Every finding on record at Harrison Pavilion Care Center

Based on record review, observations, staff interviews, policy review, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess Resident #09's skin, failed to timely identify the resident's pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), until it had reached an advanced stage and failed to timely implement provider ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm to Resident #09, who was admitted without pressure ulcers but was at risk for the development of pressures and subsequently developed an avoidable, facility acquired pressure ulcer. Resident #09 was assessed by Wound Nurse Practitioner (WNP) #60 on 11/04/25 and treatment orders were recommended but not implemented until 11/11/25. On 11/10/25, Resident #09 had red areas to both buttocks with bleeding. Resident #09 was assessed on 11/13/25 by WNP #60 with two pressure ulcers, one of which was first identified as a stage III pressure ulcer (full-thickness skin loss in which adipose [fat] is visible) to the resident's sacrum and a stage II pressure ulcer (partial thickness loss of skin with exposed dermis) to the residents left buttock. This affected one (Resident #09) of three residents reviewed for pressure ulcers. The facility census was 78.Findings include: Review of the medical record of Resident #09 revealed an admission date of 10/20/25. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included cellulitis, stage III pressure ulcer to sacrum, atrial fibrillation, and hemiparesis and hemiplegia to right dominant side. Review of the admission care plan initiated on 10/21/25, revealed Resident #09 was at risk for altered skin integrity and pressure ulcers related to bowel and bladder incontinence, limited mobility, decreased ADL self-performance, medical diagnoses, and overall medical conditions. Interventions included a pressure reduction device to bed (low air loss mattress with bolsters). Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/21/25, revealed Resident #09 was at high risk for developing pressure ulcers.Review of the physician order dated 10/21/25, revealed Resident #09 was ordered to receive house barrier cream applied to peri-area buttocks after each incontinent episode and as needed (PRN) to prevent skin breakdown.Review of the progress note dated 11/04/25 at 2:38 P.M. and authored by Wound Nurse Practitioner (WNP) #60, revealed Resident #09 returned from the hospital and had incontinent associated dermatitis to the right buttock that measured 3.0 centimeters (cm) in length by 2.0 cm in width by 0.1 cm in depth. Treatment orders were to cleanse area with normal saline, apply Venelex (topical cream to promote the healing of skin ulcers and wounds) to base of the wound, leave open to air every shift and as needed and provide turning and repositioning per protocol for pressure prevention. Review of November 2025 Treatment Administration Record (TAR) for Resident #09 from 11/04/25 through 11/10/25, revealed no documented treatments per WNP #60's treatment orders on 11/04/25. Review of the Five-Day Medicare Minimum Data Set (MDS) assessment for Resident #09 dated 11/07/25, revealed the resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was dependent on staff for activities of daily living (ADL). Section M (skin conditions) revealed the resident did not have a pressure ulcer but was at risk.Review of the skilled nurse's note dated 11/09/25, revealed Resident #09's skin appearance was within normal limits with no new changes to skin integrity. Review of the progress note dated 11/10/25 at 7:52 A.M., revealed the staff noted red areas to Resident #09's bilateral buttocks with minimal bleeding. Resident #09 made groaning and moaning noises when the area was cleaned. Resident #09's sister and other parties were notified. Review of the physician order dated 11/11/25, revealed Resident #09 was ordered to have his right buttocks cleansed with normal saline, Venelex applied, and leave open to air every shift. This order was originally supposed to be implemented on 11/04/25 per WNP #60's treatment orders. Review of the progress note dated 11/13/25 at 9:39 A.M. and authored by WNP #60, revealed Resident #09 had the following skin concerns: right buttock had incontinence associated dermatitis which measured 5.5 cm in length by 4.0 cm in width by 0.2 cm in depth with 80 percent (%) granulation (new tissues) and 20 % slough (peeling skin), sacrum had a stage III pressure ulcer which measured 3.0 cm in length by 1.5 cm in width by 0.3 cm in depth with 90 % granulation and 10 % slough, and left buttock had a stage II pressure ulcer which measured 2.5 cm in length by 3.5 centimeters in width by 0.1 cm in depth with 100% epithelial tissue. New treatment orders were recommended including a low air loss (LAL) mattress. Review of the physician order dated 11/13/25, revealed Resident #09 was ordered the following: Left buttock cleansed with normal saline, skin prep to peri-wound hydrogel, and covered with border foam daily, sacrum cleansed with normal saline, skin prep to peri-wound, hydrogel and covered with border foam daily and right buttock cleansed with normal saline, skin prep to peri-wound, hydrogel, and covered with border foam daily.Review of the revised care plan dated 11/14/25, revealed Resident #09 had an actual impairment to skin integrity related to stage II pressure ulcer to left buttock and a stage III pressure ulcer to sacrum. Interventions included administering medications as ordered, administering treatments as ordered, encouraging good nutrition, inspecting the skin on a daily basis when performing and assisting with personal care, and monitoring and documenting location, size, and treatments.Review of the physician order dated 11/20/25, revealed Resident #09 was ordered to be turned and repositioned every two hours and to have a LAL mattress, which was supposed to be implemented on 11/13/25 per WNP #60's treatment orders. During an interview on 11/26/25 at 7:58 A.M., WNP #60 stated she saw the resident on 11/04/25 after he returned from the hospital and he had incontinence associated dermatitis to the right buttock. WNP #60 reported she saw the resident again on 11/13/25 and he had developed a stage III pressure ulcer to his sacrum and a stage II pressure ulcer to the left buttock. WNP #60 stated Resident #09 was dependent on staff for ADLs including turning and repositioning. WNP #60 verified his wounds were avoidable with proper treatments, turning, repositioning and timely incontinence care. Observation on 11/26/25 at 10:05 A.M., revealed Resident #09's wound bed was about a half dollar in size with no signs of infection or drainage noted.During an interview on 11/26/25 at 11:53 A.M., Licensed Practical Nurse (LPN) Unit Manager #29 verified Resident #09's treatment orders were not implemented timely. LPN Unit Manager #29 stated when WNP #60 rounds, it was the responsibility of the nursing staff to enter the orders. LPN Unit Manager #29 reported the nurses should be thoroughly and accurately assessing residents' skin and documenting areas in the medical record.Interview on 11/26/25 at 11:58 A.M., the Director of Nursing (DON) verified Resident #09 was dependent on staff for ADLs and went from having no pressure ulcers to the development of stage II pressure ulcer on the left buttock and a stage III pressure ulcer to the sacrum which were first identified on 11/13/25.Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.This deficiency represents non-compliance investigated under Complaint Number 2622250.

Based on record review, staff interviews and policy review, the facility failed to ensure Resident #03's power-of-attorney (POA) was notified of the resident's change in condition status and transfer to the hospital. This affected one (Resident #03) of three records reviewed for notification. The facility census was 78.Findings include:Review of the medical record revealed Resident #03 was admitted to the facility on [DATE]. Diagnoses included cognitive communication deficit, altered mental status, mood disorder, major depressive disorder, dementia and Alzheimer's disease. The resident had a designated POA listed in the record. Review of Resident #03's progress note dated 10/10/25, revealed the resident's mental status changed from baseline to increased confusion. The resident's vital signs were temperature 97.7 degrees Fahrenheit, blood pressure 136 over 85 millimeters of mercury (mmHg), heart rate 56 beats per minute and oxygen percentage of 96 percent (%). The physician was notified via voicemail, and the nurse was waiting for a response. There was no documented evidence that the resident's POA was notified. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #03 had no behaviors, severely impaired cognition, independent with eating, set up for toileting, set up for bathing, and set up for personal hygiene.Review of Resident #03's progress note dated 10/24/25 and authored by Licensed Practical Nurse (LPN) #22, revealed the physician was notified of the resident's mental status changes. The resident continued with confusion, refusal of care, and hallucinations. The resident was awake and restless during the entire night and argumentative with the staff. The resident refused medications and personal care after multiple attempts. The resident continued to wander the unit seated in a wheelchair and attempts of redirection were met with increased agitation. There was no documented evidence that the resident's POA was notified. Review of Resident #03's progress note dated 10/24/25, revealed the physician ordered the resident to be sent to the emergency room (ER) due to delirium. A report was given to University of Cincinnati (UC) Health Main ER. There was no documented evidence that the resident's POA was notified. Review of Resident #03 progress note dated 10/24/25, revealed the resident was transported to UC Hospital at 8:00 A.M. via stretcher due to altered mental status. The resident appeared confused at the time of transfer. The physician was notified. There was no documented evidence that the resident's POA was notified. During an interview on 11/25/25 at 12:20 P.M., LPN Unit Manager #29 stated if a resident was transferred out of the facility, the POA and /or guardian should be notified. During an interview on 11/26/25 at 8:25 A.M., the Director of Nursing (DON) confirmed Resident #03's guardian was not notified when the resident had a change in condition and was transported to the hospital. Review of the policy titled, Change in a Resident's Condition or Status dated 05/2017, revealed, the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when it is necessary to transfer the resident to a hospital/treatment center.This deficiency represents non-compliance investigated under Complaint Number 2622250.

Based on record review, staff interviews, review of pharmacy records, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #45) of three resident reviewed for medication administration. The facility census was 78.Findings include:Review of the medical record for Resident #45 revealed an admission date of 03/19/24. Diagnoses included hyperosmolality and hypernatremia, major depressive disorder, and pressure ulcer of the sacral region.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #45 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Review of the physician order dated 11/11/25, revealed Resident #45 was ordered Meropenem (antibiotic) Intravenous (IV) Solution Reconstituted one gram (gm), use one gram intravenously every eight hours for infected sacral wound for 14 days.Review of the Pharmacy Delivery Receipt dated 11/11/25, revealed Resident #45 received 24 bags (an 8-day supply) of Meropenem IV solution.Review of the November 2025 medication administration record (MAR), revealed Resident #45 did not receive IV Meropenem IV solution on 11/14/25 at 9:00 P.M., 11/15/25 at 5:00 A.M., 1:00 P.M., and 9:00 P.M., 11/16/25 at 5:00 A.M., 1:00 P.M., and 9:00 P.M., and 11/17/25 at 5:00 A.M.Review of the pharmacy progress note dated 11/15/25 at 4:55 A.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order.Review of the pharmacy progress note dated 11/15/25 at 11:09 P.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review of the pharmacy progress note dated 11/16/25 at 5:11 A.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review of the pharmacy progress note dated 11/16/25 at 4:15 P.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review of the pharmacy progress note dated 11/16/25 at 8:41 P.M., revealed Resident #45 did not receive Meropenem IV solution because medication on order at pharmacy.Review of the pharmacy progress note dated 11/17/25 at 4:52 A.M., revealed Resident #45 did not receive Meropenem IV solution because the medication was on order. Review pf the pharmacy delivery receipt dated 11/18/25, revealed Resident #45 received 21 bags (a seven-day supply) of Meropenem IV solution.During an interview on 11/26/25 at 8:07 A.M., Pharmacy Representative (PR) #100, stated an order was submitted on 11/11/25 for Meropenem IV solution. PR #100 reported a seven-day supply (24 bags) was sent on 11/11/25. PR #100 also reported a seven-day supply (21 bags) was sent on 11/18/25.During an interview on 11/26/25 at 9:27 A.M., the Director of Nursing (DON) verified Resident #45 missed doses of Meropenem on 11/14/25, 11/15/25, 11/16/25, and 11/17/25.During an interview on 11/26/25 at 1:05 P.M., the DON stated Resident #45 was not given IV Meropenem on the above days because an agency nurse was working and didn't ask where the IV medications were stored.Review of the facility policy titled, Administering Medications, revised April 2019, revealed medications were administered in a safe and timely manner, and as prescribed. Medications were administered within one hour of their prescribed time, unless otherwise specified.This deficiency represents non-compliance investigated under Complaint Number 2639823.

Based on observations, staff interviews, and policy review, the facility failed to ensure dishware was clean prior to serving pureed meal service. This affected one (Resident #11) of one resident who the facility identified as receiving pureed diets. The facility census was 78.Findings include:Record of the medical record for Resident #11 revealed an admission date of 05/06/24. Diagnoses included dysphagia, epilepsy, mood disorder, and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. Review of the physician order dated 11/21/25, revealed Resident #11 was ordered a regular diet, pureed texture, regular thin consistency.Observation on 11/25/25 at 11:46 A.M., revealed [NAME] #110 obtained a divided plate, which had food particles from previous meal on plate. [NAME] #110 went to sink and rinsed with water and then placed pureed pasta onto that divided plate.During an interview on 11/25/25 at 11:50 A.M. [NAME] #110 verified the divided plate was not clean and had food on it from previous meal. [NAME] #110 verified she rinsed off the plate with water and placed pureed pasta and placed onto lunch tray to be served.Review of the facility policy titled, Food Preparation and Service, revised October 2017 revealed food and nutrition services employees shall prepare and serve food in a manner that complied with safe food handling practices. Areas for cleaning dishes and utensils were located in a separate area from the food service line to ensure that a sanitary environment was maintained.

