrillation. Interventions included diagnostics as ordered, encourage rest periods to avoid overtiring, medications and treatments as ordered and vital signs as ordered and as needed. Review of the pharmacy recommendation dated 03/10/23 revealed the pharmacist recommended to change the administration times of the medication Midodrine from 9:00 A.M., 3:00 P.M. and 9:00 P.M. to upon rising, mid day and late afternoon (no later than 6:00 P.M.) and monitor blood pressure at least weekly as directed by the prescriber. The physician agreed with the recommendation as written. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive deficit. Review of the monthly physician orders for April 2023 identified an order dated 03/09/23 Midodrine 10 milligrams (mg) by mouth three times a day for dizziness. Review of the Medication Administration Record (MAR) for March 2023 revealed the medication Midodrine 10 mg by mouth three times a day was continued to be given at 9:00 A.M., 3:00 P.M. and 9:00 P.M. On 04/05/23 at 10:27 A.M., interview with Clinical Nurse Consultant (CNC) #999 verified the pharmacy recommendation was not implemented as physician ordered.

Based on observation, record review and staff interview the facility failed to ensure residents were weighed regularly and interventions implemented related to weight loss. Actual Harm occurred on 12/17/20 when Resident #100, who received all nutrition/hydration via a gastrostomy tube sustained a 7.2 pound/5.3 percent (%) significant weight loss in one month with no evidence the resident's enteral feeding was calculated to meet the resident's nutritional needs and no evidence new nutritional interventions were initiated timely. Actual Harm also occurred on 11/19/20 when Resident #102, who also received enteral nutrition/hydration via a gastrostomy tube was identified to have a 25 pound/18.7 percent severe weight loss in one month, a weight loss from 133 pounds on admission to 108 pounds without evidence the weights were verified for accuracy or evidence of new nutritional interventions or weight monitoring being initiated. On 12/09/20 Resident #102 was assessed to sustain an additional 14 pound/12.9 percent, severe weight loss in one month without evidence of comprehensive nutritional interventions to promote timely weight gain. In addition, observations on 01/06/21 revealed Resident #102 was not provided oral nutritional supplements as ordered and enteral feedings were not being provided as ordered from 01/06/21 to 01/11/21. This affected three residents (#1, #100 and #102) of three residents reviewed for weight loss. Findings include: 1. Review of the medical record for Resident #100 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The resident was admitted with pressure ulcers on the buttocks and heels (unstageable). Review of a nutritional assessment, completed 11/03/20 revealed the resident was 66 inches tall and weighed 145 pounds. An ideal body weight was listed as 130 pounds. The nutritional assessment did address the resident had pressure ulcers. Record review revealed the resident had a steady weight loss as follows: 11/03/20 142 pounds and 11/11/20 141 pounds. On 11/19/20 the resident's tube feeding was increased. On 11/20/20 the resident weighed 136.6 pounds and on 11/25/20 135 pounds. On 12/07/20 the tube feeding was increased again. There was no evidence the resident was weighed from 11/25/20 to 12/17/20. On 12/17/20 the resident weighed 127.8 pounds. This represented a 7.2 pound, 5.3 percent, significant weight loss in one month. The tube feeding was increased on 12/19/20. A nutrition note on 12/22/20 revealed the resident weighed 127.8 pounds and was receiving continuous tube feeding. The note did not evaluate the tube feeding for meeting the resident's needs. The resident had the following subsequent weights: 12/21/20 134 pounds; 12/20/20 132 pounds; 01/04/21 130 pounds. There had been no further nutritional interventions since 12/19/20. Interview with Dietician #201 on 01/11/21 at 2:25 P.M. revealed residents with tube feedings should be weighed weekly. She confirmed Resident #100 was not weighed weekly. She also confirmed the pressure ulcers were not addressed on the nutritional assessment and the tube feeding had not been evaluated for meeting the resident needs. 