Every finding on record at Heritagespring Healthcare Center of West Chester

THE FOLLOW DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUESTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, review of the hospital record, review of personnel files, and policy review, the facility failed to ensure residents were free from significant medication errors. This resulted in Actual Harm to Resident #124 on 06/25/26 at approximately 11:00 P.M., when Licensed Practical Nurse (LPN) #210 administered diabetic medication Lantus (a long-acting basal insulin that provides a steady, 24-hour baseline level of insulin) 20 units subcutaneous injection in error. Approximately 30 minutes later, Resident #124 was clammy, diaphoretic, and had a blood glucose level of 42 milligram per deciliter (mg/dL) that required Glucagon (an injectable medication to raise the blood sugar) intramuscular injection. Resident #124 was sent to the hospital five hours later for iatrogenic hypoglycemia and received intravenous dextrose. This affected one (Resident #124) of three residents reviewed for medication administration. The facility census was 122. Findings Include: Review of the medical record revealed Resident #124 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, hypertension, depression, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 06/16/26, revealed Resident #124 was cognitively intact. Review of the plan of care dated 06/16/26 revealed Resident #124 had diabetes mellitus. Interventions included administering diabetes medication as ordered by clinician, monitor for side effects and effectiveness, avoid exposure to extreme heat or cold, educating regarding medications and importance of compliance, educate the correct protocol for glucose monitoring and insulin injections. Monitor blood glucose as ordered and as needed. Monitor and report as needed of signs and symptoms of hypoglycemia that included sweating, tremor, increase heart rate, pallor, nervousness, confusion, slurred speech, staggering gait, and lack of coordination. Review of a physician order dated 06/16/26 revealed Resident #124 had an order for Metformin Hydrochloride (HCL) (a medication to reduce blood sugar levels) 1,000 milligrams (mg) take one tablet by mouth two times a day for diabetes type two. Review of a physician order dated 06/22/26 revealed Resident #124 had an order for blood glucose monitoring twice daily at 6:00 A.M., and 6:00 P.M., for seven days due to diabetes mellitus. Review of the medication administration record (MAR) revealed Resident #124 received medications on 06/25/26 that included Metformin HCL 1,000 mg one tablet at 9:00 A.M., and one tablet at 9:00 P.M. On 06/25/26 at approximately 11:30 P.M., Resident #124 received Clonidine HCL 0.1 mg one tablet and Glucagon 1 mg vial injection. On 06/26/26 at approximately 1:30 A.M., a second Glucagon 1 mg vial injection was given. Review of the facility medication error report documented a medication error for Resident #124 dated 06/25/26 at 11:30 P.M. The medication error report form had no details just a box checked of WD meaning wrong dose. Review of a physician order dated 06/25/26 at 11:30 P.M., revealed Resident #124 had an order for Glucagon 1 mg intramuscular (IM) solution to inject one vial intramuscularly once a day for hypoglycemia and an order for Clonidine Hydrochloride (HCL) 0.1 mg take one tablet by mouth one time only for hypertension. Review of a physician order dated 06/26/26 at approximately 1:30 A.M., revealed an order for a second Glucagon 1 mg IM injection for hypoglycemia Review of the facility document titled Carespring General Nursing Evaluation dated 06/26/26 authored by Unit Manager (UM) #315 revealed Resident #124 had an episode of hypoglycemia and hypertension and was diaphoretic. Vital signs included a temperature of 98.3 degrees Fahrenheit (F), a heart rate of 82 beats per minute, respirations were 16 breaths per minute, blood pressure was 211/83 millimeters of mercury (mmHg), oxygen saturation was 96 percent on room air, blood sugar was 42 mg/dL (below 54 mg/dL is considered critically low), and weight was 124.4 pounds. Resident #124 was alert and oriented to person, place, time, and situation. Notification was sent to the nurse practitioner on 06/25/26 at 11:30 P.M. The family was notified on 06/26/26 at 6:25 A.M. Review of the facility document titled Carespring Situation Background Assessment Recommendation (SBAR) Communication Form dated 06/26/26 revealed Resident #124 had a change in condition the resident appeared cool, clammy, diaphoretic, and had hypertension that started on 06/25/26 at 11:30 P.M. Resident #124 had orange juice, a bottle of coca cola, ice cream and a glucagon injection. Resident #124 was at the facility for post-acute care. Vital signs were a blood pressure of 130/59 mmHg, a heart rate of 68 beats per minute, respirations were 16 breaths per minute, temperature was 98.3 degrees Fahrenheit, weight was 124.4 pounds, oxygen saturation was 96 percent on room air, and the most recent blood glucose was 117 mg/dL. Resident #124 was alert, oriented, and lethargic. Suggestion was to monitor vital signs and transfer to hospital. Nurse had rounded on Resident #124 on 06/25/26 at 11:30 P.M. at which time Resident #124 was found to be diaphoretic and clammy. Nurse checked Resident #124's vital signs. The nurse manager and provider were notified on 06/25/26 at 11:30 P.M. The provider ordered a one-time dose of clonidine 0.1 mg and a Glucagon IM injection. The nurse was ordered to recheck vital signs in one hour. Vital signs were taken and the provider was notified a second time on 06/26/26 at 1:30 A.M. The provider ordered a second one-time dose of Glucagon IM and to follow up in one hour. The nurse notified the provider of Resident #124 vital signs and rechecked the blood sugar at 5:00 A.M. Resident #124 was sent out to the emergency room for evaluation. Review of the MAR revealed on 06/25/26 at 6:00 P.M., Resident #124's blood glucose reading was 96 mg/dL; on 06/26/26 at 6:00 A.M., the blood glucose reading was 117 mg/dL; and on 06/26/26 the 6:00 P.M., the resident was marked out of the facility. There were no other blood glucose measurements or assessments documented on the MAR. Review of the emergency room progress note dated 06/26/26 at 6:11 A.M., revealed Resident #124 had been seen for concerns of accidental injection with Lantus while at the nursing home. Resident #124 had a history of diabetes and was on oral medications; however today the nursing facility made the mistake of injecting her with Lantus presumably for another resident. Resident #124 stated she felt fine here, had no nausea, no vomiting, or dizziness. Resident #124 was hemodynamically stable in no acute distress. Resident #124 had normal mental status. Resident #124's blood glucose was 94 mg/dL. Review of the hospital Discharge summary dated [DATE] revealed Resident #124 had been seen in the emergency room on [DATE] and was admitted with Iatrogenic Hypoglycemia secondary to Lantus 20 units administered at the nursing facility. Resident #124 was hospitalized for management with intravenous dextrose. The plan was to follow up with a physician as outpatient, resume Metformin 1,000 mg on discharge. Resident #124 had a hemoglobin A1C of 5.6 mg/dL. During an interview on 08/10/26 at 1:20 P.M., the Director of Nursing (DON) said on 06/25/26 at 11:25 P.M., Licensed Practical Nurse (LPN) #210 entered the room and Resident #124 was alert but diaphoretic. LPN #210 checked Resident #124's blood glucose and found it was 42 mg/dL and her blood pressure was 211/83 mmHg. LPN #210 realized she had administered Lantus 20 units instead of her Enoxaparin Sodium (a blood thinning medication) injection prefilled syringe. LPN #210 notified the on-call physician who ordered a Glucagon 1 mg IM, and Clonidine 0.1 mg, that were both administered right away. Around 12:30 A.M. LPN #210 checked Resident #124 blood glucose and found it was 124 mg/dL. The DON stated she believed the blood glucose was checked again at 1:30 A.M. but was not recorded, but her blood glucose was higher. At 2:30 A.M. Resident #124's blood glucose was 120 mg/dL. The DON stated Resident #124 was alert, eating food, and had candy too. LPN #210 had notified the on-call physician again of blood glucose of 120 mg/dL. The nurse was recommended to give another Glucagon 1 mg IM around 2:30 A.M., which was administered right away. At 3:00 A.M. Resident #124 had a blood glucose of 254 mg/dL. At 4:00 A.M. Resident #124's blood glucose was 274 mg/dL. Around 5:00 A.M. LPN #210 checked Resident #124 to find the blood glucose was 117 mg/dL. The on-call practitioner was notified again, and the order was to send Resident #124 out to the emergency room for evaluation. The facility monitored her while at the facility from 11:30 P.M. through 5:00 A.M. She was then sent to hospital for additional monitoring. She was given Glucagon 1 mg at 06/25/26 11:00 P.M., and another Glucagon 1 mg on 06/26/26 at 2:30 A.M. The DON stated when reviewing the emergency room evaluation dated 06/26/26 around 6:00 A.M. it documented Resident #124 was hemodynamically stable and had no acute stress. The DON stated her blood sugar at the hospital was 94 mg/dL. The DON stated Resident #124 was admitted to the hospital for blood glucose monitoring hourly. Resident #124's family was called on 06/26/26 when she was sent to the hospital. The facility immediately provided education, interventions, and assessed all residents who were at risk of receiving diabetic medications. During an interview on 08/11/26 at 10:14 A.M., Nurse Practitioner (NP) #207 stated the weekend on-call physician was who ordered the Glucagon. NP #207 stated that since Resident #207 was eating and drinking, then she was fine she would have continued to monitor since her blood glucose was above 110 mg/dL. NP #207 said she could not say why the other provider did not send out Resident #124 initially. NP #207 stated the Glucagon IM administered was effective. NP #207 stated that Resident #124 was alert and oriented and contributed to the clinical judgement. Review of the personnel file for LPN #210 revealed a hire date on 11/19/25. LPN #210 had an active license. A dialogue review dated 06/30/26 revealed the Administrator and the DON had a meeting with the nurse regarding an incident on 06/25/26. The review of best practices regarding medication administration as well as the six rights of medication administration were reviewed with LPN #210. LPN #210 completed additional education in-service training and understood this would act as her final warning. LPN #210 expressed understanding and had no further questions and was signed by all parties. A follow-up interview on 08/11/26 at 2:51 P.M., the DON verified LPN #210 had not documented in the electronic medical records but used the physician communication tool with all the blood glucose readings and times and provided the tool for review. Review of the facility paper worksheet titled Physician Communication Tool (worksheet only) dated 06/25/26 documented Resident #124 had been given Lantus 20 units by mistake. Resident #124 had a blood glucose reading of 42 mg/dL, and high blood pressure. Resident #124's blood glucose measurements were documented on this sheet as follows: on 06/26/26 at 12:30 A.M. blood glucose was 124 mg/dL, at 1:30 A.M. an elevated blood glucose with an up arrow and no numerical number written, at 2:30 A.M. blood glucose was 120 mg/dL, gave one Glucagon 1 mg injection, at 3:00 A.M. blood glucose was 254 mg/dL, and at 5:00 A.M. the blood glucose was 117 mg/dL Resident #124 was sent out to the hospital. During an interview on 08/11/26 at 3:44 P.M., Physician Assisted (PA) #275 stated she received a call around 1:30 A.M. and spoke to LPN #210 who stated Resident #124 had received the medication Lantus 20 units which was an error. PA #275 explained LPN #210 had told her she had already administered a Glucagon 1 mg IM earlier to Resident #124. PA #275 stated that LPN #210 had told her the blood glucose number, that was low. PA #275 said she had no access to the chart but knew she had reported a low number. PA #275 stated she gave the order to administer another dose of Glucagon 1 mg IM and to recheck blood sugar in 30-60 minutes, then every hour thereafter. If there was another low blood glucose to send her out to the hospital to be evaluated. During an interview on 08/12/26 at 8:26 A.M., LPN #210 stated she worked the night shift on 06/25/26 and had cared for Resident #124. She accidentally gave Lantus 20 units to Resident #124 that should have been given to her roommate. LPN #210 stated she was talking to Resident #124 for 15 minutes during her oral medication pass. LPN #210 stated while she was talking about her last few pills, she asked Resident #124 if she was ready for her insulin of Lantus 20 units. Resident #124 told her she was. Resident #124 allowed her to administer the Lantus 20 units. LPN #210 stated she left the room, and had addressed a few concerns, before making it back to her medication cart. LPN #210 stated she was looking at her electronic medication record on her medication cart and noticed Resident #9 had no documentation for administration of her Lantus 20 units. When opening her page, LPN #210 realized she had administered Lantus 20 units to Resident #124 in error. LPN #210 quickly left her medication cart, entered Resident #124's room to find her sweating and looking unwell. LPN #210 assessed Resident #124, took her vital signs, and blood glucose measurement to find her blood glucose was 42 mg/dL, and her blood pressure was elevated. LPN #210 stated she called the on call provider right away, notified the DON, and a team manager on night shift. LPN #210 stated she told Nurse Practitioner (NP) #404 of Resident #124's low blood glucose and high blood pressure. She was given an order to administer Glucagon 1 mg IM right away and assess her every 30 minutes by checking her vital signs, any signs and symptoms and her blood glucose measurements. LPN #210 stated she monitored and gave glucagon to Resident #124, which raised her blood glucose level. LPN #210 stated Resident #124 was alert the entire time, eating ice cream, snacks, and drinking a soda. LPN #210 stated she also gave the resident orange juice but was educated in the future to give foods with protein, like milk, cheese, and peanut butter. LPN #210 stated the blood glucose was a little lower but could not remember the number of the blood glucose, but she called the on-call physician to notify them that Resident #124's blood glucose had dropped again. PA #275 answered to give an order of another Glucagon 1 mg IM, and continue to monitor, and call if the vital signs change, or blood glucose drops lower. LPN #210 stated she reassessed in one hour, and Resident #124 blood glucose went up to 200's mg/dL, then again the later the blood glucose was 240's mg/dL, then dropped to 210 mg/dL, then to 170's mg/dL, then to 160 mg/dL, then to 110 mg/dL in less than 30 minutes. LPN #210 messaged the on-call physician who was PA #275 who directed to send her out to the hospital for evaluation. LPN #210 stated the emergency squad came around 4:00 A.M., or 5:00 A.M. Resident #124 was alert and oriented when she left and was not lethargic. Review of the facility policy titled Medication Error, dated May 2025, revealed to establish a clear and standardized approach to medication error reporting, investigation, and prevention. When a medication error or omission was discovered in orders or on the electronic chart, a medication error report form was to be completed. When medication error is discovered, a physician will be notified and provide information regarding the type of error that was discovered, a physician will be notified, and provide information regarding the type of error, and any adverse effects experienced by the resident. The medication error report will be completed and sent to the Director of Nursing. Medication error reports will be documented, investigated, the category of medication error identified, and any necessary corrective actions taken. Review of the facility document titled Medication Lab Monitoring, dated March 2026, revealed insulin and oral hypoglycemic medications, on admission, obtain an order for finger stick blood glucose monitoring. For fasting blood glucose less than 60 mg/dL or resident with symptoms of hypoglycemia, administer oral glucose or inject with Glucagon, follow with complex carbohydrate (peanut butter, crackers and/or milk), call physician and power of attorney, call nine-one-one (9-1-1) if reaction continues or nurse deems necessary. Continue obtaining fasting blood glucose every 15-30 minutes till stable. Fasting blood glucose between 60-70 mg/dL should be rechecked as needed. Hold intermediate insulin if blood glucose was below 100 mg/dL. Contact physician if fasting blood glucose levels were below 100 mg/dL. The deficient practice was corrected on 06/26/26, when the facility implemented the following corrective actions: On 06/26/26, Resident #124 was assessed by LPN #210. The on-call provider was notified that Resident #124 had received Lantus. Resident #124 and daughter were notified. New orders were placed, and the resident was monitored in the facility. On 06/26/26, Resident #124 was immediately transferred to a local hospital via emergency medical services after the Medical Director was notified. On 06/26/26, the Director of Nursing reviewed Resident #124 medical records, including physician orders and medications administered. On 06/26/26, the pharmacist reviewed Resident #124's medications. On 06/26/26, the Director of Nursing completed an audit of current residents with orders to determine residents who received their medications including insulin according to the physician's orders. No concerns noted. On 06/26/26, the Director of Nursing or designee completed a head-to-toe assessment of residents who resided on 1100 odd hall and the 1200 hall. No concerns were noted. On 06/26/26, the Director of Nursing or designee completed audit of current residents who had an order for insulin to ensure they were given as ordered by the physician. No concerns noted. On 06/26/26, the DON and/or designee completed education for all nurses on the six rights of medication administration. On 06/26/26, LPN #210 completed a Relias training course on avoiding common medication errors. On 06/26/26, the DON and/or designee completed a performance improvement (PI) worksheet to verify residents' medications, including but not limited to insulin are administered according to the six rights of medication administration and ongoing monitoring. On 06/26/26, the DON and/or designee completed a PI work sheet to verify residents' medications were prepared for one resident at a time. On 06/26/26, the DON interviewed all residents for similar allegations, and no other problems were identified. On 06/26/26, an initial Quality Assurance and Performance Improvement Plan (QAPI) was held with team members included: the Administration, the Medical Director, the Pharmacist, the DON, and the corporate nurse. During QAPI the following was reviewed how we ensured safety for all residents, reviewed root cause, reviewed education, and reviewed monitoring. During interviews on 08/04/26, 08/05/26, 08/10/26, 08/11/26, and 08/12/26, LPN #210, Unit Manager 315, LPN #322, LPN #324, Registered Nurse (RN) #328, RN #342, RN #346, RN #349, and the Assistant Director of Nursing (ADON) #366, and Unit Manager #369 verified they had received education on the six rights of medication administration and insulin response. During an observation of medication pass on 08/05/26 at 9:40 A.M. RN #346 administered medications for Resident #81, #12, #86 and #84 without any medication errors. During an observation on 08/10/26 at 11:50 A.M. RNs #342 and #349 completed blood glucose monitoring and administered insulin for Residents #23 and #78 without error. This deficiency represents noncompliance investigated under Complaint Number 3056873.

THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication errors. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #148, when on [DATE], during admission from another long-term care facility, the facility failed to identify that pages of admission orders were missing from Resident #148's facsimiled (faxed) documents from the referring facility. Subsequently, the facility failed to accurately reconcile Resident #148's medication list and failed to identify an order for apixaban (an anticoagulant medication used to prevent blood clots), which resulted in the resident not receiving the medication. On [DATE], Resident #148 became short of breath and was transferred to a hospital where it was determined Resident #148 had a pulmonary embolism (blood clot in the lungs) and later expired. This affected one (Resident #148) of six residents reviewed for unnecessary medications. The census was 126. On [DATE] at 9:00 A.M., the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #100, Corporate Nurse Educator (CNE) #200, and Regional Nurse #350 were notified Immediate Jeopardy began on [DATE] when, upon admission to the facility, admission orders for administration of apixaban were missing from Resident #148's transfer documents from a previous facility. Resident #148 did not receive the medication throughout the stay in the facility, and on [DATE] Resident #148 began to experience shortness of breath and increased heart rate prompting an evaluation in the hospital. While in the hospital, Resident #148 was diagnoses with a pulmonary embolism and subsequently died as a result. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective action: Resident #148 no longer resided in the facility. Resident #148's medical record was reviewed by the DON on [DATE]. This included but was not limited to a review of Resident #148's medication list from admission and the admission orders transcribed into electronic medical record (EMR). On [DATE], CNE #200 conducted a review of Resident #148's medical record including but not limited to physician orders, care plans, and administration records. On [DATE], Regional Minimum Data Set (MDS) Nurses #220, #230, #235, and #240 completed an audit of all residents who were admitted to the facility in the last 60 days to ensure admission orders were transcribed correctly into the resident's medical record. Any concerns noted were reviewed with the Nurse Practitioner (NP) #360 and orders updated as needed by licensed nurses by [DATE]. On [DATE], Regional MDS Nurses #220, #230, #235, and #240 verified that all pages of admission orders from transferring facilities were received/present. On [DATE], the DON or designee completed an audit of current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness. On [DATE], the NP #360 reviewed current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness On [DATE], Nurse Educator #280 completed a medication administration observation. No concerns were noted. On [DATE], Registered Nurse (RN) #15 and RN #16 were immediately provided education by the DON. This education included but was not limited to ensuring admitting orders are received and transcribed into the medical record, that all pages of the orders are received, and hard copy of the orders are received upon resident's arrival to facility. By [DATE], licensed nurses were provided with an additional in-service education by the DON and ADON #100. This education included but was not limited to ensuring admission medication orders are reviewed and transcribed into resident medical records, that all pages of the orders are received and that a hard copy of orders is received upon resident's arrival to the facility. A performance improvement (PI) audit worksheet was being completed to verify residents' admitting orders are transcribed completely (including all pages are verified) into the medical record. The PI was being completed by the DON or designee for any residents admitting to the facility for the previous day, completing the audit daily for seven (7) days, then three (3) times per week for four (4) weeks, then weekly for 4 weeks, and then monthly. The results of this worksheet will be reviewed by the Quality Assurance and Performance Improvement (QAPI) team. Quality Assurance meetings were held on [DATE] and [DATE] with the Administrator, Medical Director, the DON, CNE #200, Regional Nurse #350, and Consultant Pharmacist #400. On [DATE] through [DATE], five (Residents #6, #9, #11, #58, and #80) additional medical records were reviewed with no concerns for significant medication errors identified. Findings include:Review of the medical record revealed the facility admitted Resident #148 on [DATE] from another nursing home. Resident #148 had a medical history that included diagnoses of atrial fibrillation, hypertension, atherosclerotic heart disease of native coronary artery, and presence of a cardiac pacemaker. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #148 had intact cognition. Resident #148 was admitted from a skilled nursing facility. and had an active diagnosis of atrial fibrillation. The assessment documented Resident #148 did not receive anticoagulant medication during the assessment's look-back period. Review of Resident #148's care plan report included a focus area, initiated on [DATE], that indicated the resident had altered cardiopulmonary status related to pulmonary hypertension, heart failure, and shortness of breath or trouble breathing when lying flat. Interventions directed staff to administer medications as ordered (initiated [DATE]). The care plan report revealed a diagnosis of atrial fibrillation was listed in the Diagnosis section of the care plan; however, anticoagulant therapy was not addressed on Resident #148's care plan. Review of a facility document titled, Medication Error Report Form, dated [DATE], revealed there was a medication error for Resident #148 on [DATE]. Resident #148's apixaban 2.5 milligrams (mg) twice daily was documented as, missed on admission, missing pages of paperwork not sent over on admission. Review of the transferring skilled nursing facility's history and physical, dated [DATE], indicated Resident #148 had unspecified atrial fibrillation, and their heart rate was controlled at the present time with apixaban. Review of Resident #148's document titled, Transfer/Discharge Report, from the transferring skilled nursing facility, with a fax date stamp of [DATE] at 5:42 P.M., indicated the facility received page one (1) of 4 and 3 of 4 of the discharge documentation; and page two (2) of 4 and 4 of 4, which included current medications, were missing from the fax. Further review revealed the fax included Resident #148's Medication Review Report from the transferring facility, which revealed pages 2 of 7, 4 of 7, and six (6) of 7 were missing. Subsequently, there was no order for apixaban for Resident #148 on the faxed Transfer/Discharge Report or the Medication Review Report from the transferring facility. An attempt to obtain the original transfer paperwork from the transferring facility on [DATE] at 10:35 P.M. revealed the facility staff only had access to the information with missing pages that was faxed to the facility on [DATE]. Review of Resident #148's facility document titled, Order Recap (Recapitulation) Report, for [DATE] through [DATE] revealed RN #16 and a Licensed Practical Nurse (LPN) signed the document on [DATE] and RN #15 signed the document on [DATE]. There was no evidence the nurses identified that there were missing pages from Resident #148's Transfer/Discharge Report or Medication Review Report and an order for the anticoagulant (apixaban 2.5 mg twice daily) was not included in the resident's Order Recap Report at the facility. Review of Resident #148's progress notes dated [DATE] at 11:40 A.M. revealed admission medications were verified with NP #360. Review of Resident #148's progress notes dated [DATE] at 12:14 P.M. revealed the NP verified admission medications. Review of Resident #148's progress notes dated [DATE] at 6:49 P.M. revealed staff documented the resident's order recap report was verified with a second nurse. Review of Resident #148's medication administration record (MAR) for March, April, and [DATE], revealed no documented evidence that the facility administered apixaban to Resident #148 during their stay at the facility. Review of Resident #148's progress notes dated [DATE] revealed NP #360 documented that they saw the resident for reports of shortness of breath and tachycardia (increased heart rate. Resident #148 stated, I just do not know why I feel so poorly. The notes revealed the resident's heart rate fluctuated between 98 to 120 beats per minute (bpm), and the resident's oxygen saturation on room air was 85 percent. Resident #148's oxygen saturation improved to 92 percent on two liters of supplemental oxygen. According to the notes, Resident #148's family member reached out to the resident's cardiologist who suggested the resident go to the emergency room (ER) for an evaluation. The notes revealed the resident's family member requested the resident be sent to the ER. Review of Resident #148's progress notes dated [DATE] at 6:46 P.M. revealed that while the resident was in therapy, the resident had an episode of decreased oxygen and an elevated pulse and blood pressure. The notes revealed NP #360 was notified and saw the resident. The resident had a weird feeling in their chest and was pale. The notes revealed the resident was transferred to the hospital and was admitted with a pulmonary embolism. Review of Resident #148's hospital documentation dated [DATE] at 2:18 P.M. revealed the resident presented with hypoxia (low levels of oxygen in the blood) and hypotension (low blood pressure) while receiving therapy at the skilled nursing facility. On arrival to the emergency department (ED), the resident became increasingly unresponsive and hypoxic to the 70s. The notes revealed that per the resident's family member, the resident was supposed to be on Eliquis (apixaban), but they were unsure whether the facility was providing the medication. The ED note revealed the resident had acute pulmonary emboli, concerns for acute right heart strain and probable pulmonary infarcts in the right upper and lower lung lobes. The note revealed the resident was admitted to the intensive care unit (ICU) for further evaluation and management of a massive pulmonary embolism. Review of Resident #148's ED addendum note dated [DATE] at 4:09 P.M. revealed an ED nurse documented that they contacted LPN #14 at the facility who confirmed that Eliquis was not on the resident's medication list and the facility had not been administering Eliquis. The resident's family member reported that the resident should have been receiving Eliquis and it should not have been stopped. Review of Resident #148's ED notes addendum dated [DATE] at 4:46 P.M. revealed a nurse documented that a hospital case manager contacted the DON at the facility who stated that the resident was transferred to the facility on [DATE] and there was no order for Eliquis. The DON confirmed that Resident #148 had not received Eliquis since she was transferred to the facility on [DATE]. Review of an ED clinical staff pharmacist's progress notes dated [DATE] at 6:55 P.M. revealed the ED pharmacist contacted the pharmacy that filled medications to both the resident's previous facility and current facility. According to the note, it was documented that the pharmacist who worked for the facility pharmacy, Pharmacist #26, that while Resident #148 was at the previous facility from [DATE] to [DATE], Eliquis 2.5 mg for twice daily administration was dispensed. The note revealed that Pharmacist #26 reported that upon transferring to the facility on [DATE], no order was placed for Eliquis 2.5 mg. The notes revealed that Pharmacist #26 indicated that once the skilled nursing facility entered orders into the Point Click Care (PCC) system (the electronic medical record system), the pharmacy filled the orders. Pharmacist #26 confirmed that no order for Eliquis 2.5 mg for twice daily administration had been entered during Resident #148's admission to the facility. Review of a hospital critical care consultation note dated [DATE] at 5:27 P.M. revealed the physician discussed treatment options with Resident #148's family for pulmonary embolism. After discussing the pros and cons and conversing with the resident and other family members on the telephone, the resident/family decided not to pursue the discussed treatment options and opted for no cardiopulmonary resuscitation (CPR), no intubation, and conservative management. During an interview on [DATE] at 11:33 A.M., the Lead Administrator stated the facility was notified that Resident #148 expired. During an interview on [DATE] at 12:43 P.M., RN #16 stated she was the nurse who made the mistake with Resident #148's medication orders on admission to the facility. She stated for resident admissions they reviewed orders uploaded into PCC. However, RN #16 stated that there was an old medication list uploaded for Resident #148 and since the resident was going to be admitted soon, she called the transferring facility and asked them to fax a medication list. She stated she entered the medication orders from the fax but did not notice that pages were missing. When the resident arrived at the facility, the resident's family brought a packet that contained a copy of the same orders that had been faxed. She stated that she documented that the orders were verified with NP #360. RN #16 also stated that within 24 hours a unit manager double-checked the order. During an interview on [DATE] at 9:39 A.M., NP #360 stated that upon admission, medications were reviewed and verified within 24 hours. NP #360 stated she reviewed Resident #148's medication orders and conducted a chart review but did not notice the missing fax. Resident #148's diagnosis of atrial fibrillation would not have triggered her to think the resident should be on Eliquis or any kind of anticoagulant due to the resident's age and other co-morbidities. NP #360 stated she recalled that after the resident was sent to the hospital, they discovered the resident was not receiving a blood thinner. Resident #148 had multiple co-morbidities that contributed to the development of pulmonary emboli on [DATE], and not receiving Eliquis did not help but it was hard to say definitively that it caused the resident's death. During an interview on [DATE] at 11:13 A.M., the ADON stated the admission nurses were responsible for transcribing orders, ensuring all pages and orders were received, and verifying orders with Medical Director (MD) #550. There were transcription errors regarding Resident #148 but he could not provide additional details. During an interview on [DATE] at 1:03 P.M., the DON stated the facility did not receive the complete admitting orders for Resident #148, and there was a transcription error because there were missing pages in the fax. Her expectation was that nurses verify all pages were received. During an interview on [DATE] at 1:57 P.M., MD #550 stated he was familiar with Resident #148 and the incident. MD #550 confirmed the resident did not receive Eliquis while at the facility. He stated that he could not say with 100 percent certainty that not getting Eliquis caused the resident's pulmonary embolism. During an interview on [DATE] at 11:29 A.M., the Administrator stated the hospital notified the facility of the medication error. They found that the even pages of the fax were missing. The Administrator stated that two nurses reviewed Resident #148's orders as required per protocol and the supervisor reviewed the resident's medical record the next day and no one caught the error. During a follow-up interview on [DATE] at 1:18 P.M., the Administrator stated that Resident #148 had a missing medication order. The Administrator stated he expected staff to review orders, ensuring all pages were received at the time of admission. Review of a facility policy titled, Practitioner Order Transcribing/Posting, revised 03/2025, indicated for Admitting Orders staff should review hospital transfer forms/paperwork and enter admit medication/ancillary orders in the EMR. Medication orders include medication name, dose, route of administration, and frequency. Staff should also verify the admission orders with the attending physician/NP/physician assistant and print an order recapitulation report after orders are verified and place copy in chart. Review of a facility policy titled, Administration Oral Medications, revised 11/2024, revealed the facility will ensure patients are given medication per the physician orders. If there are any issues with physician orders, the nurse will contact the physician for clarification. This deficiency represents non-compliance investigated under Complaint Number OH00165685 (1394609).