Based on record review, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were implemented during wound care. This affected one (Resident #09) of three residents reviewed for wound care. The facility census was 78.Findings include:Review of the medical record of Resident #09 revealed an admission date of 10/20/25. Diagnoses included cellulitis, stage three pressure ulcer to sacrum, atrial fibrillation, and hemiparesis and hemiplegia to right dominant side.Review of the Five-Day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #09 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was assessed to require dependent with toileting, bathing, dressing, and transfers.Review of the physician order dated 11/20/25, revealed Resident #09 was ordered to have right buttocks cleansed with normal saline, skin prep to peri-wound, and covered with border foam one time a day for wound care.During an observation of wound care for Resident #09 on 11/26/25 at 10:05 A.M., by Licensed Practical Nurse (LPN) #23 with the assistance of Certified Nursing Assistant (CNA) #13, revealed LPN #23 did not remove her soiled gloves and perform hand hygiene after removing the old dressing from Resident #09. LPN #23 wore the same gloves for the entirety of the dressing change.During an interview on 11/26/25 at 10:26 A.M., LPN #23 verified she did not remove her soiled gloves after removing Resident #09's old dressing. LPN #23 verified she should have removed her soiled gloves and performed hand hygiene prior to cleaning and placing a new dressing to Resident #09's wound.Review of the facility policy titled, Wound Care revised October 2010, revealed the purpose was to provide guidelines for the care of wounds to promote healing. Wash and dry hands thoroughly and put on gloves. Loosen tape and remove dressing. Pull gloves over the dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves and continue treatment.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications were stored appropriately and failed to discard expired medications. This had the potential to affect 35 facility-identified residents who receive medications from medication cart number two/back east, from medication cart short front, and from medication cart short back hall. The facility also failed to discard expired medications and supplies stored in the medication room. This had the potential to affect all of the residents residing in the facility. The facility census was 79 residents.Findings include: Observation on 09/10/25 at 9:33 A.M. of the medication room with Licensed Practical Nurse (LPN) #340 revealed there were two bottles of multi-vitamin with iron with an expiration date of August 2025. The medication room also contained a negative pressure wound therapy foam kit with an expiration date of February 2020 and expired bottles of Vital 1.5 tube feeding (10 bottles expired May 2025 and 41 bottles expired August 2025.) Interview on 09/10/25 at 9:35 A.M. with LPN #340 confirmed the expired items in the medication room were house stock items which should have been discarded.Observation on 09/10/25 at 10:15 A.M. of medication cart number two, back east for resident rooms 17 through 30 with LPN #340 and LPN #310 revealed the top drawer had 11 loose unidentified pills on the bottom of the drawer. The second drawer had 11 tablets found on the bottom of the drawer out of packaging. The third drawer on the right side of the cart had a brown sticky substance with paper stuck to it on the bottom of the drawer.Interview on 09/10/25 at 10:18 A.M. with LPN #340 confirmed the loose unidentified pills in the medication cart number two should have been discarded and the sticky brown substance in the third drawer should have been cleaned. Observation on 09/10/25 at 10:32 A.M. of the medication cart short front for resident rooms 33 through 44 with LPN #340 and LPN #316 revealed the third and fourth drawer on the right had a sticky pink substance on the bottom with paper stuck to it. In the bottom right drawer, there were three bottles of hydrogen peroxide with an expiration date of January 2025 and an intravenous (IV) start kit with chloraprep with an expiration date of 03/31/25. The bottom drawer of the cart had a light brown substance with particles in the bottom below the medications. Interview on 09/10/25 at 10:36 A.M. with LPN #340 confirmed the nurses were to the clean the carts daily and as needed, and the expired items should have been discarded. Observation on 09/10/25 at 11:05 A.M. of the medication cart for the short back hall for resident rooms 62, 64, 66, 68 and 70 with LPN #490 revealed the top drawer had 61 loose unidentified pills on the bottom of the drawer. There was a sticky clear substance on the bottom of the drawer with one pill stuck in the substance. The third drawer on the right side of the cart had a pink and brown sticky substance covering the entire bottom. Interview on 09/10/25 at 11:10 A.M. with LPN #490 confirmed the loose pills in the cart should have been discarded and the sticky substances in the cart should have been cleaned. Review of the facility policy titled Storage of Medications dated 2019 revealed the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food items were stored properly and the kitchen was maintained in clean, sanitary manner. This had the potential to affect all the residents receiving food from the facility. The facility census was 79 residents. Findings include:Observation on 09/08/25 at 10:22 A.M with the Dietary Manager (DM) revealed there was a bottle of cleaning spray on the clean dish rack and on the clean dishes there was a piece of cardboard, a soiled rag, and an opened bottle of soda. Observation 09/08/25 at 10:25 A.M of the dry storage area with the DM revealed the following unlabeled and undated items: two bags of elbow pasta, a bag of egg noodles, a container of rolled oats, a bag of croutons. There was also a package of gravy with an expiration date of 07/07/25. Interview on 09/08/25 at 10:30 A.M with the DM confirmed items should not be stored in the clean dish area and the items in the dry storage area should be labeled and dated. The DM confirmed expired items should be discarded. Observation on 09/08/25 at 10:32 A.M of the cold storage with the DM revealed in walk in refrigerator contained the following unlabled and undated items: a gallon container of orange juice, a gallon container of grape juice, an opened package of Swiss cheese, an opened package of cheddar cheese. The walk-in freezer contained a package of undated and unlabeled chicken nuggets. The walk-in freezer also had dirty gloves on the floor of the freezer and dried up a brown substance on the floor. Interview on 09/08/25 at 10:35 A.M with the DM confirmed items in cold storage should be labeled and dated and the gloves and dried substance on the floor of the freezer should have been cleaned. Observation on 09/08/25 at 10:36 A.M with the DM revealed the stand-up refrigerator contained the following undated and unlabeled items: 12 cups of fruit, two cups of shredded cheddar cheese, two cups of cottage cheese. Interview on 09/08/25 at 10:37 A.M. with the DM confirmed all items in the stand-up refrigerator should be labeled and dated. Observation on 09/08/25 at 10:38 A.M with the DM revealed there were unlabeled and undated containers of sugar, flour, and breadcrumbs in the kitchen prep station. Interview on 09/08/25 at 10:29 A.M with the DM confirmed the containers of sugar, flour, and breadcrumbs in the kitchen prep station were undated and unlabeled. Observation 09/08/25 at 10:30 A.M with the DM revealed the robot coupe (appliance used to puree food) had not cleaned after use and the hood above the stove had a dark, brown substance on top and on the wall. Interview on 09/08/25 at 10:31 A.M with the DM confirmed the robot coupe should have been cleaned immediately after use and stove hood and wall should have been cleaned. Observation on 09/11/25 at 11:15 A.M. with the DM revealed the air vent above the kitchen prep and serving area had a build-up of a dark fuzzy substance. Interview on 09/11/25 at 11:15 A.M. with the DM confirmed the air vent above the kitchen prep and serving area had a build-up of a dark fuzzy substance. Review of the facility policy titled Food Receiving and Storage dated on October 2017 revealed the facility staff should label and date all food items and use perishable items within seven days after opening.

Based on medical record review and staff interview, the facility failed to complete a significant change Pre-admission Screening and Resident Review (PASARR) assessment after residents received new diagnoses for psychiatric disorders. This affected two (Residents #7 and #76) of four residents sampled for PASARR. The facility census was 79 residents. Findings include: 1.Review of the medical record for Resident #76, revealed an admission date of 04/15/24 with diagnoses including cerebrovascular accident (CVA) with hemiplegia and hemiparesis, anxiety disorder, schizoaffective disorder, and depression. Review of the PASARR for Resident #76 dated 10/21/21 revealed it did not include a diagnosis of schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment for Resident #76 dated 07/22/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Interview on 09/10/25 at 2:57 P.M. with the Administrator confirmed the facility should have completed an updated PASARR when Resident #76 was admitted on [DATE] with a diagnosis of schizoaffective disorder. 2.Review of the medical record for Resident #7 revealed an admission date of 08/03/18 with diagnoses of major depressive disorder. A diagnosis of bipolar disorder was added on 07/07/24. Review of the PASARR for Resident #7 dated 02/22/22 revealed the resident's only psychiatric diagnosis was major depressive disorder. Review of the MDS assessment for Resident #7 dated 06/18/25 revealed Resident #7 had moderately impaired cognition. Interview on 09/09/25 at 2:38 P.M. with Social Worker (SW) #476 confirmed the facility did not complete an updated PASARR in 2024 for Resident #7 when an updated diagnosis of bipolar disorder was added 07/07/24. Interview on 09/09/2025 at 3:51 P.M. with Corporate Registered Nurse (CRN) #482 confirmed the facility should complete a significant change PASARR within 72 hours of any new psychiatric diagnosis.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents received timely treatment for respiratory infections. This affected one (Resident #7) of seven residents sampled for respiratory infections. The facility census was 79 residents. Findings include: Review of the medical record for Resident #7 revealed an admission date of 08/03/18 with a diagnosis of major depressive disorder Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 06/18/25 revealed the resident had moderately impaired cognition. Review of the progress note for Resident #7 dated 09/03/25 revealed the nurse practitioner (NP) assessed Resident #7 for complaints of complaint of cough for several days. Lung auscultation revealed concerns for wheezes bilaterally. The NP gave orders for a stat (immediate) chest x-ray and Tylenol cold & flu medication. Review of the physician's orders for Resident #7 revealed an order dated 09/03/25 for a stat chest x-ray. There was no written order for Tylenol cold and flu medication. Interview on 09/08/25 at 11:34 A.M. with Resident #7 confirmed he had for medicine for flu and had been having symptoms for a week or two including a cough and a runny nose. Interview on 09/10/25 at 10:00 A.M. NP #492 confirmed she had assessed Resident #7 on 09/03/25 and gave a verbal order to the nurse to implement the standing order for Tylenol cold and flu medication and to give a dose immediately. NP #492 stated she was unaware the order had not been placed and verified the Tylenol cold and flu medication was not on Resident #7's profile.This deficiency represents noncompliance investigated under Complaint Number OH00162888 (iQIES 1311544)

Based on medical record review, staff interview, and review of the facility policy, the facility failed to complete root cause analysis following resident falls. This affected one (Resident #39) of three residents reviewed for falls. The facility census was 79 residents.Findings include:Review of the medical record for Resident #39 revealed an admission date of 06/17/24 with diagnoses including Parkinson's disease, type two diabetes, depression, generalized anxiety disorder, and unspecified dementia. Review of care plan for Resident #39 dated 06/18/24 revealed the resident was at risk for falls. Interventions included anticipating resident needs, keeping the call light within reach, maintaining a safe environment, and educating the resident regarding appropriate footwear, using call light for assistance, and safe use of mobility devices. Review of the progress note for #39 dated 02/24/25 revealed the resident had an unwitnessed fall in her room. Staff found Resident #39 seated on the floor in front of her walker. Resident #39 stated she hit her head during the fall. Review of the facility incident report and investigation of Resident #39's fall on 02/24/25 revealed it did not include a root cause analysis of the events and factors leading to the resident's fall. Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 06/24/25 revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Interview on 09/11/25 at 10:00 A.M. with the Director of Nursing (DON) confirmed the facility did not complete a root cause analysis of Resident #39's fall on 02/24/25. The DON confirmed part of the facility's fall investigation process should include a root cause analysis. Review of the facility policy titled Managing Falls and Fall Risk dated December 2007 revealed the facility evaluated falls and identified interventions related to the resident's specific risks and causes to try to prevent the resident from falling. This deficiency represents noncompliance investigated under Complaint Number OH00162646 (1311543).

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the medication error rate was less than five percent (%). The facility had three medication errors per 25 medication opportunities with a medication error rate of 12 %. This affected two (Residents #2 and #44) of three residents observed for medication administration. The facility census was 79 residents.Findings include:1.Review of the medical record for Resident #2 revealed an admission date of 03/13/24 with diagnoses including anxiety disorder, congestive heart failure (CHF), and type two diabetes mellitus.Review of the physician's order for Resident #2 revealed an order dated 03/13/24 for spironolactone 25 milligrams (mg), give one tablet by mouth one time a day for hypertension and an order dated 03/13/24 for cyanocobalamin 100 micrograms (mcg), give one tablet by mouth one time per day. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 08/19/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Observation on 09/09/25 at 8:32 A.M. revealed Licensed Practical Nurse (LPN) #310 did not administer spironolactone and cyanocobalamin to Resident #2 because the medications were not available. Interview on 09/09/25 at 8:58 A.M. with LPN #310 verified Resident #2's spironolactone and cyanocobalamin were not available to administer.2.Review of the medical record for Resident #44 revealed an admission date of 10/31/24 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, and depression.Review of the physician's orders for Resident #44 revealed an order dated 11/11/24 Novolog insulin per sliding scale inject subcutaneously.Review of the MDS assessment for Resident #44 dated 08/07/25 revealed the resident was cognitively intact and required assistance with ADLs. Observation on 09/09/25 at 12:14 P.M. revealed LPN #313 not prime the insulin pen prior to administering four units of insulin to Resident #44. Interview on 09/09/25 at 12:25 P.M. with LPN #313 verified she did not prime insulin pen with two units prior to administration to Resident #44.Review of the facility policy titled Administering Medications dated April 2019 revealed medications were administered in a safe and timely manner, and as prescribed. Medication errors were documented in the medical record, reported to the provider and resident/resident representative, and the resident was monitored for adverse effects of the medication error as ordered by the provider.

Based on review of the medical record review, observation, staff interview, and review of manufacturer's instructions, the facility failed to prime an insulin pen prior to administration. This affected one (Resident #44) of one observed for insulin administration and had the potential to affect two residents on medication cart one on the east hall with physician orders for insulin. The facility census was 79 residentsFindings include:Review of the medical record for Resident #44 revealed an admission date of 10/31/24 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #44 dated 08/07/25 revealed the resident had intact cognition and required assistance with activities of daily living (ADLs.)Review of the physician's orders for Resident #44 revealed an order dated 11/11/24 Novolog insulin inject subcutaneously per sliding scale.Observation on 09/09/25 at 12:14 P.M. of medication administration revealed Licensed Practical Nurse (LPN) #313 did not prime the Novolog insulin pen prior to administering four units of insulin to Resident #44.Interview on 09/09/25 at 12:25 P.M. with LPN #313 verified she did not prime the insulin pen with two units prior to administration.Review of the insulin pen instructions titled Using Insulin Pens and Pen Needles revealed prior to administration one should always prime the insulin pen before each injection. Dial two units on the pen and then press the button to shoot some insulin into the air to make sure it worked. This was called an air shot or priming the pen. If you did not see at least two drops of insulin after repeated priming, do not use the pen.

Based on observation, staff interview, and review of the facility policy, the facility failed to measure correct portion sizes to meet resident nutritional needs. This affected one (Resident #73) of one resident with physician's orders for a pureed diet. The facility census was 79 residents. Findings include: Observation of food preparation on 09/11/25 at 11:02 A.M revealed Dietary Staff (DS) #404 used a spatula to scoop pureed stuffed peppers onto Resident #73's plate. Interview on 09/11/25 at 11:03 A.M with DS #404 confirmed Resident #73 was on a pureed diet, and he used a spatula to plate the pureed stuffed peppers for the resident because he did not have the proper scoop.Observation on 09/11/25 at 11:15 A.M reveled DS #404 used a three-ounce scoop when plating Resident #73's mashed potatoes. Interview on 09/11/25 at 11:20 A.M with DS #404 confirmed he used a three-ounce scoop when plating Resident #73's mashed potatoes, but the recipe called for a four-ounce portion of mashed potatoes. DS #404 confirmed he used the three-ounce scoop, because he did not have a four-ounce scoop on hand. Review of the facility policy titled Kitchen Weights and Measurements dated April 2007 revealed that the facility should use proper measurements for portion control of foods.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff maintained sterile technique during tracheostomy care. This affected one (Resident #11) of one resident sampled for tracheostomy care. The facility also failed to ensure staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). This affected one (Resident #12) of 13 residents reviewed for EBP. The facility census was 79 residents.Findings include: 1.Review of the medical record for Resident #11 revealed an admission date of 06/13/25 with diagnoses including anoxic brain damage, anxiety disorder, tracheostomy status, and schizophrenia.Review of the physician's orders for Resident #11 revealed an order dated 06/14/25 for tracheostomy care every day and night shift and as needed.Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 08/08/25 revealed the had severe cognitive impairment and was dependent on staff with activities of daily living (ADLs), and had a tracheostomy. Review of the care plan for Resident #11 dated 09/08/25 revealed the resident was at risk for developing complications secondary to altered respiratory status/difficulty breathing related to tracheostomy status, chronic respiratory failure. Interventions included the following: deliver three liters of oxygen via trach mask may titrate to keep oxygen saturation levels above 90 percent (%) every shift as ordered, administer medications and nebulizers as ordered, avoid lying flat due to shortness of breath, monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. Observation of tracheostomy care for Resident #11 on 09/11/25 at 10:02 A.M. per Licensed Practical Nurse (LPN) #310 revealed when setting up the sterile field for trach care, the nurse used clean gloves to place all sterile items onto the field including the sterile gloves. LPN #310 did not remove clean gloves prior to donning sterile gloves. LPN #310 provided trach care to Resident #11 with contaminated sterile medical supplies. Interview on 09/11/25 at 10:23 A.M. with LPN #310 verified she touched all sterile items with clean gloves and then placed sterile gloves over top of clean gloves before providing trach care to Resident #11. 2. Review of the medical record for Resident #12 revealed an admission date of 04/26/24 with diagnoses including anoxic brain damage, chronic respiratory failure with hypoxia, affective mood disorder, and hemiplegia and hemiparesis following cerebral infarction.Review of care plan for Resident #12 dated 05/08/24 revealed the resident was on EBP secondary to increased risk for infection related to tube feeding. Interventions included staff should follow EBP when providing care. Review of the MDS assessment for Resident #12 dated 06/30/25 revealed the resident had severely impaired cognition. Observation on 09/10/2025 at 11:21 A.M. of incontinence care for Resident #12 per Certified Nursing Assistants (CNAs) #221 and #298 revealed the aides wore gloves, but neither CNA was wearing an isolation gown. There was a sign on Resident #12's door which indicated staff were to wear gloves and isolation gowns when performing direct care. Interviews on 09/10/25 at 11:22 A.M. with CNAs #298 and #221 confirmed they did not wear isolation gowns while performing care for Resident #12.Review of the policy titled Enhanced Barrier Precautions dated August 2022 revealed examples of high-contact activities that required the use of gown and gloves included bathing, providing hygiene, changing briefs, and assisting with toileting.