2. Review of the medical record for Resident #102 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of weight records revealed on 10/26/20 the resident weighed 133 pounds. A nutritional assessment completed by the dietician on 11/03/20 revealed the resident was receiving tube feeding continuously with no oral intake. The resident was 66 inches tall and had an ideal body weight listed of 135 pounds. The resident had a physician's orders [REDACTED]. There was no evidence the resident was weighed again until 11/19/20. The resident weighed 104.8 pounds at that time. A re-weight on 11/19/20 was listed as 108 pounds. This represented a 25 pound/ 18.7 percent severe weight loss in one month. A nutrition progress note on 11/19/20 revealed the resident had a weight loss of 25 pounds which might be an error in admission weight of 133 pounds. The note revealed fortified foods, house supplement with meals, and magic cup with lunch and dinner would be added as the resident now had oral intake. physician's orders [REDACTED]. There was no evidence the resident was weighed again until 12/09/20. The resident weighed 94 pounds at that time. This represented a 14 pound/12.9 percent, severe weight loss in one month. A nutrition note on 12/10/20 revealed the resident weighed 94 pounds and had a 13 percent weight loss in one month. The note revealed the tube feedings were now continuous. An order had been obtained on 12/09/20 to increase tube feeding to 75 cubic centimeters (cc's) per hour around the clock. Review of a Minimum Data Set (MDS) 3.0 assessment completed 01/01/21 revealed the resident had short and long term memory impairment, was totally dependent upon staff with eating, and had a feeding tube. The resident was then weighed weekly and on 01/04/21 weighed 102.2 pounds. An order was obtained on 01/06/21 to decrease tube feeding to 240 cc at bedtime. However, record review revealed no evidence the resident had received any tube feeding of [MEDICATION NAME] since 01/06/21. A nutrition note on 01/11/21 revealed the resident had gained 1.2 pounds. It indicated the tube feedings had been decreased to 240 cc at night and to continue with supplements On 01/06/21 at 12:55 P.M. observations of the lunch meal revealed Resident #102 received a tray containing a sandwich, soup, crackers, fruit, and milk. The card on the tray stated the resident was to received a health shake and a magic cup with meals. The resident did not receive a health shake or a magic cup with the lunch meal. At 1:30 P.M. the resident still had her lunch tray and had eaten approximately 50% of the meal. Interview with Nursing Assistant #202 on 01/06/21 at 1:30 P.M. confirmed Resident #102 did not receive any supplements on her lunch tray to include magic cup or health shake. Interview with Registered Nurse #203 on 01/06/21 at 1:45 P.M. confirmed Resident #102 was to receive a health shake and magic cup on her lunch tray. She stated the kitchen was supposed to send them on her tray. Interview with Dietician #201 on 01/11/21 at 2:20 P.M. confirmed weekly weights should have been completed for Resident #102 and were not. She confirmed there was no evidence the resident had received any tube feeding as ordered between 01/06/21 and 01/11/21. 3. Review of the medical record for Resident #1 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of weight records revealed the residents weight was 223 pounds on admission. The resident had monthly weights and was 226 pounds on 08/11/20. Review of physician's orders [REDACTED]. There was no evidence the resident was weighed from 08/11/20 until 10/27/20. On 10/27/20 the resident weighed 203 pounds. This represented a 23 pound, 10 percent (%)/severe weight loss in 2.5 months. There was no evidence the 23 pound weight loss was evaluated or that any nutritional interventions were implemented. The resident was weighed again on 11/02/20 and weighed 203 pounds. There was no evidence the resident was weighed from 11/02/20 until 12/30/20. On 12/30/20 the resident weighed 188.4 pounds. This represented an additional 14.6 pound/7 % significant weight loss in two months. Review of a nutrition progress note, dated 12/30/20 revealed the resident weighed 188.4 pounds and had experienced a 7.4% weight loss in one month. The recommendation was to add no sugar added house supplements with meals. A physician's orders [REDACTED]. The previous nutrition note was dated 09/26/20 (prior to the weight loss). Overall, the resident experienced a 37.6 pound, 16.6 percent weigh loss in four months without intervention until 12/31/20. On 01/11/21 at 2:50 P.M. interview with Dietician #201 confirmed Resident #1 was not weighed from 08/11/20 to 10/27/20. She confirmed the resident had an order for [REDACTED]. She confirmed the resident was weighed only on 11/02/20 and 12/30/20. She confirmed the resident experienced an additional 14.6 pound weight loss as of 12/30/20. She confirmed a re-weight was not completed after the 188.4 pound weight was obtained on 12/30/20. Review of the facility weight policy, dated 2001 revealed nursing staff would weigh residents on admission and weekly times three weeks thereafter. If no weight concerns were noted, weights would be completed monthly thereafter. Weights would be recorded in resident's charts. Any weight change of five percent or more since last weight will be retaken next day for confirmation. The dietician would review weight records by the 10th of the month to follow weight trends over time. This deficiency substantiates Complaint Number OH 841.