Based on record review, staff interview, facility document review, and policy review, the facility failed to ensure medication was dispensed and administered as ordered to one (#149) of six residents reviewed for unnecessary medication. The census was 126. Findings included:Review of a medical record revealed the facility admitted Resident #149 on 05/23/25. The resident had a medical history that included a diagnosis of insomnia. Further review revealed the facility discharged Resident #149 home on [DATE]. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/29/25, revealed Resident #149 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS assessment revealed Resident #149 received hypnotic medication during the assessment's look-back period. Review of Resident #149's care plan included a focus area initiated on 05/23/25, that indicated the resident was receiving a sedative/hypnotic medication, zolpidem for a diagnosis of insomnia. The interventions instructed staff to administer the medication as ordered by the physician (initiated 05/23/25). Review of Resident #149's hospital Discharge summary dated [DATE] revealed an order for zolpidem 10 milligrams (mg) at bedtime. Review of Resident #149's order recapitulation report included an order dated 05/23/25 for zolpidem tartrate 10 mg at bedtime for insomnia. Review of Resident #149's medication administration record (MAR) for May and June 2025 revealed the resident's zolpidem was due to be administered at 9:00 P.M., nightly. The MARs revealed no documented evidence (the MAR was blank) that staff administered the 05/23/25 (day of admission) and 06/01/25 doses of medication. The MAR revealed that on 05/24/25, 05/25/25, 05/30/25, and 06/02/25, staff documented 16 for the doses. Per the MAR, code 16 indicated Medication Unavailable/Pharmacy Notified. The MAR also indicated that staff documented 9 for the resident's 05/31/25 dose of zolpidem, which indicated, Other: See Progress Notes. Review of Resident #149's progress notes dated 05/26/25 at 10:08 P.M. revealed the facility nurse contacted the on-call physician for a new prescription for zolpidem 10 mg for insomnia at bedtime and the nurse was awaiting a response. Review of Resident #149's document titled, Controlled Drug Receipt Record/Disposition Form, revealed staff documented that the pharmacy delivered three zolpidem 10 mg pills for Resident #149 on 05/27/25. Review of Resident #149's progress notes dated 05/31/25 at 10:52 A.M. revealed the pharmacy stated a new prescription was needed. Review of Resident #149's document titled, Controlled Drug Receipt Record/Disposition Form, revealed the pharmacy did not deliver zolpidem medication again until 06/03/25, the day the resident discharged from the facility. The facility provided a list of medications stocked in their Pyxis (an automated medication dispensing system) and the list revealed zolpidem was not one of the medications available. During an interview on 09/17/25 at 2:25 P.M., Licensed Practical Nurse (LPN) #6 stated that when a resident's medication was not available, the requirement was for nursing staff to contact the pharmacy and document the communication. LPN #6 further stated that staff could get medication from the Pyxis if the medication was available. During an interview on 09/17/25 at 2:31 P.M., Registered Nurse (RN) #5 stated the pharmacy notified the facility if a medication was missing, when an order required clarification, or a new prescription was needed. RN #5 stated the facility communicated the needs as soon as possible or had pharmacy contact the physician for a prescription. RN #5 further stated it was critical for medications to be delivered timely, particularly when they were not available in the Pyxis. On 09/17/25 at 3:15 P.M., Unit Manager (UM) #3 stated that upon admission, medication orders were sent to the pharmacy, and pharmacy usually delivered the medications the same night. UM #3 stated that if the medication was not in the Pyxis, the nurse must call the pharmacy, and delivery typically occurred within two hours. He stated for Resident #149, the prescribed hypnotic was not available, and the nurse documented the pharmacy was notified. During an interview on 09/17/25 at 3:57 P.M., the Director of Nursing (DON) stated the best practice was to have signed prescriptions available on admission so staff could fax them to the pharmacy and have medications delivered that evening. The DON stated that she was not aware that Resident #149's medication had not been available. The DON stated the facility contacted an on-call nurse practitioner (NP) who called the pharmacy and gave an order for three zolpidem; however, neither staff nor pharmacy called to get another prescription. She stated it was not the facility's standard not to administer medications. The DON stated that she expected staff to call the physician and get a prescription or reach out to her to assist so they could give the resident their medication.During a telephone interview on 09/19/25 at 10:06 A.M., Pharmacist #25 stated that when prescriptions were needed, the pharmacy contacted the provider. Per Pharmacist #25, on 05/25/25, they contacted the physician and received an electronic prescription from the on-call provider for a three-day supply. Pharmacist #25 further stated she did not see evidence of follow-up with the provider until a fascimilie (fax) was sent on 05/27/25. Pharmacist #25 stated they received a valid prescription on 06/02/25 and 10 pills were delivered to the facility. On 09/18/25 at 8:13 A.M., the Administrator stated that regarding Resident #149's medication, they expected the pharmacy to either send the medication or notify the facility if assistance was needed to obtain a prescription.Review of a facility policy titled, Ordering of Drugs (i.e. [id est, that is] Receiving Drug Orders from the Pharmacy, dated 01/2023, indicated, the purpose of exercising control in the ordering of drugs is to assure that the pharmacist dispenses and labels medications properly, assure correct financial responsibility and prompt delivery of drugs. Any shortage or irregularity with the order is documented and made known to the pharmacist on call by telephone.This deficiency represents non-compliance investigated under Complaint Number OH00166335 (1394611).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview and policy review, the facility failed to ensure an accurate reconciliation and accounting of all controlled substances. This affected one (#122) out of three reviewed for medication reconciliation. The facility census was 123. Findings include: Review of the medical record for Resident #122 revealed an admission date of 02/13/25 and a discharge date of 03/15/25. Diagnoses include non-pressure chronic ulcer of right heel and midfoot with unspecified severity, type 2 diabetes mellitus with foot ulcer, rheumatoid arthritis without rheumatoid factor, and spondylolisthesis. Review of the Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #122 was independent with eating, required supervision assistance with oral hygiene, personal hygiene, and wheelchair mobility, required partial assistance with bed mobility, required substantial assistance with bathing, dressing, and transfers, and was dependent on staff assistance with toileting hygiene. Review of the physician order dated 02/13/25 revealed an order for Oxycontin Oral Tablet Extended Release (ER) 12 Hour Abuse-Deterrent 10 mg tab, give 1 tablet by mouth two times a day for chronic pain syndrome. Further review of the physician orders revealed an order dated 03/14/25 that resident may discharge home with Home Health for physical therapy, occupational therapy and nursing (PT/OT/NSG) services. Review of the care plan dated 02/13/25 revealed Resident #122 required assistance with all activities of daily living. Review of the pharmacy packing slip dated 03/05/25 revealed Oxycontin Oral Tablet Extended Release (ER) 12 Hour Abuse-Deterrent 10 mg tablets, 30 tablets were delivered to the facility on [DATE] for Resident #122. Further record review revealed Resident #122's Oxycontin 30 tablets delivered on 03/05/25 could not be accounted for. Review of Resident #122's progress noted dated 03/15/25 at 10:00 A.M. revealed resident discharged to home with his wife today at 10:00 A.M., resident sent with his medications for the rest of the weekend. Interview on 04/25/25 at 10:34 A.M. with Administrator #335 confirmed on 03/16/25, the day after Resident #122 discharged home, the facility discovered 30 tablets of Oxycontin 10 mg, a full skid, came up missing on 03/16/25. Interview with Administrator #335 also revealed that the facility completed a full investigation, and two nurses, Licensed Practical Nurse (LPN) #478 and Registered Nurse (RN) #479 were terminated for not following protocol of not giving the narcotic keys to another nurse without counting narcotics first. Administrator #335 confirmed the facility was unable to determine where the 30 tablets of Oxycontin 10 mg went. Review of the Controlled Drug Reconciliation policy, dated 04/2025 revealed all controlled medications (Schedule II, III, IV, V) are counted by licensed personnel. At every change of shift and hand-off of narcotic keys, a reconciliation is conducted by both the departing and incoming licensed health care professional responsible for the security and control of the drugs in the medication cart(s). The deficient practice was corrected on 03/19/25 when the facility implemented the following corrective actions: • On 03/16/25, the Director of Nursing (DON) was notified of an inconsistency with narcotic proof of use sheets and narcotic skids regarding Resident #122's medication. The DON reported a self-reported incident (SRI) to the Ohio Department of Health and began an investigation. The DON also notified Physician #12, Administrator, Medical Director and Police regarding Resident #122's missing medications. • On 03/16/25 at 9:00 P.M., LPN #478 and RN #479 were removed from the nursing schedule and a drug screen was completed. The results of the drug screen for LPN #478 and RN #479 were negative. However, at the conclusion of the facilities investigation, LPN #478 and RN #479 were terminated. • On 3/16/25 at 11:00 P.M., all facility medication carts were audited by the DON and another licensed nurse on duty to ensure verification of controlled substance counts. Additionally, current residents' narcotic proof of use sheets and shift count sheets were reviewed by DON. No other concerns were identified. • On 03/16/25 through 03/19/25, all licensed nurses were interviewed by the DON regarding medications and missing medications. There were no other concerns identified. • On 03/17/25, a Quality Assurance meeting was completed with the Medical Director. • On 03/18/25, licensed nurses on duty verified residents' controlled substances are available for administration. No concerns were identified. • By 03/19/25, the DON or designee completed an audit of current residents on opiates or controlled substances to verify medications are available for administration. No concerns were identified. • On 03/19/25, the DON completed in-service training with all licensed nurses on the abuse policy including misappropriation and controlled substance procedures. This deficiency represents non-compliance investigated under Complaint Number OH00164014.