Based on staff interviews and record review, the facility failed to allow residents who were cognitively intact and were their own persons, the ability to independently sign out of the facility. This affected four Residents (#16, #69, #100 and #400) of the four residents reviewed for resident rights. The facility identified 63 Residents (#02, #05, #06, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #26, #27, #28, #29, #30, #31, #33, #35, #37, #38, #39, #40, #41, #42, #43, #45, #48, #49, #50, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #63, #65, #66, #67, #68, #69, #70, #71, #72, #73, #75, #76, #78, #79, #80 and #81) as being their own person without a guardian at the facility and was able to sign themselves out of the facility if desired. The facility census was 78. Findings include: 1) Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included ataxia following other cerebrovascular disease, insomnia, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), unspecified focal traumatic brain injury with loss of consciousness and hypertension. Resident #16 was recorded as his own responsible party. Review of Resident #16's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was independent with eating and required moderate assistance for all other activities of daily living (ADLs). 2) Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertensive heart disease with heart failure, hepatic encephalopathy, unspecified cirrhosis of liver, type two diabetes mellitus with diabetic neuropathy, cellulitis of left lower limb, cellulitis of right lower limb, and peripheral vascular disease. Resident #69 was his own responsible party. Review of Resident #69's admission MDS assessment dated [DATE], revealed Resident #69 was cognitively intact, and was independent with eating, required set up assistance or supervision with other ADLs. Review of Resident #69's behavior agreement dated 02/08/25, revealed the resident was not following the recommendations of the Centers for Disease Control and Prevention (CDC) and increased the health risk of others by leaving the facility unnecessarily and then returning. Resident #69 was educated on the behavioral agreement and verbalized understanding of the risk he possessed to himself, and the others. Resident #69 had been offered assistance with finding another facility that would meet his needs. Resident #69 was allowed to continue residency at the facility under the following conditions: Resident #69 would remain in the facility unless medically necessary, Resident #69 would abide by the recommendations of the facility that were present and any changes of recommendations that were implemented by the facility or CDC. Resident #69 was aware that not following the behavioral contract and leaving the facility unnecessarily may result in an against medical advice (AMA) discharge. The behavior agreement indicated that if Resident #69 failed to follow the conditions, this could result in an automatic AMA discharge. Resident #69 refused to sign the behavior agreement. 3) Review of Resident #100's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertensive heart disease without heart failure, abnormal results of thyroid function studies, lymphedema not elsewhere classified, insomnia, alcohol abuse, anemia, hyperlipidemia, alcoholic cirrhosis of liver with ascites and gastro esophageal reflux disease with esophagitis with bleeding. Resident #100 discharged from the facility on 02/08/25. Resident #100 was his own responsible party. Review of Resident #100's behavioral care plan dated 07/18/22, revealed the resident had a behavior problem as evidenced by a history of signing out of the facility and consuming alcohol in the community. Interventions included discussing the resident's behavior if reasonable, intervene as necessary to provide the rights and safety of others, monitor behavior episodes and attempt to determine the underlying cause and minimize the potential for the resident's disruptive behaviors by offering tasks to divert attention. Review of Resident #100's behavior agreement dated 11/14/24, revealed the resident was not following the recommendations of the CDC and the resident increased the health risk of others by unnecessarily leaving the facility and then returning. Resident #100 was educated and the resident verbalized understanding of the risks he possessed to himself, and others. Resident #100 had been offered assistance with finding another facility that would meet his needs. The facility agreed to allow Resident #100 to continue residency in the facility under the following conditions: Resident #100 would remain in the facility unless medically necessary, Resident #100 would abide by the recommendations of the facility that were present and any changes of recommendations that have been implemented by the facility or CDC, and Resident #100 was aware of not following the contract and leaving the facility unnecessarily, may result in an AMA discharge. The behavior agreement stated failure to follow the conditions could result in an automatic AMA discharge. Resident #100 signed the behavior agreement along with the Administrator on 11/14/24. Review of Resident #100's 30-day discharge notice dated 01/13/25, revealed Resident #100 was given a 30-day discharge notice with a discharge date of [DATE]. Resident #100's discharge notice stated Resident #100 was being discharged because Resident #100's needs could not be met by the facility and the safety of other individuals was endangered. Resident #100 was given a behavior contract on 11/14/24 for going out of the facility and coming back drunk and disorderly. On 01/10/25, Resident #100 broke the behavior contract as the resident did not sign out of the facility and then returned with a beer for himself and others then refused to give the contraband to the nursing staff at first. The appeal information and contact information for the Ombudsman were listed on the notice. The notice was signed by Resident #100, the Administrator and Registered Nurse (RN) #437 on 01/13/25. Review of Resident #100's quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. Resident #100 was independent or required supervision with ADLS. Review of Resident #100's care conference dated 01/30/25, revealed Resident #100 attended in person. Resident #100 was leaving in his wheelchair in a negative two-degree weather to go to the store and he went down a hill in his wheelchair. Resident #100 was given a 30-day discharge notice and was in the process of looking for another facility. Review of Resident #100's progress note written by Licensed Practical Nurse (LPN) #434 dated 02/08/25 at 5:10 P.M., revealed Resident #100 left the facility around 2:00 P.M. and did not notify the nurse he was leaving. Resident #100 returned to the facility at 1:00 P.M. Resident #100 was made aware that he could not reenter the facility due to his behavior contract and Resident #100 refused to sign AMA papers. Review of Resident #100's progress note dated 02/08/25 at 5:31 P.M. revealed LPN #434 notified the physician of Resident #100's discharge. Review of Resident #100's incomplete discharge summary dated 02/08/25, revealed the resident broke his behavior contract agreement by going out of the facility without signing out. Resident #100 was on a 30- day discharge notice for the same behavior and Resident #100's family was coming to pick up his belongings. Review of Resident #100's physician order dated 02/08/25, revealed Resident #100 discharged from the facility AMA. Review of Resident #100's undated AMA form revealed Resident #100 refused to sign the AMA form. The form was signed by LPN #434 and RN #437. 4) Review of Resident #400's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, acquired absence of right leg below the knee, acquired absence of left leg below the knee, schizoaffective disorder and constipation. Resident #400 discharged from the facility on 02/10/25. Resident #400 was his own responsible party. Review of Resident #400's medical record from 11/08/24 to 02/12/25 revealed no documentation a discharge notice was given to Resident #400. Review of Resident #400's admission MDS assessment dated [DATE] revealed Resident #400 was cognitively intact, was independent with eating, and required maximal and moderate assistance with ADLs. Review of Resident #400's behavior agreement dated 01/10/25, revealed Resident #400 was not following the recommendations of the CDC and the facility regarding signing out of the facility with the nursing staff. Resident #400 had verbalized understanding of the risk he possessed to himself, and others and Resident #400 had been offered assistance with finding another facility that would meet his needs. The facility agreed to allow Resident #400 to continue residency with the facility under the following conditions: Resident #400 would remain in the facility unless medically necessary, Resident #400 would abide by the recommendations of the facility that were present and any changes of recommendations that have been implemented by the facility or CDC, and Resident #400 was made aware that not following the contract and leaving the facility unnecessarily may result in an AMA discharge. The behavior agreement stated failure to follow the conditions could result in an automatic AMA, 30-day or immediate discharge from the facility. Resident #400 signed the behavior agreement. Interview with Licensed Practical Nurse (LPN) #435 on 02/11/25 at 8:44 A.M. revealed the residents were not allowed to sign out of the facility alone. LPN #435 stated the residents could only sign out of the facility with family or supervision. LPN #435 stated Resident #100 violated his behavior contract which stated he would not leave the facility. LPN #435 reported Resident #100 was discharged from the facility AMA on 02/08/25 because he went out of the facility against his behavior contract on that date. Interview with Resident #16 on 02/11/25 at 8:52 A.M., revealed the resident had resided at the facility for over four years, and he had previously been allowed to sign himself out of the facility to go to the store alone. Resident #16 stated the facility no longer allowed him to sign out or leave the facility unless he was with family. Interview with Resident #69 on 02/11/25 at 12:47 P.M., revealed the Administrator presented him with a behavioral contract because he went out of the facility with his family. Resident #69 reported the behavior contract stated he would not leave the facility, and he refused to sign the behavioral contract. Interview with the Administrator by telephone, and Regional Director of Operations (RDO) #600 and the DON in person on 02/11/25 at 2:14 P.M. revealed residents in the facility were not allowed to leave the facility without supervision. The Administrator reported the facility was located in an area with a large amount of violence and it was not safe for the residents to sign themselves out and sit in front of the facility. The Administrator stated Resident #69 was given a behavior agreement after he left the facility with family at 1:30 A.M. The DON stated Resident #69 told the nurse he was leaving the facility, but the nurse told him that he could not go out of the facility because they needed a physician order. The Administrator, DON and RDO #600 confirmed the behavior agreement provided to Resident #69 on 02/08/25 stated he would not leave the facility unless medically necessary. The Administrator stated Resident #100 was constantly leaving the facility and they discussed with Resident #100 that he could not sign out without supervision or without physician orders. The Administrator verified a behavior agreement was completed with Resident #100 on 11/14/24 which stated Resident #100 would not leave the facility unless medically necessary. The Administrator stated Resident #100 continued to go out of the facility without signing out and without supervision and the facility issued Resident #100 a 30-day discharge notice on 01/13/25 because Resident #100 went out during the cold weather and brought other residents alcohol and cigarettes. The Administrator stated Resident #100 went out of the facility on 02/08/25 without supervision and without signing out and he was discharged AMA on 02/08/25 for violating his behavior agreement. The Administrator stated the staff told Resident #100 that they would pack up his stuff and Resident #100's sister came and got his stuff. The Administrator reported Resident #100 remained in the lobby until he was picked up by family or a bus, she couldn't remember which one. The Administrator stated that Resident #100 wanted to remain in the facility after he left without signing out of the facility. The Administrator stated he broke the behavior agreement so that's him basically saying he was going AMA. The Administrator stated Resident #400 had a behavioral agreement that was put in place on 01/10/25 which stated Resident #400 would remain in the facility unless medically necessary. The Administrator stated Resident #400 was also smoking marijuana in the facility and he was discharged from the facility because he was smoking marijuana. The Administrator stated Resident #400 was given an immediate discharge notice, but she could not recall the date. The Administrator confirmed Resident #400 discharged from the facility on 02/10/25 to another long-term care facility. Telephone interview with Resident #100's sister on 02/11/25 at 2:53 P.M. revealed the DON informed her that Resident #100 was discharged from the facility because he was leaving the facility without supervision. Resident #100's sister stated the facility had Resident #100 sign a behavior agreement that he would not leave the facility, and he left the facility against the agreement. Resident #100's sister reported Resident #100 was currently at the homeless shelter, but she was not sure who picked Resident #100 up from the facility on 02/08/25 to take him to the homeless shelter. Attempted to call Resident #100 on 02/11/25 at 2:57 P.M. with no response. This deficiency represents non-compliance investigated under Complaint Number OH00162483 and OH00160783.