Based on record review, a fall investigation review and staff interview, the facility failed to provide a resident with adequate assistance during personal care that resulted in an avoidable fall with injury. This affected one (Resident #45) of three residents who were reviewed for falls and resulted in harm for Resident #45 who sustained a femur fracture as a result of the avoidable fall. Findings include: Review of Resident #45's medical record revealed the resident was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] revealed the resident was a high risk for falls. The fall risk assessment identified risk factors of the resident that included intermittent confusion, being chair bound, and having [DIAGNOSES REDACTED]. Additional quarterly fall risk assessments completed after 08/10/11 continued to assess the resident as a high fall risk. A quarterly Minimum Data Set assessment dated [DATE] revealed the resident was dependent on the assistance of two staff for bed mobility. A care plan for Impaired Physical Mobility included interventions to transfer the resident with the assistance of two. It also indicated the facility staff may use a mechanical lift for transfers. The care plan included updated interventions that were added on 10/01/12 instructing the staff to provide two person assist with all personal care. Review of the nurse's notes revealed the resident sustained [REDACTED].M. when a nursing assistant was providing care to the resident. The note indicated that while the care was being provided to the resident she rolled out of bed and fell on to the floor. As a result of the fall, the resident reported hitting her head and complained of left hip pain. After being assessed by the nurse, the resident was transported to the emergency room for an evaluation. A nurse's note after the documentation of the fall indicated the resident was admitted to the hospital with [REDACTED]. Review of a fall investigation report completed for the fall that occurred on 09/27/12 determined that only one nursing assistant was present at the time of the incident. The investigation concluded the resident rolled out of bed when a nursing assistant was providing personal care to the resident. Through interviewing the nursing assistant involved, the Director of Nursing (DON) discovered the resident accidentally rolled out of bed when she was being turned by the nursing assistant. The state tested nursing assistant (STNA)#10 reported that he felt he could provide the care to the resident on his own without help from the other staff. Interview with licensed practical nurse (LPN) #11 on 10/25/12 at 12:15 P.M. revealed Resident #45 did require extensive assistance with her activities of daily living (ADL's) prior to the fall that occurred on 09/27/12. She stated it took two staff members to provide incontinence care or when changing the resident. She reported that she thought it was possible for one staff member to turn the resident in bed but it would have been necessary to raise the side rail up on the opposite side when turning the resident to prevent her from rolling out of bed. Interview with STNA #12 on 10/25/12 at 12:20 P.M. revealed Resident #45 was considered total care with her ADL's even prior to the fall that occurred on 9/27/12. She reported she thought the resident could have been turned by only one person but they should have had the side rail on the other side raised to prevent her from rolling out of the bed. She stated two people were required when changing the resident or providing personal care. Interview with the DON on 10/25/12 at 3:35 P.M. revealed the facility did not have a policy on the provisions of ADL assistance. She stated the staff was to follow the resident's plan of care. She confirmed the fall with a femur fracture occurred with Resident #45 as a result of STNA #10 providing unsafe care. She stated he should have had another staff member with him when personal care was being provided to the resident.