Based on open and closed medical record review, staff interviews, review of Emergency Medical Services (EMS) report, review of electronic monitoring device video footage, review of witness statements, review of the facility's timeline, and review of facility policy, the facility failed to ensure Resident #60 received appropriate treatment and care and medical intervention to timely treat a change in condition. This resulted in Immediate Jeopardy and serious life-threatening harm which ultimately resulted in death beginning on [DATE] at 7:40 A.M. when Resident #60, who was dependent on staff for oral intake, was being fed breakfast by Certified Nursing Assistant (CNA) #13, started coughing, became congested and eventually had white secretions from his nose and mouth impairing his airway. Subsequently, Resident #60 coded on [DATE] around 9:36 A.M. and expired in the facility after failed attempts of resuscitation. This affected one (#60) of five residents reviewed for assessing a change in condition. The facility census was 111. On [DATE] at 12:52 P.M., the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #45, [NAME] President of Nursing (VPN) #112 and Administrator #02 via phone, were notified Immediate Jeopardy began on [DATE] at 7:40 A.M. when CNA #13 entered Resident #60's room and began feeding him breakfast. Resident #60 suddenly started coughing, sounded congested and refused to eat anymore. CNA #13 left the resident's room to inform Licensed Practical Nurse (LPN) #22 of the sudden onset of coughing, congestion, the resident may vomit, and the resident ate less than his normal 75 to 100 Percent (%) oral intake. At 8:17 A.M. (via review of the electronic monitoring equipment inside the resident's room) LPN #22 entered the room, administered Resident #60's routine morning medications along with a routine ordered blood pressure and pulse, but failed to perform an assessment to address the resident's change in condition. At 8:59 A.M., CNA #12 entered Resident #60's room and noticed white phlegm-like secretions draining from the resident's nose, wiped his nose, left the room, and informed LPN #22 of the findings. At 9:14 A.M., Unit Manager (UM)/LPN #21, was doing routine morning rounds, entered Resident #60's room, noticed the white secretions from Resident #60's nose and wiped his nose. UM/LPN #21 retrieved a blanket, covered the resident up, left the room without completing an assessment and reported her findings to LPN #22. At 9:34 A.M., CNA #11 and CNA #12 entered the resident's room to give Resident #60 a bed bath and noticed white frothy secretions coming from Resident #60's nose and mouth. At 9:37 A.M., Resident #60 stopped breathing, cardiopulmonary resuscitation (CPR) was started, EMS was summoned and worked on the resident until he was pronounced dead at 10:14 A.M. after failed attempts at resuscitation. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:39 A.M., according to the facility's timeline, CNA #13 entered Resident #60's room, repositioned the resident to eat, fed the resident, left room at 8:08 A.M. and went to notify LPN #22 that the resident was congested. On [DATE] at 8:18 A.M., according to the facility's timeline, LPN #22 assessed Resident's #60 blood pressure and heart rate. On [DATE] at 8:58 A.M., according to the witness statement, CNA #12 entered Resident #60's room and noted the resident was trying to blow his nose. CNA #12 looked in the back of the resident's throat, did not observe anything, and kept the resident sitting upright. On [DATE] around 9:10 A.M., LPN #22 notified Nurse Practitioner (NP) #80 of her respiratory observation. New orders were received for a stat (immediately) chest X-ray (CXR). On [DATE] at 9:14 A.M., according to the documentation in the medical record, UM/LPN #21 was conducting routine rounds and entered Resident #60's room to check on the resident and nasal drainage was noted. UM/LPN #21 assisted the resident as he blew his nose. No other complaints were voiced, or signs and symptoms of distress were noted at that time. On [DATE] at 9:31 A.M., according to the facility's timeline, CNA #12 entered Resident #60's room to prepare the resident for a bed bath. On [DATE] at 9:39 A.M., per the facility's timeline, CNA #11 entered Resident #60's room to assist with the bed bath. The CNAs in the room noted the resident had vomited as they were gathering supplies and noted the resident appeared to not be breathing. CNA #12 ran to get the nurse. On [DATE] at 9:41 A.M., according to the facility's timeline, multiple licensed nurses entered Resident #60's room due to the resident not breathing. On [DATE] at 9:49 A.M., according to the medical record, EMS entered Resident #60's room and took over care of the resident. EMS called the time of death at 10:14 A.M. On [DATE] at 11:00 A.M., Resident #60's progress notes, orders, and care plans were reviewed by Corporate Registered Nurse (CRN)/Nurse Educator #111. No concerns were noted. On [DATE] at 11:00 A.M., the DON and UM/LPN #21 interviewed LPN #22, CNAs #12, #11 and #13 in regard to Resident #60's condition prior to the resident coding. Interviews were completed on [DATE] at 5:15 P.M. On [DATE] at 9:00 A.M., ADON #45 reviewed all current residents with any new progress notes during the past 24 hours to review for a possible change of condition. No concerns were identified. On [DATE] at 8:30 A.M., the DON reviewed all current residents with any new progress notes during the past 24 hours to review for a possible change of condition. No concerns were identified. On [DATE] at 3:00 P.M., the DON was provided in-service education by VPN #112 on the Change of Condition policy and conducting assessments including, but not limited to, vital signs and pulmonary assessment. On [DATE] at 3:54 P.M., a Quality Assurance (QA) meeting was held with the Administrator, Medical Director #90 (Via Phone), the DON, ADON #45, CRN/Nurse Educator #111, and VPN #112 to review findings. The QA committee developed, reviewed and approved the plan of action. This QA meeting included a review of the Change of Condition policy. No changes were made to the Change of Condition policy. A determination was made for a plan of action including, but not limited to, plan to assess all residents' vitals and lungs in house. Starting on [DATE] at 4:15 P.M., all 107 current residents' vital signs were obtained by the DON, ADON #45, LPN #21, RNs #32, #30, #33, #28, Physical Therapist (PT) #110, Director of Therapy #100 and all vital signs were completed at 5:43 P.M. Resident #05 refused vital signs. Beginning on [DATE] at 4:15 P.M., all 107 current residents' pulmonary status were assessed by the DON, ADON #45, UM/LPN #21, RNs #32, #30, #33 and #28. All assessments were completed on [DATE] at 10:00 P.M. Resident #05 and Resident #42 refused assessments. Resident #32 was assessed with left lung rhonchi and right lung with diminished breath sounds. NP #80 was notified, and a new order for chest x-ray and albuterol (bronchodilator for difficulty breathing) was obtained. Resident #30 was assessed with coughing and diminished bilateral lung sounds. NP #80 was notified, and guaifenesin (expectorant) and a chest x-ray were ordered. On [DATE] at 4:39 P.M., the DON and CRN/Nurse Educator #111 started an additional in-service education to the current 37 licensed nurses. This education was sent electronically, verified it was delivered, then reached out to every nurse for verification. The education included, but was not limited to, ensuring a nurse assesses residents for potential change in condition. A resident assessment for a change in condition assessment includes, but not limited to, vital signs and cardiopulmonary assessment. On [DATE], the DON and CRN/Nurse Educator #111 provided the 37 licensed nursing staff with one-on-one (1:1) additional in-service education. This additional in-service education included, but was not limited to, ensuring a nurse assesses residents for potential change in condition. A resident assessment for a change in condition assessment includes, but not limited to, vital signs and cardiopulmonary assessment. Any licensed nurse not on-site was provided education via telephone by the DON. The education onsite and via telephone were completed for all licensed nursing staff on [DATE] at 7:30 P.M. All licensed nurses were able to verbalize understanding of the educational content. On [DATE] at 9:00 A.M, the DON reviewed all current residents with any new progress notes during the past 24 hours to review for a possible change of condition. No concerns were identified. On [DATE], to monitor ongoing compliance, the DON or designee will review current residents progress notes daily from the past 24 hours to review for a possible change of condition. This will be completed daily for 30 days. Beginning on [DATE] at 7:00 A.M., a Performance Improvement Audit Worksheet is being completed for 10 random residents to ensure the residents are assessed for potential changes in condition using a general physical assessment and obtaining vital signs. The Performance Improvement Audit Worksheet is being completed by the DON or designee daily for seven days, then three times per week for four weeks, then weekly for four weeks, then monthly. If any issues are noted, the DON will take appropriate action at the time the concern is noted. Results of the Performance Improvement Audit Worksheet will be reported to the QA committee for a determination of the need for further ongoing formal monitoring. On [DATE] at 12:00 P.M., a QA meeting was held with the Administrator, Medical Director #90 (Via Phone), DON, ADON #45, CRN/Nurse Educator #111, and VPN #112 to review education and the audit findings. The QA committee reviewed the plan and no concerns were identified. The QA committee will monitor weekly for four weeks. On [DATE] at 2:33 P.M., Medical Director #90 was notified of Immediate Jeopardy by the Administrator. On [DATE], interviews with LPN #23 at 4:30 P.M., LPN #27 at 4:32 P.M., LPN #24 at 4:34 P.M., LPN #21 at 4:35 P.M., and ADON #45 at 4:37 P.M., revealed the staff had received education and in-service training on change in condition, physician notification, documentation and were knowledgeable about the facility's procedures and processes. Review of the medical records for five additional residents (#30, #32, #75, #112, and #113) related to a change in condition, revealed no concerns were noted. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with the 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 include: Review of the closed medical record for Resident #60 revealed an original admitted [DATE] and the resident expired in the facility on [DATE]. Medical diagnoses included Alzheimer's disease, dementia, hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, major depressive disorder, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD). Review of the care plan revised [DATE] revealed Resident #60 had a nutritional problem and was at risk for malnutrition related to Alzheimer's, heart disease, cerebrovascular accident, self-feeding deficit, and COPD. Interventions included providing and serving diet as ordered and monitor, document, and report any signs and symptoms of dysphagia (pocketing, choking, coughing, drooling, holding food in mouth, and refusing to eat), administer medications as ordered, monitor weight and provide recommendations as needed. Review of the nutritional assessment, dated [DATE], authored by Registered Dietitian (RD) #60 revealed Resident #60 was on a regular diet with regular texture, thin consistency and dependent on staff for meals. The oral and swallowing status revealed Resident #60 had no concerns with coughing or choking during meals or when swallowing medications. The meal intakes were approximately 75 to 100 %. Review of physician orders for Resident #60 dated [DATE], revealed the resident was ordered a soft touch call light with brightly colored tape to the call light. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. Resident #60 was dependent on staff with eating, toileting, bathing, dressing, and transfers. Review of the facilities timeline of staff entering Resident #60's room dated [DATE], revealed at 7:39 A.M., CNA #13 entered Resident #60's room with a tray and at 8:08 A.M., CNA #13 exited the resident's room. At 8:18 A.M., LPN #22 entered the resident's room. At 8:35 A.M., RD #60 entered the resident's doorway to check on the resident. At 8:58 A.M., CNA #12 entered the resident's room for three minutes. At 9:14 A.M., LPN #21 entered the room. At 9:31 A.M., CNA #12 entered the resident's room. At 9:39 A.M., CNA#12 and CNA #11 entered the resident's room. At 9:41 A.M., multiple nurses entered the resident's room and at 9:41 A.M., EMS entered the resident's room. Review of the electronic monitoring device video footage from Resident #60's room dated [DATE] revealed the following observations for Resident #60: a. At 7:40 A.M., CNA #13 entered Resident #60's room with a breakfast tray to feed him breakfast, which included fried eggs, sausage patties, toast, and diced pears. CNA #13 raised his bed and the head of the bed (HOB) minimally and prepared his tray. b. At 7:45 A.M., Resident #60 coughed, and CNA #13 immediately looked up from her phone in her lap at the resident. CNA #13 was able to give the resident one additional bite of pears, and then he refused to eat after multiple attempts by CNA #13. c. At 7:48 A.M., CNA #13 got up, moved the bedside table with his breakfast tray on it near the window, lowered his bed, and left Resident #60's room. The resident's call light was hanging over the headboard from the back, looped down between the headboard and mattress and out of the resident's reach. d. At 7:49 A.M., Resident #60 coughed up white phlegm and expelled a piece of food, which appeared to be a pear. e. From 7:50 A.M. through 7:53 A.M., Resident #60 continued to forcibly cough and expelled more white secretions from his mouth. f. From 7:55 A.M. through 8:16 A.M., Resident #60 continued to cough intermittently. g. At 8:17 A.M., LPN #22 entered Resident #60's room, poured a medicine cup of medications in the resident's mouth, and placed a cup of water with a straw in it in the resident's mouth. LPN #22 obtained a blood pressure of ,d+[DATE] millimeters of mercury (mm/Hg) in the resident's right wrist. LPN #22 noticed the resident was coughing and asked if he could cough it up and asked if his throat was hurting. LPN #22 stated to Resident #60 he sounded gurgly and stated, you feel cold. LPN #22 stated she would have NP #80 come see him later. LPN #22 raised the HOB and left the room. LPN #22 did not complete an oxygen saturation level or complete an assessment on Resident #60. h. At 8:25 A.M., Resident #60 had white phlegm-like secretions protruding from bilateral nostrils and increased mouth breathing. i. From 8:35 A.M. through 8:58 A.M., Resident #60 appeared to be working harder to breathe with an open mouth and using his accessory (chest) muscles. j. At 8:59 A.M., CNA #12 entered the room to pick up his breakfast tray. CNA #12 noticed the white phlegm-like secretions from his nose and stated, you're not feeling good huh. CNA #12 wiped his nose, picked up his breakfast tray, and left the room. k. From 9:04 A.M. through 9:13 A.M., Resident #60 had produced more white phlegm-like secretions from bilateral nostrils going over his mustache and near the opening to his mouth. l. At 9:14 A.M., UM/LPN #21 entered Resident #60's room, noticed the thick white secretions coming from Resident #60's bilateral nostrils and stated she was going to put on gloves. UM/LPN #21 wiped his nose and instructed Resident #60 to blow his nose into the tissue. UM/LPN #21 covered the resident with a blanket and exited the room at 9:17 A.M. No assessment was completed. m. From 9:20 A.M. through 9:26 A.M., Resident #60 had increased white phlegm-like secretions protruding from bilateral nostrils, was taking shallow, rapid breaths through his mouth using accessory muscles. n. From 9:27 A.M. to 9:30 A.M, Resident #60 had copious amounts of thick white secretions protruding from bilateral nostrils but significantly more on right side, which was now observed in Resident #60's beard. Resident #60 was observed with signs of respiratory distress. o. At 9:31 A.M., CNA #12 entered Resident #60's room with linens. CNA #12 wiped his nose and exited the room. p. At 9:33 A.M., Resident #60 was seen with copious amount of white frothy secretions protruding from his mouth and down into his beard with respiratory distress and respirations diminished. q. At 9:34 A.M., CNA #11 and CNA #12 entered Resident #60's room and observed the white frothy secretions coming from his mouth. CNA #12 wiped his mouth. r. At 9:37 A.M., Resident #60 stopped breathing. CNA #11 checked for breathing and CNA #12 left the room. s. At 9:38 A.M., LPN #22 entered Resident #60's room and started sternal rubs and attempted to get a blood pressure. t. At 9:40 A.M., CPR was initiated on Resident #60. A backboard was placed underneath the resident along with an AED (automated external defibrillator - a medical device that can help people experiencing sudden cardiac arrest). u. At 9:48 A.M., EMS arrived in Resident #60's room and took over resuscitation measures for approximately 25 minutes when the resident expired. Review of the nurse's progress note for Resident #60 dated [DATE] at 9:25 A.M. authored by LPN #22, revealed an order by NP #80 for a stat chest x-ray related to congestion. Review of the EMS report dated [DATE], revealed EMS was dispatched to the facility at 9:40 A.M. for cardiac arrest. EMS arrived at the resident's bed at 9:50 A.M. and assumed CPR and life saving measures. The resident was found to be in asystole (a lethal heart rhythm), no vital signs and CPR was continued. EMS had to suction the resident's airway prior to inserting an endotracheal (ET) tube (a tube inserted into an airway to provide manual respirations). EMS administered advanced cardiac life support (ACLS) for approximately 25 minutes when the resident's power-of-attorney (POA) arrived and requested EMS to cease the life saving measures. EMS contacted medical control for a field termination and the resident was pronounced dead at 10:16 A.M. Review of the witness statement dated [DATE] at 12:59 P.M. revealed CNA #12 reported seeing Resident #60 only when she was getting ready to provide a bed bath. CNA #12 stated he was spitting up, and she assisted with blowing his nose and looked in the back of his throat. CNA #12 saw nothing in his throat, and he kept spitting up. Review of a witness statement dated [DATE] at 1:11 P.M., revealed CNA #11 went into Resident #60's room at roughly 9:30 A.M. with CNA #12 to perform a bed bath. CNA #11 reported it appeared Resident #60 had vomited. CNA #12 was cleaning him up while CNA #11 got the bath basin ready. When CNA #12 returned with the basin, CNA #11 came out of the bathroom after washing her hands and asked if Resident #60 was breathing. CNA #11 told CNA #12 Resident #60 was not breathing. CNA #12 ran to find a nurse, while CNA #11 stayed with Resident #60. Once a nurse entered the room, CNA #11 went to get the crash cart. Review of the witness statement dated [DATE] at 1:45 P.M., revealed CNA #13 entered Resident #60's room with a breakfast tray. CNA #13 repositioned Resident #60 to eat. CNA #13 fed him three bites of food. Resident #60 started calling her names and sounded congested. CNA #13 notified LPN #22. Review of the nurse's progress note for Resident #60 dated [DATE] at 2:03 P.M. authored by UM/LPN #21, revealed at approximately 9:21 A.M. the nurse was in the room to check on the resident and nasal drainage was noted. The nurse assisted the resident with blowing his nose. No other complaints were voiced, or signs/symptoms of distress noted at this time. At approximately 9:30 A.M., two aides were in with the resident preparing for a bed bath when the resident became unresponsive. The nurses were immediately notified and responded to the room. The nurse observed the resident not breathing, verified the code status, and initiated CPR. EMS and the family were notified. An AED was applied to the resident with no shock advised. At 9:49 A.M., EMS arrived and took over the life saving measures. Resident #60 remained asystole, and the time of death was 10:14 A.M. NP #80 was notified and gave orders to release the body to the funeral home. The DON called the coroner to release the body to the funeral home. Post-mortem care was provided. The family entered the room and asked the funeral home to be notified. At approximately 12:00 P.M., the funeral home arrived to retrieve the body. Review of the witness statement dated [DATE] at 3:44 P.M., revealed LPN #22 administered Resident #60's morning medications and noted congestion. LPN #22 obtained his blood pressure and received an order for a stat chest x-ray from NP #80. LPN #22 notified Resident #60's sister of the new orders. CNA #12 notified LPN #22 that Resident #60 didn't look right. Upon entering Resident #60's room, LPN #22 noticed he was not breathing. LPN #22 verified code status and instructed CNA #12 to get another nurse and call a code blue. LPN #22 lowered the head of the bed and began chest compression and suctioned his mouth. EMS arrived on site and took over care. Interview with CNA #12 on [DATE] at 4:04 P.M., revealed CNA #13 fed Resident #60 breakfast on [DATE] and she reported Resident #60 barely ate. CNA #12 reported she went into the resident's room to pick up his breakfast tray when she noticed a white substance coming out of his nose. CNA #12 wiped his nose, left the room and notified LPN #22 the resident looked like he needed to be suctioned. CNA #12 stated at approximately 9:31 A.M. her and CNA #11 went into Resident #60's room to give him a bed bath and upon entering the room, CNA #12 noted the resident had thick white secretions similar to foam coming out of his nose and mouth. CNA #12 wiped the resident's mouth and nose, but he kept spitting up the foamy substance. CNA #12 reported she looked at the resident, and he was not breathing. CNA #12 stated she asked CNA #11 if he was breathing, and she said no. CNA #12 went to get the nurse (LPN #22) while CNA #11 stayed with the resident. LPN #22 came in and assessed him, and then initiated a code. CNA#12 went to get other nurses and notified them of the incident. Interview with CNA #13 on [DATE] at 11:36 A.M., revealed she fed Resident #60 breakfast on [DATE]. The resident had sausage patties, fried eggs, toast, and diced pears. CNA #13 reported the resident started coughing, stopped eating, and wouldn't allow her to give him a drink or complete eating, which was unlike him because the resident normally ate 75 to 100 % of his food. She was the primary staff member that fed him lunch and breakfast and he was not congested or coughing prior to feeding him. CNA #13 reported she told LPN #22 the resident sounded like he was congested. CNA #13 spoke to LPN #22, who stated she would notify the provider. Interview with UM/LPN #21 via phone on [DATE] at 7:20 P.M., revealed she was completing her morning rounds on [DATE] at approximately 9:15 A.M. when she went into Resident #60's room and noticed a whiteish secretion pouring from his nose. UM/LPN #21 stated she grabbed tissues and had the resident blow his nose. UM/LPN #21 reported he was mouth breathing at that time but had no other signs of respiratory distress. UM/LPN #21 reported she was notified a code was initiated on Resident #60 a little after 9:30 A.M., and she went to assist. Interview with LPN #22 via phone on [DATE] at 7:39 P.M., revealed CNA #13 came to her on the morning of [DATE] and reported Resident #60 appeared congested and could possibly vomit. LPN #22 reported she went into his room, administered his routine morning medications, checked his blood pressure and pulse and noticed the resident had congestion. LPN #22 stated she did not complete an assessment on Resident #60. LPN #22 stated she obtained an order for a stat chest x-ray. LPN #22 stated she saw her supervisor (UM/LPN #21) go in to assess him and have him blow his nose. LPN #22 revealed she was notified by CNA #12 that the resident didn't look right so she responded to the resident's room and noticed Resident #60 was not breathing and appeared gray. LPN #22 checked his code status, began CPR, had staff notify the other nurses and called 911. A follow-up interview with UM/LPN #21 via phone on [DATE] at 10:05 A.M., verified she did not complete an assessment on Resident #60 when she was in the resident's room on [DATE] and noticed the white secretions coming from the resident's nose. UM/LPN #21 stated she had the resident blow his nose and reported these findings to LPN #22 and instructed her to check on the resident frequently. A follow-up interview with CNA #13 on [DATE] at 11:29 A.M., while reviewing the videos, stated Resident #60 sounded congested after she started feeding him breakfast. CNA #13 reported Resident #60 started coughing, became more agitated than usual, and then refused to eat. CNA #13 stated he was not coughing or congested prior to breakfast. CNA #13 verified she reported to LPN #22, Resident #60 sounded very congested, didn't eat very much, and appeared as if he could vomit. A follow-up interview with LPN #22 on [DATE] at 12:19 P.M., while reviewing the videos, revealed she went into Resident #60's room at 8:17 A.M. to give him his routine morning medications and to get a routine blood pressure. LPN #22 stated CNA #13 reported to her Resident #60 sounded congested, didn't eat well, and looked like he could vomit. LPN #22 stated when she administered his morning medications, he sounded gurgly, which was not normal for him, and she reached out to the on-call provider to get an order for a STAT chest x-ray. LPN #22 verified she did not complete any kind of assessment on Resident #60. LPN #22 verified CNA #12 and UM/LPN #21 informed her of Resident #60's congestion before he coded. LPN #22 verified she did not go back into his room between when she administered his medications and before the resident coded. A follow up interview with UM/LPN #21 on [DATE] at 12:58 P.M., while reviewing the videos, verified Resident #60 had a change in condition on [DATE] when the resident was observed with mucous pouring out of his nose. UM/LPN #21 verified the mucous was not a normal finding for Resident #60. UM/LPN #21 verified she did not complete any kind of assessment or obtain vital signs on Resident #60. UM/LPN #21 verified she told LPN #22 about his condition and instructed her to check on the resident frequently. Interview with the DON on [DATE] at 1:54 P.M., while reviewing the videos, verified Resident #60 had a change in condition on [DATE] and stated the expectations were for nursing staff to complete an assessment on a resident when a change in condition was identified. The DON verified Resident #60 was not accurately assessed by nursing staff after Resident #60 had a change in condition. Interview with NP #80 on [DATE] at 2:14 P.M., revealed LPN #22 sent her a text message on [DATE] at 9:10 A.M. noting Resident #60 sounded severely congested and had crackles in his lungs. NP #80 stated she ordered a STAT chest x-ray and duo neb (combination of ipratropium and albuterol medications via hand-held nebulizer to treat respiratory conditions) every eight hours. NP #80 reported her expectations would be for the nurses to complete a thorough assessment of the residents prior to reaching out to her, so she could understand what was going on with the residents. NP #80 revealed severe congestion was not Resident #60's baseline. Interview on [DATE] at 4:37 P.M. with Medical Director (MD) #90, while reviewing the videos, verified the resident was having a change in condition due to the congestion and unknown white frothy secretions was not a baseline for Resident #60. MD #90 stated he did not know what the white frothy secretions were coming from the resident's nostrils and mouth but stated it could have been a sign/symptom of aspiration. MD #90 stated if a resident was having an acute change in condition, his expectations would be for the nursing staff to complete a timely and thorough assessment. Review of the facility document titled LPN Job Description revealed LPN duties included evaluating the resident's care needs, conditions, develop and or add to existing plan of care for the individual resident, instruction and observation of adherence to treatment or care protocols prescribed per the physician, and completing rounds and providing supervision of nursing staff care being provided. Review of the facility policy titled, Change of Condition, dated [DATE], revealed the facility staff would report identified significant changes in a resident's status. Skilled resident or residents with an active illness will be assessed every day based on the resident's specific needs and issues. Documentation of the condition would be noted in the nurse's charting or interdisciplinary charting as indicated. A significant change in a resident's condition included a resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). This deficiency represents non-compliance investigated under Complaint Number OH00158336.