Based on staff interview, record review, and review of discharge notices, the facility failed to permit a resident to remain in the facility and not transfer or discharge from the facility without the proper documentation regarding the need for discharge from the facility or the physician. This affected one Resident (#400) of the three residents reviewed for transfers. The facility also failed to allow a resident to remain in the facility for the duration of their discharge notice. This affected one Resident (#100) out of three residents reviewed for transfer or discharge. The facility census was 78. Findings include: 1) Review of Resident #400's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, acquired absence of right leg below the knee, acquired absence of left leg below the knee, schizoaffective disorder and constipation. Resident #400 discharged from the facility on 02/10/25. Resident #400's census information revealed Resident #400 was his own responsible party. Review of Resident #400's medical record from 11/08/24 to 02/12/25, revealed no documentation a discharge notice was given to Resident #400. Review of Resident #400's admission MDS assessment dated [DATE] revealed Resident #400 was cognitively intact, was independent with eating, and required maximal and moderate assistance with activities of daily living (ADL)s. Review of Resident #400's behavior agreement dated 01/10/25, revealed Resident #400 was not following the recommendations of the Centers for Disease Control (CDC) and the facility regarding signing out of the facility with the nursing staff. Resident #400 had verbalized understanding of the risk he possessed to himself, and others and Resident #400 had been offered assistance with finding another facility that would meet his needs. The facility agreed to allow Resident #400 to continue residency with the facility under the following conditions: Resident #400 would remain in the facility unless medically necessary, Resident #400 would abide by the recommendations of the facility that were present and any changes of recommendations that have been implemented by the facility or CDC, and Resident #400 was made aware that not following the contract and leaving the facility unnecessarily may result in an against medical advice (AMA) discharge. The behavior agreement stated failure to follow the conditions could result in an automatic AMA, 30-day or immediate discharge from the facility. Resident #400 signed the behavior agreement. Review of Resident #400's progress note dated 02/10/25 at 1:57 P.M., revealed Resident #400 was discharged from the facility. Review of Resident #400's incomplete discharge summary dated 02/10/25, revealed Resident #400 discharged to another long-term care facility and Resident #400 was fine with the discharge. Information regarding Resident #400's admitted , date of discharge, reason for admission, reason for the discharge, treatment provided, progress in the facility, nutritional information, and therapy services were missing from the discharge summary. Interview with the Administrator by telephone and Regional Director of Operations (RDO) #600 and the Director of Nursing (DON) in person on 02/11/25 at 2:14 P.M., revealed residents in the facility were not allowed to leave the facility without supervision. The Administrator reported the facility was located in an area with a large amount of violence and it was not safe for residents to sign themselves out and sit in front of the facility. The Administrator stated Resident #400 had a behavior agreement that was put in place on 01/10/25 which stated Resident #400 would remain in the facility unless medically necessary. The Administrator stated Resident #400 was also smoking marijuana in the facility and he was discharged from the facility because he was smoking marijuana. The Administrator stated Resident #400 was given an immediate discharge notice, but she could not recall the date. The Administrator verified Resident #400 discharged from the facility on 02/10/25 to another long-term care facility. Interview with the DON on 02/11/25 at 2:45 P.M., verified the facility did not have a copy of a discharge notice given to Resident #400 and there was no documentation in Resident #400's chart that Resident #400 was provided with a discharge notice. The DON stated Resident #400 had a discharge summary dated 02/10/25 that reported Resident #400 was fine with the discharge. The DON verified the discharge summary did not include information regarding Resident #400's admitted , date of discharge, reason for admission, reason for discharge, treatment provided, progress in the facility, nutritional information, and therapy services. 2) Review of Resident #100's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including hypertensive heart disease without heart failure, abnormal results of thyroid function studies, lymphedema not elsewhere classified, insomnia, alcohol abuse, anemia, hyperlipidemia, alcoholic cirrhosis of liver with ascites and gastro esophageal reflux disease with esophagitis with bleeding. Resident #100 discharged from the facility on 02/08/25. Resident #100's census information revealed Resident #100 was his own responsible party. Review of Resident #100's quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. Resident #100 was independent or required supervision with ADLS. supervision with showering. Review of Resident #100's discharge care plan dated 08/08/21, revealed Resident #100 expressed the wish to discharge home. Resident #100 was currently homeless but wished to apply to Medicaid waiver programs once eligible. Interventions included notifying the physician of discharge plans and needs, making referrals to community agencies, encourage the resident to be involved in discharge planning, and discuss the discharge planning process with the resident as requested. Review of Resident #100's behavioral care plan dated 07/18/22, revealed the resident had a behavior problem as evidenced by a history of signing out of the facility and consuming alcohol in the community. Review of Resident #100's behavior agreement dated 11/14/24, revealed the resident was not following the recommendations of the CDC and the resident increased the health risk of others by unnecessarily leaving the facility and then returning. Resident #100 was educated and the resident verbalized understanding of the risks he possessed to himself, and others. Resident #100 had been offered assistance with finding another facility that would meet his needs. The facility agreed to allow Resident #100 to continue residency in the facility under the following conditions: Resident #100 would remain in the facility unless medically necessary, Resident #100 would abide by the recommendations of the facility that were present and any changes of recommendations that have been implemented by the facility or CDC, and Resident #100 was aware of not following the contract and leaving the facility unnecessarily, may result in an AMA discharge. The behavior agreement stated failure to follow the conditions could result in an automatic AMA discharge. Resident #100 signed the behavior agreement along with the Administrator on 11/14/24. Review of Resident #100's 30-day discharge notice dated 01/13/25, revealed Resident #100 was given a 30-day discharge notice with a discharge date of [DATE]. Resident #100's discharge notice stated Resident #100 was being discharged because Resident #100's needs could not be met by the facility and the safety of other individuals was endangered. Resident #100 was given a behavior contract on 11/14/24 for going out of the facility and coming back drunk and disorderly. On 01/10/25, Resident #100 broke the behavior contract as the resident did not sign out of the facility and then returned with a beer for himself and others then refused to give the contraband to the nursing staff at first. The appeal information and contact information for the Ombudsman were listed on the notice. The notice was signed by Resident #100, the Administrator and Registered Nurse (RN) #437 on 01/13/25. Review of Resident #100's care conference dated 01/30/25, revealed Resident #100 attended in person. Resident #100 was leaving in his wheelchair in a negative two-degree weather to go to the store and he went down a hill in his wheelchair. Resident #100 was given a 30-day discharge notice and was in the process of looking for another facility. Review of Resident #100's progress note written by Licensed Practical Nurse (LPN) #434 dated 02/08/25 at 5:10 P.M., revealed Pt left from the facility around 1400 Pt did not notify nurse that he was leaving PT returned to facility at 1300. Made Pt aware that he could not re-enter to the facility due to behavior contract Pt refused to sign AMA papers. Review of Resident #100's progress note dated 02/08/25 at 5:31 P.M., revealed LPN #434 notified the physician of Resident #100's discharge. Review of Resident #100's physician order dated 02/08/25, revealed Resident #100 discharged from the facility AMA. Review of Resident #100's incomplete discharge summary dated 02/08/25, revealed Section B (Social Services) indicated the resident understood the discharge due to having a Brief Interview Mental Status (BIMS) of 15, indicating cognitively intact, was on a 30-day discharge and behavioral contract. The resident was discharged with family and sister called to pick up his belongings. There was no documentation about a follow physician appointment including name, address, phone and appointment time, no documentation about community resources offered, and if any special treatments were required. The Service Discharge Summary indicated the resident broke his behavior agreement by going out of the facility without signing out. Resident #100 was on a 30-day discharge notice for the same behavior and Resident #100's family was coming to pick up his belongings. The discharge summary had no documentation in the recapitulation of residents stay, dietary/nutrition, activities, Rehabilitiation services, discharge instructions/follow-up precautions and the resident and/or the resident representative signature. Review of Resident #100's undated AMA form, revealed Resident #100 refused to sign the AMA form. The form was signed by LPN #434 and RN #437. Interview with LPN #435 on 02/11/25 at 8:44 A.M., revealed residents were not allowed to sign out of the facility alone. LPN #435 stated that residents could only sign out of the facility with family or supervision and Resident #100 violated his behavior agreement that stated he would not leave the facility. LPN #435 reported Resident #100 was discharged from the facility AMA on 02/08/25 because he went out of the facility against his behavior agreement on that date. Interview with the Administrator by telephone and Regional Director of Operations (RDO) #600 and the Director of Nursing (DON) in person on 02/11/25 at 2:14 P.M., revealed residents in the facility were not allowed to leave the facility without supervision. The Administrator reported the facility was located in an area with a large amount of violence and it was not safe for residents to sign themselves out and sit in front of the facility. The Administrator stated Resident #100 was constantly leaving the facility and they discussed with Resident #100 that he could not sign out without supervision or without physician orders. The Administrator verified a behavior agreement was completed with Resident #100 on 11/14/24 that stated Resident #100 would not leave the facility unless medically necessary. The Administrator stated Resident #100 continued to go out of the facility without signing out and without supervision and the facility issued Resident #100 a 30-day discharge notice on 01/13/25 because Resident #100 went out during the cold weather and brought other residents alcohol and cigarettes. The Administrator stated Resident #100 went out of the facility on 02/08/25 without supervision and without signing out and he was discharged AMA on 02/08/25 for violating his behavior agreement. When Resident #100 returned to the facility, the Administrator stated staff told Resident #100 that they would pack up his stuff and was to remain in the lobby until he was picked up by family or a bus. The Administrator stated she was not sure how Resident #100 left the facility. The Administrator reported Resident #100's sister came and got his stuff. The Administrator stated that Resident #100 wanted to remain in the facility after he left the facility without signing out of the facility. The Administrator stated he broke the behavior agreement so that's him basically saying he was going AMA. Telephone interview with Resident #100's sister on 02/11/25 at 2:53 P.M., revealed the DON informed her that Resident #100 was discharged from the facility because he was leaving the facility without supervision. Resident #100's sister stated the facility had Resident #100 sign a behavior agreement that he would not leave the facility, and he left the facility against the agreement. Resident #100's sister reported Resident #100 was currently at the homeless shelter, but she was not sure who picked Resident #100 up from the facility on 02/08/25 to take him to the homeless shelter. Attempted to call Resident #100 on 02/11/25 at 2:57 P.M. with no response. Review of an electronic mail (email) note dated 02/12/25 at 1:35 P.M., from the Surveyor to the Administrator, DON and RDO #600, revealed the Surveyor asked the facility to clarify the times from the progress noted dated 02/08/25 at 5:10 P.M. when Resident #100 was recorded as leaving the facility at 2:00 P.M. and then returning at 1:00 P.M. Review of an email note dated 02/12/25 at 1:38 P.M., from the Administrator, revealed we are told he left multiple times that day. He didn't sign out for any of them so I really can't answer that sorry. Review of the policy titled Facility-Initiated Transfer or discharge date d October 2022 revealed residents have the right to remain in the facility once admitted in the facility. The residents and their representatives are given a 30 day advance written notice of an impending transfer or discharge from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00162483 and OH00160783.

Based on staff interview and record review, the facility failed to ensure a resident's discharge summary included a recapitulation of the resident's stay. This affected one Resident (#400) out of three residents reviewed for transfer or discharge summaries. The facility census was 78. Findings include: Review of Resident #400's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, acquired absence of right leg below the knee, acquired absence of left leg below the knee, schizoaffective disorder and constipation. Resident #400 discharged from the facility on 02/10/25. Resident #400's census information revealed Resident #400 was his own responsible party. Review of Resident #400's medical record from 11/08/24 to 02/12/25, revealed no documentation a discharge notice was given to Resident #400. Review of Resident #400's admission MDS assessment dated [DATE], revealed Resident #400 was cognitively intact, was independent with eating, and required maximal and moderate assistance with activities of daily living (ADL)s. Review of Resident #400's behavior agreement dated 01/10/25, revealed Resident #400 was not following the recommendations of the Centers for Disease Control (CDC) and the facility regarding signing out of the facility with the nursing staff. Resident #400 had verbalized understanding of the risk he possessed to himself, and others and Resident #400 had been offered assistance with finding another facility that would meet his needs. The facility agreed to allow Resident #400 to continue residency with the facility under the following conditions: Resident #400 would remain in the facility unless medically necessary, Resident #400 would abide by the recommendations of the facility that were present and any changes of recommendations that have been implemented by the facility or CDC, and Resident #400 was made aware that not following the contract and leaving the facility unnecessarily may result in an against medical advice (AMA) discharge. The behavior agreement stated failure to follow the conditions could result in an automatic AMA, 30-day or immediate discharge from the facility. Resident #400 signed the behavior agreement. Review of Resident #400's incomplete discharge summary dated 02/10/25, revealed Resident #400 discharged to another long-term care facility and Resident #400 was fine with the discharge. Information regarding Resident #400's admitted , date of discharge, reason for admission, reason for the discharge, treatment provided, progress in the facility, nutritional information, and therapy services were missing from the discharge summary. Review of Resident #400's progress note dated 02/10/25 at 1:57 P.M., revealed Resident #400 was discharged from the facility. Interview with the Administrator by telephone and Regional Director of Operations (RDO) #600 and the Director of Nursing (DON) in person on 02/11/25 at 2:14 P.M., revealed residents in the facility were not allowed to leave the facility without supervision. The Administrator reported the facility was located in an area with a large amount of violence and it was not safe for residents to sign themselves out and sit in front of the facility. The Administrator stated Resident #400 had a behavior agreement that was put in place on 01/10/25 which stated Resident #400 would remain in the facility unless medically necessary. The Administrator stated Resident #400 was also smoking marijuana in the facility and he was discharged from the facility because he was smoking marijuana. The Administrator stated Resident #400 was given an immediate discharge notice, but she could not recall the date. The Administrator verified Resident #400 discharged from the facility on 02/10/25 to another long-term care facility. Interview with the DON on 02/11/25 at 2:45 P.M., verified the facility did not have a copy of a discharge notice given to Resident #400 and there was no documentation in Resident #400's chart that Resident #400 was provided with a discharge notice. The DON stated Resident #400 had a discharge summary dated 02/10/25 that reported Resident #400 was fine with the discharge. The DON verified the discharge summary did not include information regarding Resident #400's admitted , date of discharge, reason for admission, reason for discharge, treatment provided, progress in the facility, nutritional information, and therapy services. Review of the facility's undated discharge summary and plan policy revealed the discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. The discharge summary shall include a description of the resident's current diagnoses, medical history, course of illness, treatment, and therapy since entering the facility, current laboratory, radiology, consultation and diagnostic test results, physical and mental functional status, ability to perform activities of daily living, and nutritional status.

Based on staff and resident interviews, medical record review, review of Self-Reported Incident (SRI), review of police report, and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#34) resident out of four residents reviewed for abuse. The facility census was 80. Findings included: 1. Review of the medical record for Resident #34 revealed an admitted [DATE] with medical diagnoses of hypertension (HTN), nephrotic syndrome, heart disease, chronic obstructive pulmonary disease (COPD), and schizophrenia. Review of the medical record for Resident #34 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #34 was cognitively intact and was independent with eating, toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors. Review of the medical record for Resident #34 revealed a nurse progress note, dated 01/08/24 at 6:00 A.M. with stated Resident #34 reported to the nurse that his roommate, Resident #84, was physically aggressive towards him which was witnessed by staff. The note continued to state the two (#34 and #84) residents were separated, assessments were completed, and the physician was notified. The note stated no injuries were noted. 2. Review of the medical record for Resident #84 revealed an admitted [DATE] with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of [DATE]. Review of the medical record for Resident #84 revealed an admission MDS, dated [DATE], which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers. The MDS did not indicate any behaviors. Review of the medical record for Resident #84 revealed a nurse progress note, dated 01/08/24 at 6:19 A.M., which stated Resident #84 initiated physical aggression towards his roommate Resident #34. The note stated Resident #84 informed the nurse that Resident #34 hit him on the left hip and lower back with the bathroom door before leaving their room. The note continued to state Resident #84 followed Resident #34 out into the hallway and started to hit Resident #34 with his walker in his back. The note stated the residents were separated and skin assessments were completed with no injuries noted. Interview on 2/15/24 at 10:01 A.M. with Resident #34 confirmed Resident #84 hit him with his walker in the hallway which was witnessed by staff. Resident #34 stated he had a little pain at the time of the incident but denied any injuries . Resident #34 stated the incident was unprovoked and denied hitting Resident #84 while in their room. Resident #34 stated Resident #84 was moved to a different room and there were no further incidents between the two residents. Interview on 02/15/24 at 10:56 A.M. with Licensed Practical Nurse (LPN) #122 confirmed she witnessed Resident #84 intentionally hit Resident #34 with his walker while in the hallway on 01/08/24. LPN #122 stated she separated the residents and Resident #34 called the police to report the altercation. Interview on 02/15/24 at 12:00 P.M. with Director of Nursing (DON) stated an investigation was completed on 01/08/24 into the allegation of abuse by Resident #84 to Resident #34. DON stated she did not substantiate the allegation because she did not believe Resident #84 intentionally hit Resident #34 with his walker. DON stated Resident #84 was moved to a different room and there were no further incidents between the two residents. Review of the SRI report, dated 01/08/24, stated Resident #84 was observed by staff throwing his walker at Resident #34 and hitting him in the back. The report stated no injuries were noted and an investigation was completed. The facility did not substantiate the allegation of abuse. Review of the police report dated 01/08/24, Resident #84 was charged with simple assault. Review of the facility policy titled, Abuse and Neglect Protocols, stated residents have the right to be free abuse, neglect, misappropriation or resident property, exploitation, corporal punishment, physical or chemical restraints. The policy stated abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resident physical harm, pain, or mental anguish. This deficiency represents non-compliance investigated under Complaint Numbers OH00150614 and OH00150334.

Based on medical record review and staff and pain specialist staff interviews, the facility failed to ensure a pain specialist appointment was scheduled and failed to effectively manage a resident's pain. This affected one (#84) resident out of three residents reviewed for pain management. The facility census was 80. Findings included: Review of the medical record for Resident #84 revealed an admitted [DATE] with medical diagnoses of HTN, peripheral neuropathy, anxiety, diabetes mellitus, and chronic pain syndrome. Review of the medical record for Resident #84 revealed a discharge date of [DATE]. Review of the medical record for Resident #84 revealed an admission Minimum Data Set (MDS), dated [DATE], which indicated Resident #84 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers. Review of the medical record for Resident #84 revealed a Nurse Practitioner (NP) note, dated 01/18/24, which revealed Resident #84 stated his current pain management was no longer working for his pain and Resident #84 asked for a pain management referral. The note stated Resident #84 rated his pain a seven out of ten on the pain scale. Review of the medical record for Resident #84 revealed a physician order, dated 11/14/23, for Norco 7.5-325 milligram (mg) one tablet by mouth every six hours as needed for pain and an order dated 11/11/23 for gabapentin 600 mg one tablet by mouth three times per day for pain. Further review of the physician orders revealed an order dated 01/29/24 for a consultation for pain management. Review of the medical record for Resident #84 revealed a nurse's note, dated 01/29/24 at 8:16 P.M. that stated a pain specialist office was contacted per the order and Resident #84's medical information was faxed to the office. The note stated the nurse was informed by the office staff that a determination would be made in three to four days if the pain specialist would accept Resident #84. Further review of the medical record revealed no documentation to support Resident #84 was scheduled an appointment with the pain specialist or that the facility followed up on the referral. Interview on 02/15/24 at 11:27 A.M. with Receptionist #210 from pain specialist office stated there was no documentation to support their office received a referral for Resident #84. Interview on 02/15/24 at 11:48 A.M. with Director of Nursing (DON) confirmed the facility staff did not follow up with the pain specialist office to schedule Resident #84's consultation appointment. DON also confirmed the medical record for Resident #84 did not contain any documentation to support the facility staff adjusted Resident #84's pain medications or offered other non-pharmacological interventions to effectively manage his pain. This deficiency represents non-compliance investigated under Complaint Number OH00150614.

Based on medical record review, observation, staff interview, and review of facility policies, the facility failed to follow infection control guidelines when administering medications. This affected one (#70) out of three residents reviewed for medication administration. The facility census was 80. Findings included: Review of the medical record for Resident #70 revealed an admitted [DATE] with medical diagnoses of depression, diabetes mellitus (DM), hypertension (HTN), chronic obstructive pulmonary disease, dementia, and schizoaffective disorder. Review of the medical record for Resident #70 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #70 had moderate cognitive impairment and was independent with eating, bed mobility and transfers. Review of the medical record for Resident #70 revealed a physician order dated 11/27/21 for metformin 500 milligram (mg) one tablet by mouth daily for DM, an order dated 01/13/22 for metoprolol 25 mg one tablet by mouth daily for HTN, and an order dated 06/30/22 for Risperdal one mg one tablet by mouth three times per day for schizoaffective disorder. Observation on 02/14/24 at 8:35 A.M. of Licensed Practical Nurse (LPN) #196 administering medications to Resident #70 revealed LPN #196 placed the metoprolol 25 mg tablet, the metformin 500 mg tablet, and the Risperdal one mg tablet directly into her bare hand from the pill card and then placed the medications into the pill cup. LPN #196 was observed handing the pill cup with the medications to Resident #70 who consumed the medication in the presence of LPN #196. LPN #196 did not wash her hands, use hand sanitizer, or use gloves before or after administering medications to Resident #70. Interview on 02/14/24 at 8:45 A.M. with LPN #196 confirmed she placed Resident #70's metoprolol, metformin, and Risperdal tablets directly into her bare hand then placed the medications into the pill cup prior to administering the medications to Resident #70. LPN #196 also confirmed she did not perform hand hygiene prior to or after administering medications to Resident #70. Review of the facility policy titled, Administering Medications stated the staff should follow infection control procedures (e.g. handwashing, antiseptic technique, gloves) for administering medications. Review of the facility policy titled Handwashing/Hand hygiene, revised August 2019, stated hand hygiene is the primary means to prevent the spread of infections. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, review of the hospital record, resident and staff interview, policy review, and review of a [MEDICATION(S)] Plus Medical Encyclopedia document, the facility failed to ensure a resident was free from an avoidable fall during incontinence care. This resulted in Actual Harm when Resident #15 fell out of bed during incontinence care and sustained an acute displaced fracture of the proximal right femur requiring surgical intervention, when State tested Nursing Assistant (STNA) #50 rolled Resident #15 away from her and Resident #15 rolled out of the raised bed onto the floor. This affected one resident (#15) out of three residents reviewed for falls. The facility census was 81. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included [CONDITION(S)], [CONDITION(S)], cerebral infarction, heart failure, right sided [CONDITION(S)], and dysphagia. Resident #15 was discharged to the local hospital on 06/08/22. Review of the fall risk assessment dated [DATE] revealed a score of 12 which indicated Resident #15 was a high risk for falls. Review of the Discharge Return Anticipated Minimum Data Set, dated dated dated [DATE] revealed Resident #15 had mild cognitive impairment, required extensive assistance with bed mobility, transfers, toilet use, hygiene, and was occasionally incontinent of bowel and bladder. Review of the care plan revealed Resident #15 was at risk for falls and fall related injuries, related to diabetes, generalized muscle weakness, and right sided [CONDITION(S)] related to history of a stroke. Review of the incident note dated 06/08/22 revealed Resident #15 was laying on the floor on his side with both feet out in front of him. Resident #15 stated he was positioned on his left side while getting a bed bath during a check and change. He then slid off the bed onto the floor. Head to toe assessment was completed. The resident had complaints of pain to his forehead, knees, and pain on the right side. The medical doctor was made aware, and Resident #15 was transferred to the local hospital. Review of the hospital record dated 06/14/22 revealed Resident #15 stated that he rolled from his bed to the floor. The Computed Tomography (CT) scan for the right hip revealed an acute displaced fracture of proximal right femur. A telephone interview on 07/05/22 at 11:51 A.M. with STNA #50 revealed she turned Resident #15 away from her while providing care, when he slipped off the raised bed onto the floor on his right side. Interview on 07/05/22 at 1:26 P.M., STNA #52 said you were not supposed to roll a resident away from you if you were by yourself, your supposed to roll the resident towards you or get help. Interview on 07/05/22 at 1:31 P.M. with STNA #53 said she never turned any resident without asking for help or assistance because of the fear if the resident turned too far, they would fall to the floor. STNA #53 said when rolling/turning you should always turn the resident towards you, never away from you. Review of the policy titled Repositioning Level Three, dated 05/2013 steps in the procedure revealed step nine to use two people and a draw sheet to avoid shearing while turning or moving the resident. Review of Turning Patients Over in Bed: [MEDICATION(S)] Plus Medical Encyclopedia undated revealed the following steps should be followed when turning a patient from their back to their side or stomach: explain to the patient what you are planning to do so the person knows what to expect, encourage the person to help if possible; stand on the opposite side of the bed the patient will be turning towards, and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you, this will be the direction in which the person is turning. The following steps should be followed when turning a patient: if you can, raise the bed to a level that reduces back strain for you, make the bed flat. Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient. Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot (or knee if you put your knee on the bed) as you gently pull the patient's shoulder toward you. Then shift you weight to your back foot as you gently pull the person's hip towards you. As a result of the incident, the facility took the following actions to correct the deficient practice as of 06/09/22: · On 06/09/22, the Assistant Director of Nursing (ADON) #75 audited fall interventions for residents ensuring they were placed in the care plan. · On 06/09/22, ADON #75 completed audits to ensure bariatric beds were in place per care plan for residents who required the bariatric bed. · On 06/09/22, ADON #75 audited all residents fall interventions and completed corrections. There were no additional residents who required updated fall interventions. · On 06/09/22, the DON/Designee educated/in-serviced clinical staff to the importance of following the fall interventions for bariatric beds and ensuring they were in place. All clinical staff were trained on 06/09/22 either in person or by telephone. · The DON/Designee will complete audits to ensure the interventions are in place per the care plan, as well as bariatric beds. This will be completed three times a week for four weeks, and then monthly times three. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) committee for review. Review of the audits provided revealed they began the week of 06/10/22 and no concerns had been identified. This deficiency substantiated allegations in Complaint Number OH 428.