Based on review of the video footage from the electronic monitoring device, staff interviews, observations, and policy review, the facility failed to ensure appropriate hand hygiene was maintained during resident care. This affected two (#60 and #114) of three residents reviewed for infection control. The facility census was 111. Findings include: 1) Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included major depressive disorder, emphysema, peripheral vascular disease (PVD), and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was dependent on staff for all activities of daily living (ADLs). Review of the electronic monitoring device video footage dated 10/24/24 at approximately 7:39 A.M. revealed Certified Nurse's Aide (CNA) #13 entered Resident #60's room with his breakfast tray. CNA #13 put the breakfast tray down on the bedside table. CNA #13 picked up the bed controller from the floor and raised the resident's bed. CNA #13 repositioned Resident #60 in bed. CNA #13 walked over to the bedside table after touching her face with her hand and moved the table over to the bed to prepare for feeding Resident #60. No hand hygiene was completed during the above observations and CNA #13 was not wearing any gloves. CNA #13 uncovered Resident #60's breakfast tray. During observation, CNA #13 removed the utensils from the napkin by grabbing the ends that would touch the resident's food. CNA #13 used the butter knife to cut up the resident's sausage then fed it to the resident. CNA #13 picked up the toast with her bare hands, buttered the toast and applied jelly. Throughout the video footage, CNA #13 was touching her personal phone sitting on her lap and rubbing her hands on her pants as she continued feeding Resident #60 without performing any kind of hand hygiene. Interview on 11/12/24 at 11:29 A.M. with CNA #13 while watching the electronic monitoring video footage, verified there were several infection control concerns including no hand hygiene or use of gloves while feeding Resident #60 his breakfast. 2) Review of the medical record for Resident #114 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, retention of urine, dementia, and chronic kidney disease (CKD) stage three. Review of the care plan dated 10/30/24 revealed Resident #114 had an indwelling Foley catheter related to urinary retention. Interventions included catheter care and empty bag every shift and as needed, change catheter, tubing, and/or bag per order and as needed for obstruction, non-functioning, or accidental removal, check catheter tubing for kinks, enhanced barrier precautions (EBP) due to indwelling catheter, and monitor and report signs and symptoms of infection including pain, burning, blood-tinged urine, cloudiness, no output, increase temperature, altered mental status, and foul-smelling urine. Review of the MDS assessment dated [DATE] revealed Resident #114 had severe cognitive impairment as evidenced by a BIMS score of seven and dependent on staff for being incontinent. Review of section H for bowel and bladder, revealed Resident #114 had an indwelling catheter and was frequently incontinent of bowel. Observation of catheter care and peri-care for Resident #114 on 11/14/24 at 1:57 P.M. performed by Certified Nurse's Aide (CNA) #17 and assistance from Unit Manager /Licensed Practical Nurse (LPN) #21, revealed CNA #17 had to be coached and instructed by LPN #21 during catheter care. Unit Manager/LPN #21 instructed CNA #17 to change her gloves and wash hands after providing care from a dirty to clean area. CNA #17 also touched Resident #114's sheets and comforter without changing her gloves and performing hand hygiene before she started cleaning the catheter tubing. CNA #17 was instructed again by Unit Manager/LPN #21 to change her gloves and wash her hands after cleaning the catheter tubing but had picked up a clean washcloth before doing so. CNA #17 used the same washcloth she contaminated to rinse the catheter tube of Resident #114. Interview on 11/14/24 at 2:10 P.M. with Unit Manager/LPN #21 verified she had to coach and instruct CNA #17 on multiple occasions to change her gloves and wash her hands during Resident #114's catheter and peri-care. Interview on 11/14/24 at 2:12 P.M. with CNA #17 verified she handled Resident #114's sheets prior to cleaning catheter tubing and did not change her gloves or complete any hand hygiene. CNA #17 also verified she used the contaminated washcloth to rinse the catheter tubing. Review of the facility policy titled, Hand Hygiene, dated August 2024 revealed all team members of the facility would follow hand hygiene guidelines to reduce the incidence of health care associated infections. Indications for handwashing included when hands were visibly soiled or dirty. Staff are to change gloves during patient care if moving from a contaminated body site to a clean body site. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient. Decontaminate hands after removing gloves. This deficiency represents non-compliance investigated under Complaint Numbers OH00159762 and OH00159005.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, review of the facility policy, and review of the electronic monitoring device recording, the facility failed to ensure residents were free from verbal abuse. This affected one (#60) of the three residents reviewed for abuse. The facility census was 111. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included major depressive disorder, emphysema, peripheral vascular disease (PVD), and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was dependent on staff for all activities of daily living (ADLs). Review of the care plan dated 08/01/23 revealed Resident #60 had behavior problems including combative with staff, resistive to care, using racial slurs, and swearing at staff. Interventions included administering medications as ordered, staff to anticipate and meet the resident's needs. staff to provide opportunities for positive interaction and attention, and staff to intervene as necessary to protect the rights and safety of others. Review of the electronic video recording in Resident #60's room dated 09/09/24 at 3:50 P.M. revealed Certified Nursing Assistant (CNA) #14 was providing incontinent care to Resident #60. CNA #15 was also present to assist as needed with care. CNA #14 was very rough with the resident during repositioning and the resident became agitated and stated expletive you to CNA #14. CNA #14 responded and said expletive you back to Resident #60. CNA #14 then extended her middle finger up to the resident's face asked Resident #60 if he saw it and said expletive you again. Throughout the video, CNA #14 continued to handle Resident #60 roughly during care. Resident #60 became agitated again and raised his arm up in a possible attempt to hit CNA #14. CNA #14 told Resident #60 she would call the police on him if he hit her. Resident #60 yelled call the police multiple times. CNA #14 stated she would call the police if he hit her and would tell them to come and get him. CNA #14 told Resident #60 to do it. CNA #14 continued to taunt Resident #60, and he stated expletive you again as CNA #14 repeated it back. CNA #14 stated she would bust his expletive. CNA#15 was observed standing at the bedside and did not intervene during the verbal abuse by CNA #14. CNA #14 and CNA #15 finished providing care and lowered Resident #60's bed to the floor and covered him up. The Director of Nursing (DON) arrived in the room and asked who had just provided care. The DON asked CNA #14 and CNA #15 to wait in the hallway. Review of the Self-Reported Incident (SRI) dated 09/09/24 at 5:35 P.M. revealed at approximately 5:20 P.M., the DON notified the Administrator regarding a message left with the receptionist. Resident sister called the facility and felt staff handled Resident #60 roughly by CNA #14 during care. Resident #60 had a history of being verbally aggressive and combative with staff. CNA #14 was immediately removed from the facility. A head-to-toe assessment was completed on Resident #60 with no negative findings. The local Police Department were called to the facility. According to Police Department, no physical assault occurred. CNA #14 admitted to using profanity toward Resident #60. CNA #14 was terminated. Education on abuse with all staff was completed. Other residents were assessed and interviewed with no negative findings. Review of the progress note dated 09/10/24 at 12:00 A.M. revealed Resident #60 was seen for a physical exam. Resident #60 was at baseline and reported he was not in any pain. Resident #60 was free from bruising, rashes, or lesions and vital signs were stable. Review of the police report dated 09/10/24 at 7:10 A.M. revealed the videos were observed of CNA #14 and CNA #15 providing care to Resident #60. In the video, Resident #60 cursed at CNA #14 several times. CNA #14 was heard saying expletive you to Resident #60 and continued changing him. CNA #14 was heard saying she would call the cops on Resident #60. The videos revealed no sign that CNA #14 physically assaulted Resident #60. Interview on 10/30/24 at 3:17 P.M. with interim Administrator revealed Resident #60's sister called the facility, while watching the live feed of the electronic monitoring device in the resident's room related to concerns during care to Resident #60. The interim Administrator reported she had notified the police of the alleged abuse. A head-to-toe assessment was completed on Resident #60 with no negative findings. The interim Administrator stated CNA #14 was immediately suspending pending investigation. Abuse education was completed with all staff and all residents were assessed or interviewed with no negative findings. The interim Administrator stated verified CNA #15 should have intervened during care to prevent further abuse from occurring. Interview on 10/30/24 at 3:52 P.M. with the Director of Nursing (DON) verified she had seen the videos regarding the incident on 09/09/24. The DON verified CNA #15 should have intervened during care to protect Resident #60 from the abuse. Review of the facility policy titled, Abuse/Neglect/Misappropriation of Property, dated September 2022 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The facility staff should immediately report all such allegations to the Administrator and the respective State Survey Agency. Verbal abuse was the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but were not limited to threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. The deficient practice was corrected on 09/10/24 when the facility implemented the following corrective actions: On 09/09/24, immediately following the allegations of abuse, the DON separated CNA #14 and CNA #15 from Resident #60's room, notified the Administrator, physician, and the resident's responsible party. On 09/09/24, Resident #60 had a head-to-toe assessment completed with no negative findings related to abuse On 09/09/24, the interim Administrator filed an SRI with the state agency, filed a police report, and initiated an investigation for the allegations of abuse towards Resident #60. On 09/09/24, the DON educated all staff on the facility abuse policy. On 09/09/24 and 09/10/24, Social services (SS) #70 and nursing staff conducted body audits and interviews on all residents in house to ensure no evidence of abuse was present. No abnormal findings were discovered. Interviews with RN #30, LPN #22, CNA #10, and STNA #11 confirmed they had received education on the facility abuse policy on 09/09/24. Beginning on 09/11/24, audits for abuse were conducted by DON of random residents for concerns of abuse. Audits were conducted every day for a week, and then weekly for eight weeks. No negative findings were identified during the audits. On 09/09/24, CNA #14 was terminated from employment with the facility. This deficiency represents noncompliance investigated under Complaint Number OH00158336.