Based on interviews with facility staff, the Medical Director, and Non-Physician Practitioners (NPPs), medical record review, review of the pre-admission screening form, review of hospital records, review of Emergency Medical Services (EMS) run report, review of the coroner ' s report, review of facility e-mails, review of the facility timeline investigation, review of the police report, and review of facility policies, the facility failed to provide adequate behavioral health services for one resident (#231) with a known history of [CONDITION(S)], paranoia, delusions, and who had a recent hospitalization for suicide ideations. This resulted in Immediate Jeopardy and life-threatening serious injuries and ultimate death when Resident #231 placed an upright dresser on his neck and committed suicide on [DATE]. This affected one (#231) of 49 residents identified by the facility with a history of [CONDITION(S)]/attempts since the incident on [DATE]. The facility census was 79. On [DATE] at 5:13 P.M., the Administrator, Director of Nursing (DON), Regional Clinical Director (RCD) #170, Regional Director of Operations (RDO) #200, and Director of Clinical Operations (DCO) #121, were notified that Immediate Jeopardy began on [DATE], when Resident #231 was admitted to the facility after a lengthy hospital admission for suicidal and homicidal ideations, worsening agitation, and paranoid delusions when he threatened to kill himself and his wife. On [DATE], the facility Medical Director (MD) #160 saw resident via tele-health for chief complaints of [CONDITION(S)] and [CONDITION(S)] and ordered resident to be seen by a psychiatrist. During the resident ' s admission from [DATE] through [DATE], the resident was noted to have paranoid behaviors and frequently commenting they are coming to get me. The facility had no monitoring in place, no care plan with interventions in place for specified behaviors and was not followed up on by the psychiatrist for [CONDITION(S)]. On [DATE], Resident #231 was found lying on the floor of his room with a four-drawer upright dresser across his neck/head and after a short course of resuscitative efforts by facility staff and Emergency Medical Services (EMS), the resident was determined to be deceased and later determined by the coroner ' s report that Resident #231 ' s manner of death was suicide. The Immediate Jeopardy was removed on [DATE] at 5:28 P.M. when the facility implemented the following corrective actions: · On [DATE], Resident #231 was no longer a resident in the facility. · On [DATE], Nursing management, the DON, Former Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #120, and LPN/Unit Manager #70, were in-serviced by the Administrator related to reviewing hospital notes prior to accepting admissions to ensure that needs can be met prior to admission. · On [DATE], all nursing staff were in-serviced by the DON/designee, Vice President (VP) #172, and RCD #171 related to assessments upon admission, care planning, behavior health assessments, suicidal threats, safety and supervision of residents, medication administration, and medication changes. · On [DATE], Social Services Director (SSD) #26 was in-serviced by VP #172 related to completion of behavior and trauma assessments. · On [DATE], Minimum Data Set (MDS) assessment nurse LPN #162 was in-serviced by VP #172 related to MDS accuracy/coding/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] · On [DATE], all 79 current residents residing in the facility were assessed for [CONDITION(S)] or history of [CONDITION(S)] and six current residents were identified with a history of [CONDITION(S)]; however, zero of 79 residents voiced current suicidal ideation thoughts. The six current residents were assessed to ensure that behavioral health services were in place by the Administrator/designee and SSD #26 and determined that four of the six residents are currently receiving services and the remaining two residents had previous refusals. · On [DATE], all rooms of residents with [CONDITION(S)] or history of [CONDITION(S)] were assessed for risks by the Administrator, RDO #200 and dressers were secured to the wall by Maintenance Director #108/designees, Floor Technician #40, Central Supply staff #51, and the Administrator. · On [DATE], any resident with [CONDITION(S)] requiring behavioral health services were referred by SSD #26. Two residents were referred due to history of [CONDITION(S)], and no residents voiced any current suicidal ideation thoughts. · On [DATE], residents that were determined to have [CONDITION(S)] or a history of suicidal ideation had a medication review completed by RCD #170 to determine if there were any recent psychiatric medication changes and none of the residents identified had any psychiatric medication changes in the past 30 days. · On [DATE], the DON and Current LPN/ADON #54 verified that all psychiatric medications ordered for residents identified for [CONDITION(S)] and history of [CONDITION(S)] are present in the medication cart. · On [DATE] to [DATE], all residents were assessed for risk utilizing the behavior assessment and trauma assessment and record reviewed by SSD #26/designee, Activities Director (AD) #29, LPN/Unit Manager #70, the DON, LPN/ADON #54, and Marketing/Admissions Director #111. · On [DATE], audits to start related to behavior assessments, medication change monitoring, behavioral health services, care plan related to behaviors, behavior monitoring, and interventions, to be completed by the DON/designee two times weekly for four weeks, then weekly for four weeks, then reported to the Quality Assurance Performance Improvement (QAPI) committee for review. · On [DATE], the Verbal Order Policy was updated to include verification of orders via telehealth visits by VP #172. · On [DATE], the Interdisciplinary Team (IDT) team (DON, LPN/ADON #54, LPN/Unit Manager #70, LPN/MDS #49, SSD #26, Marketing/Admissions Director #111, the Administrator, and AD # 29) were in-serviced by RCD #170 regarding assessments upon admission, care planning, behavior health assessments, suicidal threats, safety and supervision of residents, medication administration, medication changes, behavioral health services, verbal order verification including telehealth visits, and medication error/omission. · On [DATE], the DON and LPN/ADON #54, LPN/Unit Manager #70, the Administrator, LPN/MDS #49 and Marketing/Admissions Director #111 were in-serviced by RCD #170 and RDO #200 related to Admission Criteria, Clinical Review Checklist, and White Sheet (a pre-admission screening tool). · On [DATE], all nursing staff in-servicing was initiated by the DON/designee related to assessments upon admission, care planning, behavior health assessments, suicidal threats, safety and supervision of residents, medication administration, medication changes, verbal order verification including telehealth visits, and medication error/omission. In-servicing to be completed for all new hires and annually. · On [DATE], all staff in-serving was initiated by the DON/designee related to safety and supervision of residents, suicidal threats, behavior assessment, intervention, and monitoring. In-servicing to be completed for all new hires and annually. · On [DATE], SSD #26 and LPN/ADON #54 were in-serviced by RCD #170 related to completion of behavior and trauma assessments, the referral process, and tracking log. LPN/ADON #54/designee will review all received progress notes for any orders that need to be transcribed prior to SSD #26 placing note in the chart. · On [DATE] from 8:30 A.M. to 12:20 P.M. and [DATE] from 3:00 P.M to 5:00 P.M., interviews were conducted with the DON, LPN/ADON #54, LPN/Unit Manager #70, LPN/MDS #49, SSD #26, Marketing/Admissions Director #111, and AD #29 and verified they were in serviced regarding care planning, assessments upon admission, white sheet (admission form) and admission criteria, behavior health assessments, suicidal threats, safety and supervision of residents, medication administration, medication changes, completion of behavior and trauma assessments, referral process and tracking log, behavioral health services, verbal orders verification including telehealth visits, and medication error/omission and all verbalized they were knowledgeable. · On [DATE] from 3:00 P.M. to 5:00 P.M., interviews were conducted with LPNs (#75, #82, and #86) and STNAs (#101 and #106) and verified they were in-serviced on safety and supervision of residents, suicidal threats, behavior assessment, intervention, and monitoring and all verbalized they were knowledgeable. Although the Immediate Jeopardy was removed on [DATE], the facility remains 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: Review of the medical record for Resident #231 revealed the resident was admitted on [DATE] and expired in the facility on [DATE]. The resident had diagnoses which included Parkinson ' s disease, dementia with behavioral disturbances, major depressive disorder, hypertension, restlessness and agitation, and psychotic disorder with delusions. Review of the five-day admission MDS assessment dated [DATE] revealed Resident #231 was cognitively intact, had no behaviors, and required limited assistance with Activities of Daily Living (ADL). Section-D of the MDS (Resident Mood Interview) indicated the resident had feelings of being down, depressed, or hopeless, and no thoughts of self-harm. Review of the base line care plan for Resident #231 dated [DATE] revealed resident was alert and cognitively intact. The base line care plan did not document any mental health issues and/or history of [CONDITION(S)] and was not person centered for Resident #231. The baseline also revealed no evidence Resident #231 had recently been discharged from a lengthy hospital admission for mental health and psychiatric conditions which included self-harm and [CONDITION(S)]. Review of the undated handwritten pre-admission screening document for Resident #231 revealed the resident was admitted to the hospital on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The pre-admission screening form revealed no documented evidence of resident ' s behaviors and/or history of suicidal and homicidal ideations from admission. Review of the hospital discharge summary for Resident #231 dated [DATE] revealed resident was admitted to the hospital on [DATE] with worsening agitation, paranoid delusions when resident was at home with his wife when he grabbed a knife threatened to kill himself and his wife. Hospital notes indicated resident had previous admissions in [DATE] for same symptoms and resident had previously threatened suicide. Hospital notes indicated a discharge suicide screen was completed and resident was recorded as being low, moderate, or high suicide severity during hospital stay and resident wished he was dead or could go to sleep and not wakeup. Review of a facility e-mail generated by Marketing/Admissions Director #111 dated [DATE] at 10:09 A.M. and titled Admit Alert revealed Resident #231 was being admitted on this date along with an attachment which included Resident #231 ' s hospital discharge summary and medical records. Further review of the e-mail revealed the following staff members were forwarded the e-mail with records attachment: DON, LPN/Unit Manager #70, SSD #26, Environment Services Director (ESD) #51, Director of Human Resources/Business Office Manager #110, Corporate Resident Funds Staff #166, Former LPN/ADON #120, MDS #162, Medical Records Staff #163, Maintenance Director #164, Dietary Technician #165, Dietary Manager #167, and Therapy Director #168. Review of the Pre-admission Screening/Resident Review (PAS/RR) document for Resident #231 dated [DATE] and created by Marketing/Admissions Director #111 revealed resident had documented diagnoses of dementia, and Alzheimer ' s disease, or some other organic mental disorder. Section-D (indications of serious mental illness) indicated resident had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PAS/RR indicated resident scored a zero on the level one PAS/RR and therefore did not trigger the level two screening assessment. Review of the behavioral assessment and data collection for Resident #231 dated [DATE] revealed resident did not have history of behavior issues, had no acute change in mental status from resident ' s baseline, no hallucinations, no wandering, resident was not at risk for physical illness or injury and resident had no recorded behaviors. Review of the social services assessment for Resident #231 dated [DATE] by SSD #26 revealed resident was admitted with Parkinson ' s disease and had diagnoses of depression/anxiety/mood disorder due to psychotic disorder with delusions due to known physiological condition. Review of the progress notes titled physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #160 revealed resident was seen via tele-health for a new admission/history and physical along with LPN #80 reviewing the call/visit. MD #160 ' s notes indicated the chief complaint was [CONDITION(S)] and suicidal ideation. Notes indicated MD #160 reviewed the medical chart and past medical history. Notes indicated MD #160 completed a physical assessment on resident and assessment indicated resident was alert and oriented, had depression, was agitated but appropriate affect and mood. Notes indicated the plan was to continue medications and monitor, a psychiatrist consult due to depression with [CONDITION(S)], and monitor for behaviors and dementia due to restless and agitation. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the audit trail in the orders indicated Former LPN/ADON #120 discontinued the [MEDICATION(S)] 25 mg on [DATE] at 10:34 A.M. from a verbal order provided by MD #160. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #160. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #169. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan dated [DATE] for Resident #231 revealed the resident had slightly impaired cognitive function or impaired thought process related to paranoid delusions and agitation and a psychosocial well-being problem related to ineffective coping, recent admission, social isolation, Parkinson ' s disease, and psychotic disorder with delusions. Interventions included consult with pastoral care, social services, and psychiatry services, and assess for depression. The care plan revealed no documented evidence resident had recently been discharged from a lengthy hospital admission for mental health and psychiatric conditions which included suicidal and homicidal ideations. Review of the psychiatric NP #169 progress notes dated [DATE] revealed Resident #231 was seen due to chief complaint/reason for visit for medication management and consideration for a gradual dose reduction. Notes indicated resident had reckless and aggressive behavior at home and threatened to kill himself and his wife. Notes indicated resident had presenting problems of anxiety, cognitive decline, hopelessness, negative symptoms, sadness, socially isolating and resident was not currently a danger to self/others. Notes indicated resident had multiple psychiatry admissions to hospital and resident was ordered to continue [MEDICATION(S)]-[MEDICATION(S)] ER ,d+[DATE] mg three times daily, Hydroxine 25 mg three times daily, [MEDICATION(S)] 25 mg nightly, and [MEDICATION(S)] 3 mg at bedtime. Notes indicated resident was ordered to start [MEDICATION(S)] 12.5 mg daily. Notes indicated NP #169 discussed possibility of initiating [MEDICATION(S)] 34 mg for overall management of resident psychotic disorder. Review of the progress notes type Nursing Order Note for Resident #231 dated [DATE] indicated physician saw resident and created a new order for [MEDICATION(S)] 25 milligrams, give half tablet daily for depression, resident was a candidate for [MEDICATION(S)], and physician would call family to discuss. Notes indicated resident was diagnosed with depression, [CONDITION(S)], and dementia with [CONDITION(S)]. Review of notes revealed these orders were from NP #169 ' s visit on [DATE]. Review of the progress notes type Health Status Notes for Resident #231 dated [DATE] indicated resident was assessed by NP #169 and resident was ordered [MEDICATION(S)] 34 mg daily related to Parkinson ' s disease, psychotic disorder with delusions due to known physiology condition. Health statuses note effective [DATE] and recorded as late entry on [DATE] indicated the facility was to start [MEDICATION(S)] 34 mg when medications were available from pharmacy. Health status note dated [DATE] at 8:43 P.M. by LPN #75 indicated nurse was called to resident ' s room at 4:50 P.M. and resident was noted to be lying on the floor, on his back with both arms out and legs straight and a dresser sitting across his neck. Notes indicated a small amount of blood was noted under resident, vital signs were unable to be obtained, and chest compressions started. Notes indicated EMS arrived and assumed care. Review of other health status notes lacked documented evidence for any indication resident ' s paranoia and/or behaviors were being monitored at admission, a reason why [MEDICATION(S)] was discontinued on [DATE], and no documentation to monitor behaviors following discontinuation of [MEDICATION(S)]. Review of an e-mail dated [DATE] at 3:10 P.M. by LPN/MDS #162 indicated she was having a Utilization Review (UR) meeting with Marketing/Admissions Director #111 when Marketing/Admissions Director #111 informed her Resident #231 ' s son contacted him with concerns about medications found in the resident ' s room while the son visited. The e-mail also indicated Resident #231 stated he had been cheeking (hoarding) his medications. The e-mail indicated the message was sent to the Administrator, the DON, Former LPN/ADON # 120 and LPN/Unit Manager 70. Review of the EMS run report for Resident #231 dated [DATE] indicated EMS was dispatched to the facility at 4:53 P.M. and arrived at resident at 4:58 P.M. Notes indicated when EMS arrived, resident was found down not breathing, no pulse and staff indicated resident was initially found in his room underneath a small dresser. Notes indicated EMS assumed care/scene, continued Cardiopulmonary Resuscitation (CPR) with an initial cardiac rhythm being asystole (flat line/no heartbeat) and no return of spontaneous circulation during care. Notes indicated resident had large bruising and deformity to neck. Notes indicated resident was pronounced deceased at 5:31 P.M. and the local Law Enforcement (LE) was requested due to the nature of the incident and bruising on the resident ' s neck and shoulder area. Review of the Police Department (PD) incident detail report dated [DATE] at 4:51 P.M. indicated 911 was called at 4:51 P.M. for a dresser that fell on a resident ' s head and CPR had been started. Notes indicated at 5:13 P.M. the resident was deceased /dead on arrival (DOA). Notes indicated the PD arrived on scene at 5:36 P.M. and assumed scene. Notes at 5:47 P.M. indicated EMS had closed their incident. Review of the discharged residents list dated [DATE] indicated Resident #231 was noted to be discharged to a funeral home. Review of the incident/accident log revealed Resident #231 was recorded as having an unwitnessed fall on [DATE]. Review of the Coroner ' s report for Resident #231 revealed the case was reported on [DATE] and case/report completed on [DATE]. Notes indicated resident ' s cause of death was asphyxiation, compression of his neck and dresser placed on his neck and head. The manner of death was suicide. Review of an undated facility timeline investigation for Resident #231 revealed the resident was admitted to the facility on [DATE] after an episode at home where the resident threatened to kill himself and his wife. Timeline notes indicated resident had past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Notes indicated when the resident was admitted to the facility, the Continuity of Care (COC) form was reviewed, and all medications were verified with MD #160. Notes indicated the resident was admitted and the following was to be completed: continue medications; monitor for Parkinson ' s disease; consult with psychiatrist; monitor for restlessness and agitation; monitor for behaviors and resident was ordered to receive Physical Therapy (PT) and Occupational Therapy (OT). Timeline notes dated [DATE] indicated resident continued with paranoid behavior and frequently commenting they are coming to get me but made no comments of self-harm. Notes dated [DATE] indicated a referral to Psychiatric NP #169 was created and a care conference completed via phone. Notes dated [DATE] indicated the physician was in the facility and ordered [MEDICATION(S)] 12.5 mg daily for depression and Resident #231 was a candidate for [MEDICATION(S)]. Notes dated [DATE] revealed resident continued with paranoid behavior and stated they are coming to get me but no statements of self-harm. Notes dated [DATE] indicated Psychiatric NP #169 assessed resident and created order for [MEDICATION(S)] 34 milligrams daily related to Parkinson ' s disorder with delusion due to known physiological condition. Notes dated [DATE] revealed resident continued with Paranoid behaviors and frequently commenting they are coming to get me, and notes indicated resident did not make statements regarding harming himself or others and resident had no behaviors of self-harm or harming others. Notes dated [DATE] indicated resident had calm demeanor while he ambulated in the facility and spoke to numerous individuals and never mentioned harming self or others and no behaviors observed. Notes indicated other residents were interviewed and indicated Resident #231 made comments of they are coming to get me. Timeline notes dated [DATE] indicated resident was last seen at 4:20 P.M. when he was standing in his doorway and at 4:35 P.M., Housekeeper #33 walked by his room and saw him lying on the floor. Notes indicated LPNs (#80 and #75) responded to resident ' s room where resident was found lying flat on back with arms and legs spread out at side with dresser sitting upright on top of neck/head area. Notes indicated dresser was removed by nurse ' s, resuscitative measure started and 911 was called. Timeline notes indicated EMS arrived and assumed care and resident was pronounced deceased by EMS at approximately 5:05 P.M. Notes indicated local law enforcement arrived in facility and took over investigation. Notes indicated coroner and local Sheriff ' s Office arrived at approximately 12:00 A.M. and removed deceased resident. Review of the May and [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of the May and [DATE] Treatment Administration Record (TAR) for Resident #231 revealed no documented evidence resident ' s behaviors were being monitored. During interview with the DON on [DATE] at 5:06 P.M. revealed Resident #231 committed suicide in the facility, and she kept the large investigation file/binder on her desk waiting for the state agency to visit the facility. The DON further stated the facility did not submit an SRI and she did not know why. Interview with the Administrator and RDO #200 on [DATE] at 5:15 P.M indicated the facility did not submit an SRI since the incident did not involve abuse, neglect, or injuries of unknown origin. RDO #200 stated the facility knew how resident ' s injury occurred so therefore, they were not required to submit an SRI. The Administrator stated the detectives determined the resident had committed suicide prior to them leaving the facility on [DATE]. The Administrator stated they did not have a coroner ' s report, so they did not have an official cause of death. Interview with Marketing/Admissions Director #111 on [DATE] at 8:35 A.M. revealed he went to the hospital where Resident #231 was admitted and completed an in-person admission assessment. Marketing/Admissions Director #111 stated resident had an altercation with his wife and was admitted to the hospital. Marketing/Admissions Director #111 stated he interviewed nurses and social workers and all parties indicated the resident was on the proper medications and was calm and appropriate for facility admission. Marketing/Admissions Director #111 stated he purposefully sat next to the resident on the hospital bed to see what kind of reaction he would get from the resident, and the resident was calm and the politest person you could meet. Marketing/Admissions Director #111 stated the resident never made suicidal statements during his admission assessment. Marketing/Admissions Director #111 indicated Resident #231 ' s admission was discussed in a morning Intradisciplinary Team (IDT) meeting on [DATE] and an e-mail which included the continuity of care and medical records was sent to numerous staff members on [DATE] at 10:09 A.M. Marketing/Admissions Director #111 additionally stated he realized he made a mistake completing the admission PASRR when surveyors questioned the accuracy of the PASRR. Marketing/Admissions Director #111 confirmed he did not provide accurate information regarding a psychological diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN/MDS #49 on [DATE] at 8:50 A.M. revealed Resident #231 was admitted and discharged before she was employed at the facility. LPN/MDS #49 indicated a normal process for new admissions included Marketing/Admissions Director #111 attending the morning IDT meetings to discuss new admissions, and to provide admission paperwork and/or records. LPN/MDS #49 stated the DON would review the paperwork, then disseminate it to everyone else for review. LPN/MDS #49 stated the DON made the final decision on admissions. LPN/MDS #49 stated if a resident came in with [CONDITION(S)] or similar history, the social worker would assist in creating an appropriate care plan. During an interview with LPN #80 on [DATE] at 9:09 A.M. he stated he completed the admission assessment for Resident #231 on [DATE]. LPN #80 stated MD #160 saw the resident via a telehealth visit on [DATE]. LPN #80 stated MD #160 and he reviewed the hospital records and reconciled the medication list. LPN #80 further stated he never heard MD #160 give a verbal order for the resident to be referred to the Psychiatrist. LPN #80 stated he never saw MD #160 ' s notes from [DATE] and was not sure how the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Psychiatric NP #169 on [DATE] at 9:28 A.M. indicated he only saw Resident #231 on one occasion which was on [DATE] after he received a referral for medication management, and he did not see the resident from a referral for [CONDITION(S)]. NP #169 stated he was not aware of the psychiatrist referral created by MD #160 on [DATE]. NP #169 stated the resident was restless, agitated with history of Parkinson ' s disease and he had numerous hospitals stays for psychiatric admissions. NP #169 stated he ordered resident to be started on half dose of [MEDICATION(S)] due to depression on a short-term basis to see how the resident tolerated the medications. NP #169 stated resident denied any [CONDITION(S)] and resident ' s behavior did not indicate any [CONDITION(S)]. NP #169 stated he had an extensive conversation with the residents ' son about [CONDITION(S)] and the numerous psychiatric admissions. NP #169 stated the resident was a candidate for [MEDICATION(S)] for Parkinson ' s disease with delusions which is rarely covered by insurances. NP #169 stated he was working with the manufacturer to get some vouchers or somehow get the medication to the resident. NP #169 stated the one thing the resident said when he was walking out of the resident ' s door that still haunts him was I am never getting out of here am I?. NP #169 stated there were no orders created by him to have the [MEDICATION(S)] discontinued. During a subsequent interview with the DON on [DATE] at 9:35 A.M. she stated she was not aware NP #169 saw Resident #231 for medication management and not for the suicidal ideation ' s referral from MD #160. The DON verified the facility had no documented evidence of a referral being made to the psychiatrist. The DON stated the facility had a new medical records staff and was not able to locate a lot of the admission paperwork for Resident #231. The DON further stated the nurses who sat in on the telehealth visits were responsible for any verbal orders provided from the physicians and NPPs. The DON stated she was not aware of what staff members had received and reviewed the hospital records for Resident #231 when he was admitted . During the interview, the DON continued to indicate she did not know the answers to the surveyor ' s questions. Interview with LPN/MDS #162 on [DATE] at 12:05 P.M. indicated during a UR meeting, Marketing/Admissions Director #111 informed her Resident #231 ' s son called him and stated when he visited the resident, there was a cup of pills in the resident ' s room where he had been spitting them into a cup and hoarding them. LPN/MDS #162 stated she sent an e-mail to the Administrator, DON, and LPNs (#120 and #70) to alert them of the reported incident with the medications. During another interview with the DON on [DATE] at 12:37 P.M. she stated she never received an e-mail regarding Resident #231 hoarding his medication and stated she was never informed of the incident. The DON stated if she was alerted of an incident, she would have done a room sweep. Interview with MD #160 on [DATE] at 2:13 P.M. indicated he saw Resident #231 on [DATE] via a telehealth visit and provided LPN #80 with verbal orders for the resident to be seen by the psychiatrist. MD #160 indicated he reviewed Resident #231 ' s hospital records and medications and was aware of the behaviors and [CONDITION(S)] history. MD #160 stated nursing staff was tasked with monitoring residents for behaviors and other residents with similar suicidal history. MD #160 stated he was never consulted about the resident ' s behaviors and paranoia and s [TRUNCATED]