Based on review of the medical record, staff interviews, and job description, the facility failed to ensure interventions were implemented timely in order to appropriately treat a urinary tract infection (UTI). This affected one (#112) of four residents reviewed for infections. The facility census was 111. Findings include: Review of the closed medical record of the Resident #112 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included osteomyelitis of vertebra, mood disorder, generalized anxiety disorder (GAD), and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was dependent on staff for all activities of daily living (ADLs). Review of the care plan dated 08/07/24 revealed Resident #112 had a UTI. Interventions included to give antibiotic therapy as ordered, obtain and monitor vital signs, monitor intake and output, obtain and monitor laboratory (lab)/diagnostic work as ordered and report results to the provider, follow up as indicated, and encourage adequate fluid intake as diet allowed. Review of the nurse's progress note dated 08/07/24 at 12:00 A.M., revealed Resident #112 complained of suprapubic tenderness on exam. Resident #112 was noted to have cloudy urine in the Foley catheter bag with a moderate amount of sediment present. The resident was afebrile with stable vital signs. The plan was to collect a urinalysis (UA) with culture and sensitivity (UA C&S) and continue monitoring vitals signs and change in condition, mood, or behavior. Review of a physician order dated 08/07/24 revealed Resident #112 was ordered to have an UA C&S every shift for urinary discomfort. Review of a physician order dated 08/13/24 revealed Resident #112 was ordered an UA C&S every shift for urinary discomfort. Review of the UA C&S results for Resident #112 dated 08/19/24 at 7:29 A.M. revealed the resident's urine was collected on 08/16/24. The results determined the resident had an abnormal UA and the C&S determined the resident was positive Klebsiella Pneumouniae. Review of the nurse's progress note for Resident #112 dated 08/19/24 at 3:42 P.M. revealed the resident's UA C&S was final and new orders were received to start Macrobid (antibiotic) 100 milligrams (mg) twice a day for seven days. Review of the physician order for Resident #112 dated 08/19/24 revealed the resident was ordered Macrobid 100 mg two times a day for UTI. Interview with Nurse Practitioner (NP) #80 on 11/14/24 at 2:35 P.M. revealed if dayshift nurses had difficulties getting a UA completed, it would be passed on to the next shift. NP #80 reported it can be difficult for staff to get a resident's urine if residents are continent, but with an indwelling catheter, there should be no delay in getting a urine sample. NP #80 verified Resident #112 had a urinary catheter at that time. NP #80 also verified Resident #112 was seen on 08/07/24 and complained of suprapubic pain, which was why she ordered a UA C&S. NP #80 verified Resident #112 did not start on antibiotics until 08/19/24. Interview with the Director of Nursing (DON) on 11/14/24 at 3:00 P.M., verified Resident #112 had an original order for a UA C&S dated 08/07/24 and the resident did not have a UA C&S collected until 08/16/24, which caused a delay in the administration of an antibiotic to the resident. Review of the Licensed Practical Nurse (LPN) Job Description revealed duties included to evaluate resident care needs, condition, developed and or added to existing plan of care for the individual resident, instruction and observation of adherence to treatment or care protocols prescribed per the physician, and completing rounds and providing supervision of nursing staff care being provided. This deficiency represents non-compliance investigated under Complaint Number OH00159762 and OH00159005.

Based on medical record review and staff interview, the facility failed to ensure the physician and nurse practitioner (NP)'s progress notes were timely written and signed at each visit. This affected three (#30, #32, and #75) of the three residents reviewed for physician progress notes. The facility census was 111. Findings include: 1) Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of upper lobe of right bronchus, anxiety disorder, chronic kidney disease , and depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. Review of the progress note for Resident #30 dated 11/12/24 at 12:00 A.M. authored by NP #80, revealed the NP's note was signed on 11/13/24 at 10:17 P.M. 2) Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, diabetes mellitus, convulsions, and atrial fibrillation. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #32 had severe cognitive impairment as evidenced by a BIMS score of seven. Review of progress note for Resident #32 dated 10/15/24 at 11:00 P.M. with a date of service on 10/16/24 and authored by NP #80, revealed the NP's note was signed on 10/18/24 at 12:50 P.M. Review of the progress note for Resident #32 dated 10/28/24 at 11:00 P.M. authored by NP #80, revealed the NP's note was signed on 10/29/24 at 12:48 P.M. Review of the progress note for Resident #32 dated 11/04/24 at 12:00 A.M. authored by NP #80, revealed the NP's note was signed on 11/05/24 at 9:13 P.M. Review of the progress note for Resident #32 dated 11/05/24 at 12:00 A.M. authored by NP #80, revealed the NP's was signed on 11/07/24 at 9:45 A.M. Review of the progress note for Resident #32 dated 11/11/24 at 12:00 A.M. authored by NP #80, revealed the NP's note was signed on 11/13/24 at 9:20 A.M. Review of the progress note for Resident #32 dated 11/13/24 at 12:00 A.M. authored by NP #80 revealed the NP's note was signed on 11/15/24 at 12:33 A.M. Review of the progress note for Resident #32 dated 11/14/24 at 12:00 A.M. authored by NP #80 revealed the NP's note was signed on 11/15/24 at 10:09 P.M. 3) Review of the medical record for Resident #75 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included fracture of right femur, diabetes mellitus, anxiety disorder, and Alzheimer's disease. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #75 was unable to complete a BIMS because she was rarely/never understood. Review of the progress note for Resident #75 dated 09/09/24 at 12:00 A.M. authored by NP #80 revealed the NP's note was signed on 09/11/24 at 9:31 P.M. Review of the progress note for Resident #75 dated 09/20/24 at 12:00 A.M. authored by NP #80 revealed the NP's note was signed on 09/22/24 at 10:53 P.M. Review of the progress note for Resident #75 dated 09/25/24 at 12:00 A.M. authored by NP #80 revealed the NP's note was signed on 09/27/24 at 7:59 P.M. Review of the progress note for Resident #75 dated 10/06/24 at 11:00 P.M. with a date of service of 10/07/24 authored by NP #80, revealed the NP's note was signed on 10/08/24 at 11:01 P.M. Review of the progress note for Resident #75 dated 10/15/24 at 11:00 P.M. with a date of service of 10/16/24 authored by NP #80 revealed the NP's note was signed on 10/18/24 at 12:59 P.M. Interview on 11/14/24 at 2:35 P.M. with NP #80 revealed she did not chart her visits while she saw the residents. NP #80 reported when she was hired, she was instructed by her manager she had up to 48 hours to complete and sign her progress notes after seeing the residents. NP #80 verified her progress notes were not signed and completed at the time of the visit for residents.

Based on medical record review, staff interviews, and review of a job description of the Medical Director (MD), the facility failed to ensure residents were seen at least every 60 days after the initial assessment by the physician. This affected two (#30 and #75) of three residents reviewed for physician visits. The facility census was 111. Findings include: 1) Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, DM II, convulsions, and atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of seven. Review of the physician progress notes dated July through November 2024 revealed Resident #32 had not been seen by MD #90, who was the resident's physician, since 07/19/24. 2) Review of the medical record for Resident #75 revealed an admitted [DATE] with a discharge date of [DATE]. Diagnoses included fracture of right femur, type two diabetes mellitus (DM II), anxiety disorder, and Alzheimer's disease. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #75 was unable to complete a BIMS because she was rarely/never understood. Review of the physician progress notes dated February through October 2024 revealed Resident #75 had not been seen by MD #90, who was her physician, since 02/27/24. Interview on 11/14/24 at 4:37 P.M. with the Administrator verified Resident #32 and Resident #75 had not been evaluated by their physician every 60 days. Review of the job description for the medical director, revealed the medical provider must acquire, maintain, and apply knowledge of social, regulatory, political, and economic factors that relate to resident care services in the long-term setting. The medical director would coordinate and oversee medical care and treatment including physician services and services of other professionals as they relate to resident care. The medical director would oversee that all necessary medical services provided to residents were adequate and appropriate.

Based on review of the medical record, review of video footage from the electronic monitoring device, staff interviews, and job description of a licensed practical nurse (LPN), the facility failed to ensure accurate documentation in a resident's medical record. This affected one (#60) of three residents reviewed for documentation. The facility census was 111. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included major depressive disorder, emphysema, peripheral vascular disease (PVD), and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was dependent on staff for all activities of daily living (ADLs). Review of the vital signs record for Resident #60 dated 10/24/24 revealed the following: blood pressure was 114/72 millimeters of mercury (mmHg), heart rate was 69 beats per minute (bpm), and oxygen saturation of 94 percent (%) on room air. Review of the electronic monitoring device video footage in Resident 60's room dated 10/24/24 at 8:17 A.M., LPN #22 entered Resident #60's room, poured a medicine cup of medications in the resident's mouth, and placed a cup of water with a straw in it in the resident's mouth. LPN #22 obtained a blood pressure of 114/72 millimeters of mercury (mm/Hg) in the resident's right wrist. LPN #22 noticed the resident was coughing and asked if he could cough it up and asked if his throat was hurting. LPN #22 stated to Resident #60 he sounded gurgly and stated, you feel cold. LPN #22 stated she would have NP #80 come see him later. The resident's left arm stayed tucked under the sheets and under his leg hanging over the right side of the bed. LPN #22 raised the HOB and left the room. LPN #22 did not complete an oxygen saturation level or complete an assessment on Resident #60. Interview with LPN #22 on 11/12/24 at 12:29 P.M. with Director of Nursing (DON) in the room and while reviewing the video footage of Resident #60's care, verified she did not complete an oxygen saturation on Resident #60. LPN #22 verified she documented a pulse oximetry of 94 %. Review of the LPN Job Description revealed duties included to evaluate resident care needs, maintain appropriate documentation per the resident chart and the facility policies, instruction and observation of adherence to treatment or care protocols prescribed per the physician, and completing rounds and providing supervision of nursing staff care being provided.