Based on observation, record review, staff and resident interview, and review of facility policy, the facility failed to provide each resident with a therapeutic diet as ordered by the physician, and planned by the Registered Dietitian, and/or receive interventions per the plan of care to ensure the resident maintained acceptable parameters of nutritional status including body weight. This resulted in actual harm for three residents (#22, #40, #74) who experienced avoidable, unplanned significant to severe weight loss and/or failed to maintain their weight or improve weight status per the plan of care. Additionally, the facility failed to provide a therapeutic diet as ordered by the physician for one resident (#05) out of eight residents reviewed for Nutrition. The facility census was 79. Findings include: 1. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE], and readmitted [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was hospitalized from 10/26/21, and returned on 11/01/21. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as having moderate cognitive losses, was understood and able to understand, and required the physical assistance of one staff person to complete activities of daily living. The resident was assessed as being 73 (inches) tall and weighing 143 lbs (pounds) at the time of the assessment. Review of the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The November MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 12:00 A.M., 2:00 P.M., 5:00 P.M., and 9:00 P.M. daily. Interview on 11/17/21 at 10:37 A.M. with Licensed Practical Nurse #79, caring for Resident #22, reported that she doesn't give the Magic Cup, if it doesn't come on the resident's tray she will give the resident a chocolate Ensure supplement that he likes. Review of the MAR for November 2021 through 11/17/21 revealed that LPN #79 signed off as giving the resident the Magic Cup five times on 11/16/21, twice at 9:00 A.M. Interview on 11/17/21 at 10:40 A.M. with unit manager, LPN #70 reported that she believed the Magic Cup order was a duplicate order, and stated she was going to get clarification on the Magic Cup order and the reported as needed use of the Ensure. She affirmed that LPN #79 was signing off as giving the Magic Cup on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent assessment of the resident's nutritional status dated 08/24/21 completed by DTR #152 revealed the resident was on a pureed consistency diet with honey thick liquids at that time. She noted the resident's appetite as good, 50-100% and was accepting 240 to 480 milliliters of fluid at each meal. DTR #152 documented the resident's height as being 73, weighing 142 lbs, with a body mass index of 18.7 indicating the resident was underweight. She noted the resident was on Magic Cup three times daily to help prevent further weight loss. DTR #152 documented the resident's diet provided 2000 calories a day and 90 grams of protein, and each Magic Cup provided an additional 290 calories and 9 grams of protein. She noted the residents nutritional needs would be met with his current diet, and supplementation. Review of the resident's current comprehensive plan of care revealed the resident was identified has having a potential nutritional/hydration problem related to diabetic restrictions, mechanically altered diet, acute kidney injury, chronic kidney disease, adult failure to thrive, and diabetes mellitus type 2, [CONDITION(S)], intellectual disability, skin breakdown, hypertension, depression, underweight, [CONDITION(S)], dysphagia, and difficulty chewing and swallowing. 10/10/21 significant weight gain in the past 180 days; desired. The goal was for the resident to maintain adequate nutritional status as evidence by maintaining weight within 3% of 125 lbs, no signs or symptoms of malnutrition, and consuming at least three meals daily, and the resident would maintain his weight without significant weight change, through the review date of 12/08/21. Interventions included but were not limited to provide and serve the resident's diet as ordered, monitor intake and record each meal. Review of the resident's height and weight history revealed the resident stood 73 tall and weight was 142.8 lbs on 10/10/21. Further review revealed no weight was recorded for the resident after he was readmitted from the hospital on 11/01/21. Review of nutrition progress notes dated 10/12/21 by contracted Dietetic Technician Registered (DTR) #152 revealed the resident was identified on 10/10/21 at weighing 142.8 lbs which was an increase in weight of 10%. DTR #152 noted that weight gain for the resident was desirable, and to continue the Magic Cups three times a day. Review of the resident's hospital discharge records dated 11/01/21 revealed the resident's weight was recorded as being 136 lbs at the time of discharge. The resident's current weight was requested on 11/17/21. Interview on 11/18/21 at 9:07 A.M. with unit manager LPN #70 revealed the resident was weighed on 11/17/21 as requested by the nurse aides and affirmed resident weighed 121.6 lbs. LPN #70 stated she did not think the resident's weight recorded in the 140 lb range were accurate. This represented a severe weight loss of 10.59% (percent) of the resident's total body weight in approximately two and a half weeks from the time of readmission. Observation of the resident on 11/15/21 at 1:05 P.M. revealed the resident was served one bowl of pureed food, brown in color, and two cups of a lemonade appearing beverage. The resident was not served any additional food items including no fruit and no dessert. State tested Nurse Aide (STNA) #102 who was present affirmed the resident received only the one bowl of pureed food and the two cups of lemonade. The resident ate all of what was served. Review of the planned menu approved by Registered Dietitian (RD) #151 revealed that residents on a pureed diet were to receive two 4 ounce scoops of pureed chicken pot pie, and a 4 ounce scoop of pureed Italian green beans, a four ounce scoop of pureed pears, and four ounces of milk during the lunch meal on 11/15/21. Observation of the resident on 11/15/21 at 6:04 P.M. revealed the resident was served a large scoop of an unidentifiable pureed food in a Styrofoam container, and a cup of orange drink/punch. STNA #106 who had served the resident affirmed what was on the resident's meal tray. Review of the planned menu approved by RD #151 revealed that residents on a pureed diet were to receive a six ounce scoop of pureed soup, four ounces of vegetable juice, a six ounce scoop of sloppy [NAME] on bun, and a three ounce scoop of pureed cake during the evening meal on 11/15/21. Observation of the resident on 11/18/21 at 8:55 A.M. revealed the resident was eating his breakfast and receiving speech therapy services from Speech Therapist (ST) #25 at that time. On the resident's meal tray was a bowl of oatmeal, and a bowl of a milky slurry of what appeared to be a bread product made with milk, and orange juice. ST #25 confirmed what was on the resident's tray and left the room to get the resident a carton of milk and sugar for his oatmeal. Review of the planned menu approved by RD #151 revealed that residents on a pureed diet were to receive six ounces of hot cereal, a three ounce scoop of pureed scrambled eggs with ham, a two ounce scoop of pureed toast, and eight ounces of milk during the breakfast meal on 11/18/21. 2. Review of Resident #74's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment of the resident dated 10/07/21 revealed the resident was assessed as having severe cognitive deficits, and requiring the extensive physical assistance of one staff person to complete activities of daily living, with the exception of eating for which the resident was assessed as being independent with set-up help only. The resident was edentulous and did not have dentures. The resident was assessed as standing 72 tall and weighing 178 lbs at the time of the assessment. The resident was not identified as having any known weight loss at that time. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's weight history revealed the resident weighed 178 lbs on 10/01/21, and 167.4 lbs on 11/03/21. This was a 10.6 lb weight loss, and represented a severe weight loss for a one month time period. On 11/18/21 it was requested for the resident to be reweighed. The resident's weight was recorded as 158.9 lbs in the electronic medical record by LPN #70. This represented a 10.17% weight loss a little over one and a half months. Review of a the resident's admission nutrition assessment completed by DTR #152 on 10/04/21 revealed the resident was exhibiting lethargy and confusion, and needed curing to eat at the time of the assessment. She noted the resident was sent out to the hospital for altered white blood cell count on 12/01/21, and his prealbumin was found to be low. DTR #152 documented that weight stabilization would be ideal for the resident, and the resident needed to eat for strength and healing. She noted she requested to have Ensure added twice daily to increase calorie and protein in diet. Review of a nutrition progress noted dated 11/12/21 by DTR #152 revealed the resident weight on 11/03/21 was 167.4 lbs. The resident's weight triggered for a significant weight loss over 30 days. She noted the resident was a one-person physical assist with eating meals, and was receiving Ensure supplement twice daily. DTR #152 documented on 11/12/21 that she would request to have the Ensure increased to three times a day, and noted the Registered Dietitian and nursing were made aware of the resident's weight change. Review of the November 2021 significant weight change sheet completed by DTR #152, with review dates of 11/11/21 and 11/12/21 revealed that a recommendation was made to increase the resident's Ensure from twice daily to three times daily. Review of the resident's November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Interview on 11/19/21 at 8:50 A.M. with the Director of Nursing (DON) revealed that when DTR #152 comes in she will send the significant weight change to me by e-mail. She affirmed the November significant weight change sheet was e-mailed to her, but did not have time to address it on Monday 11/15/21. She stated when DTR #152 makes recommendations it comes to her e-mail as well as the Assistant Director of Nursing (ADON), and LPN #70, and then the information for changes in diet/supplements would be conveyed to the physician and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's current plan of care initiated 10/04/21 revealed the resident had a potential nutrition/hydration problem related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan of care documented the resident as having poor oral intake, and his own teeth. The plan of care problem for nutrition added for 11/03/21 documented the resident as having significant weight loss over the past 30 days. The goal was for the resident to maintain his weight without any significant changes and be free from signs and symptoms of dehydration. Interventions included but were not limited to: Ensure twice daily, and on 11/12/21 increase to three times daily; provide and serve diet as ordered; and nursing would inform the physician, family/representative of significant weight changes. The care planned interventions did not include assisting the resident to eat as needed as documented in DTR #152's assessment and progress notes. Observation on 11/15/21 at 6:07 P.M. revealed the resident was in his room sitting up in a lounge chair attempting to feed himself, and the resident was edentulous. The food was served in a Styrofoam container sitting to the resident's left. The resident was served a hamburger, and a portion of vegetable soup that was put into one of the small compartments in the tray, and a glass of orange drink/punch. The resident was working on eating the hamburger. STNA #102 confirmed what the resident was served, and that there was nothing else on his tray. Review of the planned, approved menu for regular diets for the evening meal on 11/15/21 revealed that residents on a regular diet were to receive a six ounce bowl of soup with crackers, a garden salad, a personal pizza, a piece of cake, and four ounces of milk. Review of the resident's meal tray card revealed the resident did not have any of these items listed as a dislike. Observation on 11/16/21 at 9:26 A.M. revealed the resident was observed sitting up in his bed asleep with his breakfast tray in front of him. LPN #79 who was working on the unit affirmed the resident was asleep in bed with his uneaten tray in front of him. The nurse woke the resident up, set up the tray, and encouraged the resident to start eating. Observation on 11/16/21 at 6:12 P.M. revealed the resident was laying in bed, in the dark, with a tray of food on an overbed table at the foot of his bed. Observation on 11/16/21 at 6:23 P.M. revealed the resident was still laying in bed, in the dark with his tray of food on an overbed table at the foot of his bed. Patient Care Assistant (PCA) #61 affirmed at that time she had taken the resident's tray to him and not served it as she needed someone to help her set him up to eat. On 11/16/21 at 6:47 P.M., the resident was observed sitting up in bed, in the dark, with his meal tray in front of him uneaten. The resident was served a regular hamburger and stated he didn't want it. The resident was not observed to be offered feeding assistance or cueing during the meal period via intermittent observations. Observation on 11/17/21 at 9:46 A.M. of the resident eating his breakfast revealed the resident was sitting up in a lounge chair with his food in front of him. The resident was served a scoop of oatmeal on his plate, a waffle, scrambled eggs, a piece of sausage, coffee and orange juice. The resident had eaten what appeared to be a bite or two of the waffle. When the resident was asked if he was going to eat his breakfast he stated no you eat it. He then pointed to the sausage and stated that it was pretty hard. The resident had consumed nearly nothing. Certified Nurse Aide (CNA) #65 who was assigned to the unit came in to check on the resident at that time. The nurse aide offered the resident some oats on a spoon and the resident declined. When asked what percent of the meal the resident usually consumed, she stated it depended on the day as some were better than others, but typically about 40% and anywhere from 0 % to 50%. CNA #65 then covered the residents plate and removed the tray from the room. Review of the meal intake records for the breakfast meal on 11/17/21 revealed CNA #65 recorded the resident as having eaten 51 to 75% of his breakfast in the electronic health record on 11/17/21 at 10:12 A.M. Observation of the resident on 11/19/21 at 9:14 A.M. revealed the resident was up in his lounge chair with his breakfast tray in front of him. His breakfast included orange juice, toast, and scrambled eggs on the main plate, and it appeared one menu item was missing. The resident had not touched the scrambled eggs. No staff were present in the room with the resident. When asked why he wasn't eating his eggs he stated there was no salt. When asked how they tasted he took a bite and said they needed salt. When asked if he had a salt packet he stated no, which observation of his tray confirmed. The resident did not eat his eggs or toast. Interview on 11/17/21 at 2:42 P.M. with Registered Dietitian (RD) #151 revealed that she visited the facility only once monthly, but DTR #152 was there weekly. RD #151 was queried about DTR #152's recommendation to increase the residents Ensure on 11/12/21, and how soon a recommendation is to be acted on. She reported that if the recommendation is made early in the day it would be possible for the physician to be contacted and the order changed the same day. If the recommendation was made late on a Friday, the expectation would be for nursing to contact the physician and get the new order by the end of the day the following Monday. 3. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment of the resident dated 10/04/21 revealed the resident was assessed as having intact cognitive skills, and required the physical assistance of one staff person to complete activities of daily living with the exception of eating which he could do independently with set-up help. The resident was assessed as standing 69 tall and weighing 128 lbs at the time of the assessment, and as having experienced weight gain and being on a physician prescribed weight gain regimen. Review of the resident's current physician' orders dated 11/12/21 revealed the resident had an order to receive a mechanical soft textured diet effective 11/12/21 (previously regular texture with no double portions 04/21/20 through 11/12/21), with thin liquids and double portions at all meals. In addition, the resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's weight history revealed the residents weights were documented as follows: 08/05/21, 138.2 lbs; 09/07/21, 117 lbs (no reweigh evident); 09/17/21, 120 lbs; 10/01/21, 129.2 lbs; and on 11/03/21, 124 lbs representing a significant 14.2 lb weight loss over a three month period. Review of the resident's most recent nutrition progress notes dated 11/12/21 by DTR #152 revealed documentation that the resident's weight on 11/03/21 was 124 lbs and had decreased significantly, but has increased since 09/07/21. She noted weight gain is desired as the resident's current body max index (BMI) was 18.3 (underweight). DTR #152 documented the nutrition interventions included double portions at all meals, Magic Cups three times a day, and Ensure three times a day. She noted she would request to increase the Ensure to four times daily on that date. DTR #152 documented the Registered Dietitian and nursing was notified of the resident's weight change. Further review of nutrition progress notes completed by DTR #152 on 10/12/21 and 09/19/21 revealed the technician recommended to continue nutrition interventions including a mechanical soft diet with double portions, Ensure three times daily and Magic Cups three times a day. However, review of the resident's physician ordered diet and supplements revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for mechanical soft diet with double portions was reordered on 11/12/21. Review of the resident's current plan of care with a target day of 01/22/21 revealed the resident was noted as having a potential nutrition/hydration problem related to dysphagia, subarachnoid hemorrhage, weakness, mood disorder, hypertension, left [CONDITION(S)], anxiety, decline in self feeding, low body weight, and overall medical condition. The goal for the resident was to maintain adequate nutritional status as evidence by maintaining weight within 3% of 137 lbs, no signs or symptoms of malnutrition, and consuming at least 75% of at least three meals daily. Interventions, included but were not limited to: monitor intake, weight, skin, laboratory values, medication, diet tolerance and hydration status, provide and serve supplements as ordered; Magic cup three times a day and double portions with meals; 11/12/21 increase Ensure to four times a day; serve diet as ordered and monitor intake and record each meal. Observation on 11/15/21 at 12:54 P.M. of the resident eating his lunch in his room revealed the resident did not receive double portions, and did not receive a frozen Magic Cup. STNA #102 affirmed the resident did not receive double portions. Review of the resident's tray card revealed the diet was listed as Regular, not mechanical soft, but did specify double portions. There was no documentation on the paper tray card that the resident was supposed to receive a frozen nutritional supplement (Magic Cup) at each meal. Interview on 11/15/21 at 4:45 P.M. with the resident regarding his nutrition and weight revealed that he felt he was not receiving the right kind of food to gain weight, stating that he had lost weight. The resident reported he was not getting low fat milk, and was not getting double portions of food. Observation on 11/15/21 at 6:02 P.M., and interview with the resident while he was eating supper in his room revealed the resident did not receive double portions, and no frozen nutritional supplement was evident on his tray. The resident affirmed he did not receive double portions, and got cookies and no frozen supplement or dessert. Observation on 11/16/21 at 6:06 P.M. revealed the resident received two regular consistency cheeseburgers on his meal tray, which the resident confirmed. Review of the resident's printed paper tray card revealed the resident's diet listed on the tray card was Regular. Interview on 11/17/21 at 03:42 P.M. with the resident affirmed he gets regular food which he prefers, and stated he did get mechanically soft food when he first came to the facility. Interview on 11/17/21 at 5:01 P.M. with the resident to ascertain if he was receiving any frozen nutritional supplement with his meal revealed that he got something like a sherbet or an ice cream once in a while on his tray, but denied getting any frozen supplement/dessert on his tray three times a day. He stated he did get Ensure regularly. Interview on 11/17/21 at 5:04 P.M. with LPN #79 revealed she assumed that the Magic Cup supplement for Resident #40 came on his meal tray, that she did not give it. When it was explained that the resident was not observed to receive it during meals on 11/15/21 or 11/16/21 she affirmed she was marking it off as given on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/18//21 at 8:45 A.M. with unit manager LPN #70, while observing the resident's breakfast meal tray, confirmed the resident's tray card specified the resident was on a Regular Diet not a mechanical soft diet, and double portions were specified on the tray card. LPN #70 also confirmed there was no mention of a Magic Cup supplement to be served with meals three times a day. 4. Review of the medical record for Resident #05 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/01/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating. Review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/18/21 at 1:07 P.M. revealed Resident #05 was not served double portions for lunch, which included turkey, stuffing, and vegetables. Interview on 11/18/21 at 1:08 P.M. with Certified Nursing Assistant (CNA) #66 confirmed the resident had not received double portions and verified the meal ticket on his tray indicated he should have been sent double portions. Review of facility policy titled Weight Assessment and Intervention revised 09/2008 revealed the nursing staff were to measure the resident's weight on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.

Based on observation, staff interview and record review, the facility failed to ensure all safety injury prevention interventions were in place as care planned for residents identified at risk for falls. This resulted in actual harm for one resident (#19) when the resident fell while he was not adequately supervised while up in his wheelchair and was subsequently hospitalized related to a [MEDICAL CONDITION] left fibula. This affected two (Resident #11 and #19) of three residents reviewed for falls. The facility census was 83. Findings include: 1. Record review revealed Resident #19 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment, dated 02/12/19, revealed the resident to be cognitively impaired and required extensive assistance with bed mobility and transfers. Resident #19 had one fall with major injury. Review of Resident #19's fall risk assessment, dated 01/27/19, revealed the resident had recent falls and was at a high risk for falls. Review of the resident's fall care plan, dated 03/18/19, revealed the resident was to have a fall mat next to the bed and colored tape on his call button. Resident #19's care plan was also revised on 02/05/19 with an intervention to keep in a supervised area when up. Review of Resident #19's fall investigations revealed the resident had numerous falls: · On 09/08/18, the resident fell while walking towards the smoking area in the courtyard and the new intervention was for the facility to provide Resident #19 with shoes. · On 09/08/18, the resident fell in his room and he reported he was trying to get into his chair in his room at the time of the incident. The new intervention was a wheelchair. · On 01/02/19, the resident fell on the floor in his bathroom. Resident #19 was reported to complain of dizziness and he was sent out to the emergency room and returned with a [DIAGNOSES REDACTED]. · On 01/05/19, the resident fell on the floor in front of the weight scale. Resident #19 was placed on 15-minute checks for 72 hours after his fall on 01/05/19. · On 01/06/19 at 1:15 P.M., the resident fell in the floor in his room by his bathroom. Resident #19 reported he was trying to take himself to the bathroom at the time of the fall. The new intervention was to place colored tape on his wheelchair brakes. · On 01/06/19 at 4:00 P.M., the resident fell in the floor in his room. He was observed to have a hematoma on the right side of his head and was noted with tremors after the fall. Resident #19 was sent out to the hospital and he returned with an indwelling catheter. · On 01/07/19, the resident fell on the floor in his room. Resident #19 reported the floor was wet at the time of the incident, but the floor was observed to be dry when staff assessed the area. The new intervention was to apply colored tape to his call light. · On 01/14/19, the resident was observed on his knees on the floor in his room and new intervention was to place a scoop mattress to his bed. · On 01/15/19, the resident was noted with blood on his pillow and the resident reported he slid out of bed and bit his lip. He was sent to the emergency room and another indwelling catheter was placed. · On 01/23/19, the resident was observed on the floor in his room with his wheelchair behind him and the new intervention was to place dycem to his wheelchair. · On 01/26/19, the resident was observed on the floor of his room and the new intervention was to provide the resident a reacher to allow the resident to pick stuff up easier. · On 01/27/19, the resident fell on the floor in his room. The new intervention was to keep the resident in a supervised area when he was up. · On 02/06/19, the resident fell on the floor in the hallway. Resident #19 was reported to have previously been in his wheelchair. Resident #19 was provided a prompt sign not to get out of bed by himself. · On 02/07/19, the resident fell on the floor in the doorway to his room. Resident #19 was observed to be laying on his back with his wheelchair flipped back. Resident #19 was noted to have previously been in the courtyard smoking. Resident #19 was sent to the emergency room for evaluation and returned from the emergency room with a [MEDICAL CONDITION] proximal fibula. Resident #19 had a brace on his left leg upon his return to the facility and anti-tippers were placed to his wheelchair. Review of witness statements from the resident's fall on 02/07/19 revealed Social Services Director (SSD) #62 left his office at approximately 2:40 P.M. and returned to his office around 4:32 P.M. SSD #62's statement revealed he noticed an overturned wheelchair outside of his door and found Resident #19 holding the back of his head. SSD #62 alerted nursing staff. Review of the resident's progress notes revealed the resident fell on [DATE]. The progress note stated SSD #62 yelled out for assistance due to Resident #19 being on the floor still sitting in his wheelchair that appeared to be flipped backwards. Resident #19 was sent to the hospital for evaluation. Resident #19 was noted to return to the facility on [DATE] with a left proximal fibula. Observation of Resident #19's room on 03/25/19 at 12:30 P.M. revealed the residents' call light not to have colored tape on it. Interview with Licensed Practical Nurse (LPN) # 18 on 03/25/19 at 12:30 P.M. verified Resident #19's call light did not have colored tape on it. Observation of Resident #19 on 03/26/19 at 1:59 P.M. revealed the resident to be laying in his bed. Resident #19's fall mat was folded up behind his bed. Observation of Resident #19 on 03/28/19 at 9:00 A.M. revealed the resident to be laying in his bed. Resident #19's fall mat was folded up on the floor approximately three feet from his bed. Interview with the Director of Nursing (DON) on 03/28/19 at 9:00 A.M. verified Resident #19's fall mat was not in place next to his bed. Interview with the DON on 03/28/19 at 9:58 A.M. verified Resident #19 fell on [DATE] in the floor in his room and his intervention from the fall was to resident in a supervised area when he was up. The DON confirmed Resident #19 fell on [DATE] and was reported to be on the floor in the doorway to his room. Resident #19 was observed to be laying on his back with his wheelchair flipped back. The DON reported staff attempted to keep Resident #19 in a supervised area but the resident propelled himself in his wheelchair. Subsequent interview with the DON on 03/28/19 at 4:29 P.M. revealed the DON was unaware of if Resident #19's fall on 02/07/19 was witnessed. The DON stated Resident #19 was in the smoking area outside prior to his fall on 02/07/19 and that he was on his way back to his room when he fell . Interview with SSD #62 on 03/28/19 at 4:40 P.M. revealed he was walking down the hallway on 02/07/19 when he noticed Resident #19's wheelchair was flipped backwards in the hallway near the doorway of his room. SSD #62 reported Resident #19's doorway to his room was next to SSD #62's office. SSD #62 reported he alerted nursing staff of Resident #19's fall. SSD #62 stated the nursing staff were located near the nursing station. 2. Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/07/19, revealed the resident had problems with long and short-term memory and had severely impaired cognitive skills for decisions. The resident required extensive assistance of one to two-persons for activities of daily living (ADLs). The resident had one fall without injury since admission or the prior assessment. Review of the care plan, dated 01/09/18, revealed the resident was at risk for falls and fall related injuries. Interventions included to encourage non-skid socks/shoes, keep wheel chair in reach, colored tape on call light, clutter free environment, prompt sign to call for assistance posted in the room, and the use of a scoop mattress. Review of the fall risk assessments, dated 02/03/19 and 03/11/19, revealed the resident was at high risk for falls. Review of the fall investigation notes, dated 03/11/19, revealed the resident was found on the floor on 03/11/19 after she was assisted to her bed. Observation on 03/27/19 at 7:35 A.M. revealed the resident was in a low bed that had a regular mattress instead of a scoop mattress. Interview on 03/27/19 at 8:13 A.M. with MDS Nurse #80 verified the resident's fall risk care plan documented the resident was to have a scoop mattress on the bed. MDS Nurse #80 also verified that the resident was lying on a regular mattress instead of a scoop mattress.

Based on observation, record review, and interview, the facility failed to provide routine narcotic pain medication resulting in harm to one resident (Resident #11). The facility identified 48 residents at the facility currently on a pain management program. The facility census was 78 residents. Findings include: Review of Resident 11's accumulative [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] stated the alert and oriented resident required limited assistance with bed mobility, extensive assistance with dressing, and supervision of staff with eating and hygiene tasks. The pain assessment dated [DATE] stated the resident had two or more conditions associated with the potential for pain. Review of the pain prevention care plan, dated 12/17/12, revealed interventions including addressing complaints of pain promptly with medications and non-pharmaceutical interventions, assessing the effectiveness of pain medication, assessing the pain characteristics, the duration, location, and quality on a 1 to 10 scale, ensuring pain medication was available as needed, reporting diaphoresis, moaning, restlessness, grimace, crying, and treatment as ordered. Review of the physician order [REDACTED]. Review of the March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. dose of [MEDICATION NAME] 75 mg as ordered. Further review revealed the routine dose of [MEDICATION NAME] was not administered at 4:00 A.M., 8:00 A.M., and 12:00 P.M. as ordered. The [MEDICATION NAME] was not given because the medication was not sent to the facility by the pharmacy. The pharmacy did not send the mediation because they did not have the required prescription sent to them by the facility. Review of the 03/25/13 nurses notes revealed no pain assessments were conducted during the time period the resident missed the three routine doses of [MEDICATION NAME] to ensure her pain needs were being met. There was one notation made in the nurses notes dated 03/25/13 at 12:15 P.M. that stated the resident refused her noon medications. Review of the pharmacy records revealed the prescription for the [MEDICATION NAME] was sent to the pharmacy on 03/25/13 at 10:36 A.M. The pharmacy delivery sheet revealed the [MEDICATION NAME] was delivered to the facility on [DATE] at 11:05 A.M. During interview with Licensed Practical Nurse (LPN) #1 on 03/28/13 at 10:40 A.M., she stated when the nurses did the narcotic count on 03/24/13 and 03/25/13, they should have noticed the [MEDICATION NAME] was almost gone, and needed to be reordered. She stated they should have handled it at that time by having the resident's physician give a verbal order to the pharmacy. She confirmed three doses of the [MEDICATION NAME] were not given. During interview with Resident #11 on 03/28/13 at 10:00 A.M., she stated she had experienced severe/chronic pain since 1999 due to severe [MEDICAL CONDITION]. She stated her whole body ached and hurt on a continuous basis and the only pain medication that worked was [MEDICATION NAME]. She confirmed that she did not receive three doses of [MEDICATION NAME] on 03/25/13. She rated her pain that day on a scale of 1 to 10 as a 15. She stated she was in so much pain, she was ready to go to the emergency room to have them administer pain medication through an intravenous route (IV). When asked if she had refused to take the noon dose of [MEDICATION NAME] on 03/25/13, she stated absolutely not, that she would never refuse her pain medication. This citation substantiated Complaint Numbers OH 373 and OH 744.

Based on record review, observations, staff and resident interviews the facility failed to provide narcotic pain medications resulting in harm due to increased pain for two residents (#19 and #56 ). This affected two residents of three sampled residents receiving narcotic pain medications and had the potential to affect forty five residents receiving pain medications. Findings Include: 1. Review of Resident # 19's accumulative [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] noted the resident was cognitively intact requiring minimal assistance of one with all activities of daily living. The most recent pain assessment dated [DATE] revealed the resident had two or more [DIAGNOSES REDACTED]. Review of the doctor's orders sheet dated and signed for October 2012 noted an order for [REDACTED]. Twelve doses of his routine pain medication were not given. Review of the nurses notes for October 20, 21, and 22, did not mention anyone trying to get his medication or how the resident was reacting to not having his medications. Interview with Resident #19 on 11/27/12 at 10:45 A.M. noted he had chronic back pain and had been taking this pain medication since 2002 when he fractured his back. The resident noted he was told he did not have his medications due the doctor not signing the prescription, so the pharmacy would not send it. He stated no other pain medication was offered in its place. The resident noted he felt terrible, he just laid around, his stomach hurt his back hurt he stated he was miserable he could not sleep. Interview with the Director of Nursing (DON) on 11/27/12 at 12:30 P.M. revealed the facility had identified the problem in October when another resident ran out of his medication. Review of the Resident Council notes dated 10/17/12 noted a resident ran out of his narcotic medications. In response to that meeting a plan of action memo was initiated which noted the problem was the doctor was not signing the prescriptions and the residents were not getting there scheduled IV medications. 2. Review of the accumulative [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] assessment revealed the resident was cognitively intact and required moderate assistance of one with all activities of daily living. The resident had a plan of care for pain with interventions to anticipate the resident's pain and respond immediately, and administer routine narcotic pain medications. The most recent pain assessment dated [DATE] revealed the resident was at high risk for pain. Review of the doctor's order sheet dated 10/12 revealed the resident was to receive [MEDICATION NAME] (a narcotic pain reliever) 15 mg one every twelve hours. Review of the MAR indicated [REDACTED]. Review of the nurses notes dated 10/06/12 at 10:20 A.M. a call was placed to the pharmacy to let them know the resident was out of his medication . Review of the nurses notes for 10/07/12 at 4:30 A.M. the resident complained of not being able to sleep. Review of the nurses notes dated 10/08/12 at 2:00 P.M. revealed the pharmacy was called again and at 10:45 P.M. on 10/08/12 the nurses notes said the medication had come in at 7:30 P.M. Interview with Resident # 56 11/27/12 at 10:00 A.M. revealed when he was without his medications he could not sleep, or eat, and he felt nauseous, he noted he was in a lot of pain . Resident # 56 stated he switched doctors because he felt so bad physically he did not want it to happen again. Interview with the Director of Nursing (DON) on 11/27/12 at 12:30 P.M. she noted the facility was aware of the problem and it was due to the doctor not signing the prescriptions and stated that it should not have happened. This deficiency substantiates Complaint Number OH 969