Based on record review, staff interviews, observations, and facility policy review, the facility failed to provide timely and routine incontinence care to a resident. This affected one (Resident #7) of three residents reviewed for incontinence. The facility census was 119. Findings include: Review of Resident #7's medical record revealed an admitted on 04/17/18. Diagnoses included major depressive disorder, dementia, impairment of hearing, and osteoporosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 required extensive assistance of two-persons for toileting. Resident #7 was incontinent of bowel and bladder. Review of the plan of care dated 02/02/23 revealed Resident #7 had bowel incontinence related to dementia and impaired cognition. Interventions included to assist to the bathroom or bedpan as needed, check the resident frequently, assist with transfers and toileting as needed, keep call light within reach while in the room, monitor bowel elimination, peri care after each incontinent episode, provide loose fitting easy to remove clothing, and utilize incontinence products or barrier cream as indicated. There was also a plan of care for Resident #7's potential for skin impairment to rule out impaired immobility, incontinence, fragile skin, dementia, failure to thrive, a history of pressure ulcers, and was non-compliant with interventions. The goals included for Resident #7's skin will remain/improve through the next review. Interventions included to assist as needed with toileting and hygiene and to keep skin clean and dry. Review of the Urinary Incontinent assessment dated [DATE] revealed Resident #7 was continent of urine. Resident #7 will be checked every two hours and toileted as needed. Provide peri care after each incontinent episode. Toilet and prompts before and after each meal and bedtime. Check every two hours at night. Review of the physician order dated 07/13/23 revealed Resident #7 had an order for Calmoseptine external ointment 0.44%-20.6% to apply to the bilateral buttocks every day and night for shift for moisture associated skin damage (MASD). Review of the weekly skin round dated 07/13/23 revealed Resident #7's area of concern skin condition was a reddened area, that was blanchable to the bilateral buttocks. New or current treatment was to use Calmoseptine cream. Review of the Braden Scale dated 07/14/23 for Resident #7 revealed that sensory perception was very limited due to responds only to painful stimuli, that cannot communicate discomfort except by moaning or was restless or has sensory impairment which limited the ability to feel pain or discomfort over half of body. Degree to which skin exposed to moisture was occasionally moist that required an extra linen change approximately once a day. Resident #7 was at moderate risk of skin breakdown. Review of the stated tested nursing aide (STNA) kardex for Resident #7 dated 07/18/23 revealed the STNAs were given the information that Resident #7 used disposable briefs. Resident #7 was incontinent of bowel and bladder. Resident #7 required extensive assistance with two staff members for toileting. Continuous observations on 07/18/23 from 10:33 A.M. through 12:03 P.M. revealed Resident #7 was in her Broda chair in the activity room asleep watching television. Resident #7 had a blanket over the top of her lower abdomen and lower extremities, while sitting in her Broda chair. No staff member had come into the activity room to check Resident #7 her for incontinence care during this time. Observations on 07/18/23 at 12:03 P.M. revealed STNA #201 took Resident #7 from the activity room to the dining room for lunch. STNA #201 did not check for incontinence at this time. From 12:04 P.M. to 1:46 P.M., Licensed Practical Nurse (LPN) #650 assisted Resident #7 with her meal in the dining room. At 1:47 P.M., STNA #70 took Resident #7 from the dining room back to her room in the Broda chair. Observation and interview on 07/18/23 from 1:51 P.M. to 1:59 P.M. with STNAs #270 and STNA #282 revealed they transferred Resident #7 with a Hoyer lift from the Broda chair to her bed. STNA #282 verified the black cushion in Resident #7's Broda chair was saturated with urine. Observation on 07/18/23 at 1:52 P.M. through 1:56 P.M. revealed Resident #7 was in her full clothes on her bed. STNAs #270 and #282 verified Resident #7 had a strong malodorous odor before removing clothes and incontinent brief. STNA #270 verified Resident #7's pants were saturated with urine. STNA #282 laid out a clean pair of pants next to Resident #7's bed. At 1:59 P.M., Resident #7's incontinent brief was observed with heavy saturated dark urine. Resident #7 had bowel movement when wiped down with disposable wipes. When Resident #7 was turned to her right side, she had a round red skin issues that estimated 1.5-2.5 inches circular on bilateral buttocks. There was a small red opened area of blood on the right buttocks. STNA #282 verified Resident #7's brief was heavily saturated of urine. Interview on 07/18/23 at 2:03 P.M. with STNA #270 stated the last time he changed Resident #7 was after breakfast between 8:30 A.M. and 9:00 A.M. Interview on 07/18/23 at 2:49 P.M. with STNA #201 stated for residents who were incontinent and confused, she would provide incontinence care every two to three hours. Interview on 07/18/23 at 2:51 P.M. with the Director of Nursing (DON) stated incontinence care was to be completed every two to three-hours. The DON verified Resident #7 should have been taken before lunch for incontinence care. At 2:56 P.M., the DON stated the staff typically check and change a resident after breakfast, then lay the resident down and then check and change the resident before lunch to make sure the resident was dry. Interview on 07/18/23 at 2:58 P.M. with STNA #217 stated she had taken care of Resident #7 before and would check and change her after breakfast, laying her down, and before lunch. STNA #217 stated lunch was served after 12:15 P.M. in the dining room. Subsequent interview on 07/18/23 at 4:33 P.M. with the DON stated Resident #7's video footage revealed that STNA #270 had entered Resident #7's room on 07/18/23 at 9:13 A.M. and left Resident #7's room at 9:24 A.M. The DON stated Resident #7 was checked and changed at that time. The DON stated the video footage was reviewed at the facility. Interview with the Administrator on 07/18/23 at 4:12 P.M. revealed the facility changed their policy to check and change residents every two to four hours for incontinence. The Administrator stated the policy was changed due to staffing shortages. The Administrator stated the blanket lying on Resident #7's lap covered up urine smell and LPN #650 who fed Resident #7 her lunch did not identify any odor. Review of the facility policy titled Urinary Incontinence Management, dated 03/2016, revealed routine or scheduled toileting should be offered to incontinent residents on a consistent basis. Caregiver will take the resident to void every two to four hours, including at night. The goal was to keep the resident dry. This deficiency represents non-compliance investigated under Complaint Number OH00144029.

Based on medical record review, observation, staff interviews and review of policy, the facility failed to timely treat a resident's skin impairment present on admission. This affected one (#525) of one resident reviewed for skin concerns. The facility census was 122. Findings include: Review of medical record for Resident #525 revealed an admitted on 04/23/23, with diagnoses including pulmonary embolism. pneumonia, sepsis, seizures, diabetes mellitus, nephritis, malignant melanoma, dementia, anxiety, and osteoarthritis. Review of the nursing admission assessment for Resident #525 dated 04/23/23 revealed a skin tear and abrasions to the shin area on right lower leg. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] was in progress and unfinished. Review of the acute plan of care for Resident #525 revealed the resident has potential for skin impairment related to impaired mobility, incontinence, diabetes, fragile skin, malignant melanoma of upper limb, and prolonged periods of time in bed. Interventions include assist as needed with toileting and hygiene, assist with mobility, turning, and repositioning as needed, barrier cream as need after incontinent, Braden scale quarterly, gel cushion, pressure reducing mattress to bed, shower per schedule and as needed, skin rounds weekly, aide to check skin daily while doing routine care. Report changes to nurse. Review of the physician orders for Resident #525 orders for the month of April 2023 was silent for any orders related to the wound on the right shin. Review of the Treatment Administration record (TAR) for Resident #525 for the month of April 2023 was silent for any completed treatments related to the wound of the right shin. Observation on 04/26/23 08:50 A.M., of Resident #525 collaborating with Occupational Therapist (OT) #601 and Physical Therapist (PT) #602 with Resident #525's extremities exposed. Observation of a wound dressing dated 04/16/23 on his right lower leg. Interview on 04/26/23 09:10 A.M., with OT #601 and PT #602 verified the dressing on Resident #525 was dated 04/16/23. PT #602 stated they let the nurse know the dressing was present and dated 04/16/23. Observation on 04/26/23 at 10:10 A.M., with Team Leader Licensed Practical Nurse (LPN) #54 and LPN #93 remove old dressing, cleaned the area on right lower leg for Resident #525 and replace dressing dated 04/26/23. Interview on 04/26/23 at 10:16 A.M., with Team Leader LPN #54 verified the dressing was dated 04/16/23 and applied during the hospital stay. Further verified it was not changed on admission and should have been. Interview on 04/26/23 at 11:19 A.M., with Registered Nurse (RN) #63 who completed the initial body check and admission assessment verified she pulled the dressing back to see the wound but did not clean the area or reapply a new dressing. RN #63 verified she failed to notify the physician for treatment orders for the skin tear noted on admission for Resident #525. Review of the policy titled Skin Integrity Team (SIT)-Skin Monitoring Process dated June 2019 revealed under the area of skin rounds, the nurse will document wound location and description and notify the physician to obtain orders for treatment.

Based on observations, medical record review and staff interviews, the facility failed to provide appropriate personal care for residents who required assistance. This affected two (#53 and #58) of 33 residents reviewed for care and treatment. The facility census was 122. Findings include: 1. Review of the medical record for Resident #53 revealed admitted [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis, and Diabetes Mellitus type two. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had severe cognitive impairment, no behaviors of refusal of care, and required extensive to total assistance of one person for personal hygiene and bathing. Review of progress notes revealed Resident #53 refused baths on 04/21/23 at 11:59 A.M., 04/18/23 on 9:10 A.M., and 04/13/23 at 8:55 A.M. Observation on 04/25/23 at 11:34 A.M., revealed Resident #53 in bed and had long fingernails that were untrimmed and jagged. Interview and observation on 04/26/23 at 2:50 P.M., with Licensed Practical Nurse (LPN) #54 stated there had been some issues with refusal of baths and showers with Resident #53. She did indicate that Resident #53 would consent to a bath and then change her mind part way through. LPN #54 verified that Resident #53's fingernails were long, jagged, and dirty. 2. Review of medical record for Resident #58 revealed an admitted [DATE], with diagnoses including fracture of one rib on right side, paroxysmal tachycardia, and protein calorie malnutrition. Review of MDS assessment dated [DATE] revealed Resident #58 had severe cognitive impairment, no behaviors exhibited, and required extensive to total assistance of one for bathing and personal hygiene. Review of care plan revealed no care plan related to refusal of care or behaviors. Observation on 04/26/23 at 9:07 A.M. Resident #58 noted to have strong odor of urine. Interview and observation on 04/24/23 at 12:40 P.M., with State tested Nursing Assistant (STNA) #64 verified that Resident #58 smelled strongly of urine, and she sometimes became agitated when offered care.

Based on medical record review, review of electronic mail (email) communication, observation, resident, resident representative and staff interview and review of facility policy, the facility failed to permit a resident to possess an electronic monitoring device (camera of choice) in their room unless they sign to agree to only have the facility staff install the device for a specified fee determined by the facility. This affected one (#6) of three residents reviewed for resident rights. Facility census was 130. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with a diagnosis of cerebral infarction. Review of the Minimum Data Set (MDS) for Resident #6 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Review of the face sheet for Resident #6 revealed Resident Representative (RR) #210 was the power of attorney (POA) and medical decision maker for Resident #6. Review of the care plan for Resident #6 dated 06/23/21 revealed the resident had impaired cognition and impaired decision-making skills related to dementia and history of cerebral infarction. Interventions included the following: encourage family to bring in familiar items to help resident recognize own room and surroundings, encourage family/friends to visit, engage the resident in simple, structured activities that avoid overly demanding tasks, face the resident when speaking and make eye contact, reduce distractions as able, provide a program of activities that accommodates the resident's abilities. Review of POA paperwork for Resident #6 revealed RR #210 was designated as POA on 06/13/16. Review of nurse practitioner (NP) progress note for Resident #6 dated 03/20/22 revealed RR #210 was resident's medical decision maker. Review of social service progress note for Resident #6 dated 04/18/22 revealed Social Worker (SW) #215 spoke with RR #210 and she confirmed she would be in the facility on 04/21/22 to sign the electronic monitoring consent form. Observation on 05/11/22 at 9:15 A.M. revealed Resident #6 shared a room with Resident #5. There was a wall which created a visual barrier between the two sides of the room. There were no cameras observed on either side of the room. Interview on 05/11/22 at 9:15 A.M. with Resident #5 confirmed the facility staff had approached her about Resident #6 and her family wanting to have a camera installed in the room on the resident's side of the room. Resident #5 confirmed she had no objections to this, and she thought the camera was still in place. Observation on 05/11/22 at 11:06 A.M. of Resident #6 revealed the resident was in bed and there was no camera in her room. Interview on 05/11/22 at 11:06 A.M. of Resident #6 confirmed she had no objections to her family installing a camera in her room. Interview on 05/11/22 at 11:20 A.M. with Social Worker (SW) #215 confirmed Resident #6's family had installed a camera in the residents room but it wasn't the type of camera permitted by the facility, so it was taken down. SW #215 further confirmed RR #210 approached her on 04/18/22 regarding the family's desire to having a camera installed. SW #215 confirmed Resident #5, Resident #6's roommate had signed consent for the camera, and she was still waiting for RR #210 to sign consent and pay the $200 installation fee which was required before the camera could be installed. SW #215 further confirmed per facility policy only facility maintenance staff were permitted to install the camera and the cost was $200 which had to be paid in full prior to installation. SW #215 further confirmed RR #210 was advised the camera to be installed in resident's room could not be one which allowed for two-way communication per the facility policy and the camera family had installed themselves did not meet this requirement. Review of an email communication from the Administrator on 05/11/22 timed at 1:52 P.M. confirmed Resident #6's family member installed a camera in the resident's room, but it did not meet the facility's requirements regarding the type of camera. Family was given a handout outlining the policy and requirements regarding cameras. The family then asked the Director of Nursing (DON) to remove the camera from the wall and took the camera. Interview on 05/11/22 at 3:01 P.M. with RR #210 confirmed her nephew installed a camera in resident's room sometime in mid-April 2022, but the facility had them take it down and remove the device from the facility. RR #210 said SW #215 told her the camera couldn't be a two-way camera which allowed for communication from outside. RR #210 said they had not been able to find a camera that met the facility policy and that all of the cameras they looked at provided for two-way communication. RR #210 further confirmed the facility told her she had to pay $200 for installation of the camera, and they could not install the camera themselves. RR #210 confirmed the cost of installation and the requirement to find a one-way camera had prevented the family for being able to exercise their resident rights. Review of the facility policy titled Electronic Monitoring Devices dated March 2022 revealed the facility would permit residents and legally authorized people to install and use electronic monitoring devices in accordance with applicable laws. Further review of the policy revealed cameras installed in resident rooms could not be a bidirectional or communication device where the person viewing the video/audio could talk to the resident. Cameras could only be installed by facility personnel and payment of a $200 fee was required prior to installation. This deficiency substantiates Complaint OH 390.

Based on closed record review, staff interview and facility policy review the facility failed to ensure a resident's insulin therapeutic change was not verified for three days. This affected one (#25) of three residents reviewed for diabetes management. The facility identified 21 (#01, #03, #04, #05, #06, #07 #08, #26, #27, #28, #29, #31, #32, #34, #36, #38, #39, #40, #41, #85, #300) residents who received insulin. The facility census was 106. Findings include: Review of the closed medical record revealed Resident #25 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was mildly cognitively impaired. The resident received insulin injections on the five previous days. Review of the plan of care dated 11/26/20 revealed the resident had diabetes and interventions included to administer diabetes medications as ordered. Interventions also included to monitor blood sugars as ordered and as needed. Review of physician orders dated 11/20/20 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. on 11/20/20 at 5:00 P.M. Further review of the resident's MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of physician order dated 11/23/20 revealed [MEDICATION NAME] N 100 unit/ml suspension, inject 20 unit subcutaneously two times a day for diabetes mellitus. Review of the MAR for 11/23/20 revealed the resident received [MEDICATION NAME] N 100 unit/ml. insulin as per physician orders. Further review of the resident's MAR indicated [REDACTED]. Interview on 01/26/20 at 4:12 P.M. with the Director of Nursing confirmed the resident had not received any insulin on 11/21/20 and 11/22/20. After further review of the orders, the DON stated the admission order for the NPH insulin entered on the date of 11/20/20 required a therapeutic interchange from the pharmacy. The therapeutic interchange was not confirmed by the nurse until 11/23/20. The DON confirmed the resident should not have had a lapse in receiving her insulin. The DON confirmed the resident did not receive insulin on 11/21/20 and 11/22/20. Review of the facility policy titled, Administration of Insulin, dated December 2015 revealed it is the policy of the facility to administer insulin to the resident in a safe, consistent manner as prescribed by the physician. This citation is an incidental finding discovered during the investigation of Complaint Number OH 341.

Based on observation, staff interview and policy review, the facility failed to ensure laundry staff observed appropriate infection control interventions. This had the potential to affect all residents in the facility. The facility census was 118. Findings include: On 01/10/19 at 3:29 P.M. a tour of the laundry was conducted with Laundry Aide #118. When asked where the gowns were she indicated the laundry staff was not provided gowns to transfer dirty laundry, that only gloves were provided. She indicated she would hold the soiled linen out in front of her to keep it from touching her clothing. She indicated it had been possibly a couple of months since the plastic gowns were available. She attempted to locate a box of gowns or aprons but could not find any. She indicated linen and clothing from the isolation rooms would come with a biohazard label. The bags were not water soluble so the items had to be removed from the bags to be placed in the washers. An observation was made with Regional Laundry Supervisor #200 on 01/10/19 at 5:20 P.M. of the laundry room. She showed a box of isolation gowns and face shields that was on a shelf with other boxes. She said Laundry Aide #118 did not like the isolation gowns and preferred aprons. She was informed by the surveyor that staff did not know there were any gowns or aprons were and she had even searched for them. She was informed that Laundry Aide #118 had indicated she had not seen gowns or aprons for the past two months. Regional Laundry Supervisor #200 indicated she was not aware they were out and staff needed to let her know if they needed to be ordered. Review of the policy and procedure for management of soiled laundry indicated protective clothing such as gowns or aprons, and face shields or goggles were to be worn when handling urine soaked linen/soiled linen (follow Universal Precautions).

Based on medical record review, staff interview, and review of facility policy, the facility failed to provide written bed hold notices to residents at the time of becoming aware of hospitalization . This affected four (#44, #45, #48 and #109) of five residents reviewed for hospitalization s. The facility census was 118. Finding include: 1. Review of Resident #44's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident was severely impaired and extensive assistance required for activities of daily living (ADLs). Further review of the medical record revealed Resident #44 was hospitalized from [DATE] to 05/10/18 and 05/30/18 to 06/07/18. The medical record contained no evidence that a written bed hold notice was provided to the resident or to the resident's representative within 24 hours of the transfer. Interview on 01/08/19 at 3:00 P.M., Resident #44's spouse denied receiving a written bed hold notices with 24 hours of the resident being hospitalized from [DATE] to 05/10/18 and from 05/30/18 to 06/07/18. 2. Review of Resident #48's medical record revealed an admitted on 08/28/18 with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] documented the resident was cognitively intact and required extensive assistance for ADLs. Resident #48 had clear speech, makes self-understood, clear comprehension and adequate vision with no corrective lenses. Further review of the medical record revealed Resident #48 was hospitalized from [DATE] to 10/31/18. There was nothing in the medical record to indicate a written bed hold notice was provided to the resident or resident's representative within 24 hours of the hospitalization . Interview on 01/08/19 at 1:00 P.M., Resident #48 and his spouse reported they did not receive any type of bed hold notices when admitted to the hospital from 10/17/18 to 10/31/18. 3. Record review revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and Vitamin D deficiency. She had a quarterly MDS assessment completed on 11/07/18. She was cognitively intact. She had no behaviors. She required extensive assist of two staff for bed mobility. She needed limited assist of one staff for transfer, walking, dressing, toilet use, and personal hygiene. She required supervision and set up for eating. She needed extensive assist of one staff for bathing. Further record review revealed the resident went to the hospital on [DATE]. There was no evidence in the clinical record that she or her representative were given a bed hold notice at time of transfer or within 24 hours. During an interview conducted with Social Service Designee #86 on 01/09/19 at 10:47 A.M., revealed the bed hold notice was mailed to the family. The resident or representative did not receive the information within 24 hours or prior to transport. The notice indicated a call would be made as notification, but there was no documentation of the time of the call. 4. Review of Resident #109's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS dated [DATE] documented the resident was cognitively intact and extensive assistance of one to two was required for ADL. Further review of the medical record revealed Resident #109 was hospitalized from [DATE] to 12/12/18. The medical record contained no evidence that a written bed hold notice was provided to the resident or resident's representative within 24 hours of the transfer. Interview on 01/08/19 at 10:42 A.M., Resident #109 denied receiving a written bed hold notice with 24 hours of being hosptalized on [DATE]. Interview on 01/10/19 at 3:11 P.M., Business Office Coordinator (B[NAME]) #103 stated she mailed the bed hold letter a day after a resident was admitted to the hospital. B[NAME] #103 stated if a resident is admitted to a hospital on a Friday then she sends a letter to the family or resident that following Monday. B[NAME] #103 reported she would call the resident or family member but did not document her calls or her attempted calls. Review of the facility policy titled, Bed Hold Including Patient Unable to Return Transfer, revised 11/2016 revealed the facility's business office would telephone the appropriate parties and send a letter the next business day.

Based on record review, observation and staff interview, the facility failed to provide a dignified dining experience for cognitively impaired residents. This affected one (#33) of four residents reviewed for dignity. The facility also failed to ensure residents were treated with dignity in regards to wearing identification wrist bands. This affected three (#2, #15, and #57) of four reviewed for dignity. The facility census was 118. Findings include: Resident #33 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive deficit, memory problem and required extensive assistance with two plus persons for bed mobility, transfer and toileting. Review of Resident #33's care plan dated 10/22/18 indicated to encourage the resident to do as much as possible for self to support and help restore independence and to promote positive self-concept. Care plan also indicated the resident needed a quiet setting at meal times with adequate eating time and to encourage socialization and interaction with table mates during meal times. Review of Resident #33's meal ticket indicated the resident needed a two-handle cup with lid. Observations on 01/07/19 at 12:34 P.M., revealed Resident #33 was seated at a table with another resident. Resident #33's hands were observed to shake continuously. Resident #33 started feeding herself and was getting food on the table and on herself due to her hands shaking. Resident #33 was given an eight-ounce cup of chocolate milk in a regular cup. The milk spilled on the table as Resident #33 attempted to drink out of the cup. State tested Nursing Assistant (STNA) #108 came to the table and attempted to assist Resident #33 with her meal by trying to feed her. Resident #33 spilled her soup as STNA #108 continued to try to feed her. STNA #108 removed Resident #33 from the dining room and placed her in the activity room. There was no other residents in the activity room. Interview on 01/07/19 at 1:00 P.M., STNA #108 reported Resident #33 does not like to be fed and enjoyed feeding herself. STNA #108 stated Resident #33 liked to be independent but would allow staff to give her a few bites. STNA #108 stated Resident #33 was removed from the dining room because she was spilling food on herself and on the table. Observations on 01/08/19 at 5:52 P.M., revealed Resident #33 was in the dining room seated at a table with another resident. Resident #33 had an eight-ounce cup of chocolate milk that was in a regular cup. The Director of Nursing (DON) sat down and tried to assist Resident #33 with her meal. When Resident #33 tried to feed herself, the DON would indicate she was trying to help the resident. Resident #33 grabbed a piece of bread from the hamburger she was eating and fed herself. Resident #33 also tried to eat the salad that was in front of her. Resident #33 was removed to the activity room. There was no other resident in the activity room. STNA #59 was trying to feed Resident #33. Interview on 01/08/19 at 6:00 P.M., STNA #59 reported Resident #33 did not eat her meal and would not allow STNA #59 to feed her. Observation on 01/09/19 at 12:35 P.M., revealed Resident #33 was in the dining room seated at a table with another resident. Resident #33 had juice that was in a regular cup and she spilled it on the table when she tried to pick it up. STNA #70 attempted to assist the resident. STNA #70 escorted Resident #33 to the activity room. There was no other resident in the activity room. Resident #33 would not allow STNA #70 to feed her. Interview on 01/09/19 at 12:45 P.M., STNA #70 reported Resident #33 liked to be independent and liked to feed herself. STNA #70 verified Resident #33 did not have a two-handle cup with lid. During an observation on 01/09/19 at 1:15 P.M., Licensed Practical Nurse (LPN) #155 give Resident #33 a clear cup of ensure with a straw. LPN #33 held the cup for resident as she drank the ensure. Resident #33 kept trying to grab the plastic cup to hold but the nurse did not let go of the cup. Observation on 01/09/19 at 6:15 P.M., revealed Resident #33 was in the dining room seated a table with another resident. Resident #33's family member was also seated at the table. Resident #33 had the two-handle cup with lid and it was filled with chocolate milk. The family member allowed Resident #33 to feed herself. The family member attempted to assist the resident. The family member was observed handing a spoon to the resident and the resident ate her pudding. Resident #33 stayed in the dining room until she finished her meal. Interview on 01/09/19 at 6:20 P.M., with Resident #33's family member revealed the resident does not like to be feed so the family member lets the resident feed herself. Observation on 01/10/19 at 12:40 P.M., revealed Resident #33 was in the dining room with a family member. Resident #33 had the two-handle cup with lid and it was filled with chocolate milk. Family member was present and allowed the resident to feed herself. Resident #33 did spill any of her food on the table or on herself. The family member was observed encouraging the resident to eat more and was handing her pieces of a hamburger. The resident refused and the family member let the resident feed herself. Interview at the time of the observation, the family member reported she tried to make it each day for at least one meal to encourage her mother to eat. The family member stated if she does not have anything scheduled then she comes and visits her mother twice a day during meal times. The family member denied taken Resident #33 to another room alone due to resident not eating. Interview on 01/10/19 at 1:00 P.M., the DON indicated she attempts to deescalate some of the stimuli for Resident #33. The DON indicated she believed this helped the resident to calm down so she could focus on her meal. The DON reported she moved Resident #33 on 01/08/19 from the dining room because the resident was moving food around on her plate and throwing food. The DON reported Resident #33 was not moved to the activity room all the time just when she had too much stimulus which caused her not to eat. The DON stated there were extra people in the dining room and the change caused Resident #33 not to focus on her meal and isolating her made her focus on her meal. 2. Review of Resident #57's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated long and short-term memory problems, no behaviors, and extensive assist of one for bed mobility, transfers, and toileting with supervision only for ambulation, dressing, eating, and personal hygiene. 3. Review of Resident #2's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact and required extensive assist of one to two for activities of daily living. 4. Review of Resident #15's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #15 was cognitively impaired and required limited assist of one for activities of daily living. During an interview on 01/09/19 Resident #15 complained of having to wear an identification band on her wrist. A thick clear band was observed on her right wrist with a paper insert noting her name. Resident #15 reported she had complained to a nurse and was told the bands were needed. Residents #2 and #57 reported removing their own bands and staff replaced them twice. Observation on 01/09/19 at 8:45 A.M., revealed Resident #2 called Corporate Support Licensed Nursing Home Administrator (CS) #300 over to her table and asked for the band to be taken off. (CS) #300 explained to the resident that the facility preferred for the residents to wear them so the staff could identified the residents and give them the correct medications. As CS #300 started to walk away. Resident #2 stated loudly everyone knows her and she was capable of telling staff who she was. She stated she did not want to wear the band. CS #300 then stated they could put a bigger band on. Resident #2 repeated she could tell everyone who she was. CS #300 stated she would talk to the Director of Nursing (DON) and CS #300 left the room. Assistant Director of Nursing (ADON) #157 approached Resident #2 and stated she needed to check on the concern. CS #300 reentered the room with a pair of scissors and removed the name band from Resident #2's wrist. Resident #2 stated staff were mad at her because she wouldn't wear the band. She denied knowing she could have refused to wear the band at any time. Interview on 01/10/19 at 3:00 P.M. with SS #34 verified the admission agreement did not contain mention of the name band policy, Review of the facility policy titled Identification Bands, dated 07/2008, revealed an identification band was prepared at admission and applied to the non-dominate wrist, residents have the right to refuse to wear the bands.

Based on record review, observation, and interviews the facility failed to ensure residents were able to keep their personal items. notified of facility rules and their ability to make decisions. This affected five (#2, #9, #13, #15, #57) of seven residents who attended Resident Council meeting. The facility census was 118. Findings include: 1. Review of Resident #57's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] indicated long and short-term memory problems, no behaviors, and extensive assist of one for bed mobility, transfers, and toileting with supervision only for ambulation, dressing, eating, and personal hygiene. 2. Review of Resident #2's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact and required extensive assist of one to two for activities of daily living. 3. Review of Resident #15's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #15 was cognitively impaired and required limited assist of one for activities of daily living. 4. Review of Resident #9's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #9 had cognitive impairment and required limited to extensive assist of one for activities of daily living. 5. Review of Resident #13's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] revealed Resident #13 was cognitively intact and required extensive assist of one for activities of daily living. During an interview on 01/09/19 at 8:30 A.M., Resident #57 complained staff took her personal care items (deodorant, lotion, body spray) out of her room on 01/07/19 without her knowledge. She stated she complained to her nurse and her daughter. She stated her daughter took her shopping on 01/08/19 to replace the items. Residents #2 and #15 both stated the facility does whatever they want. Resident #15 reported someone took his Christmas wreath off his door and recently took a surge protector without his knowledge. Interview on 01/09/19 at 1:30 P.M. with Social Service (SS) staff #34 reported any personal care items over four ounces was put in a locked nightstand drawer in the resident's room if the resident was alert enough to manage a key. She reported if a locked drawer was not indicated the items were put in the locked nurses station. She stated she was unsure of the locked bathroom cabinet use and was unable to state when sweeps were done or how residents were informed of a sweep for oversized items. During Resident Council Meeting on 01/09/19 at 1:40 P.M., Resident #57 complained again of personal care items being taken. Resident #2 complained she did not have a key to the locked white bathroom cabinet containing her personal care items. Residents #9 and #13 also complained of not having a key to their locked bathroom cabinets. Interview on 01/10/19 at 2:10 P.M. with the Director of Nursing (DON) reported an aide had pulled the oversized items from resident room, that an actual sweep was not done. The DON reported the white bathroom cabinets were for personal care items since residents shared a bathroom and a resident must ask for a key to the cabinets. She was unable to state how the residents were informed of the ounce limit or how to obtain a key to the cabinets. Interview on 01/10/19 at 3:00 P.M. with SS #34 verified the admission agreement did not contain mention of the four-ounce fluid restriction, or the locked white cabinets. She reported Resident #15's wreath was taken down by facility staff for an unknown reason and was located in the facility decorations. She stated the wreath would be returned to the resident. Review of the facility policy titled Locked Individual Cabinets, dated 11/2012, revealed under procedure #2 - residents that were alert and oriented were offered and able to request a white cabinet key.