Every finding on record at Highland Pointe Health & Rehab Center

Based on closed record review, review of an Emergency Medical Service (EMS) report, review of the facility policy, review of National Institute of Health information, review of the Ohio Board of Nursing Standards of Practice and interview the facility failed to ensure Resident #91, who had advance directives for a Full Code status (life saving measures to be provided if necessary) was comprehensively assessed and provided timely monitoring after experiencing an acute change of condition to ensure prompt and necessary medical intervention was provided to the resident. Immediate Jeopardy with Actual Harm and subsequent death began on [DATE] at 10:05 A.M. when Resident #91 was noted to be pale, disoriented and confused; with changes to his eyes/vision and lung congestion. Resident #91 was assessed to be tachycardic with a pulse of 102 beats per minute. The facility lacked documented evidence to support Resident #91 was comprehensively re-assessed or monitored for additional changes/decline in condition until [DATE] at 3:30 P.M. at which time the resident was found unresponsive, cold to the touch, and without a pulse. EMS arrived on [DATE] at 3:47 P.M. and assessed Resident #91 to be cold to the touch, had obvious signs of rigor mortis and was pronounced deceased at the scene. This affected one resident (#91) of three residents reviewed for change in condition.On [DATE] at 4:01 P.M., Regional Director of Clinical Services (RDCS) #391, the Administrator, and Assistant Director of Nursing (ADON) #306 were notified Immediate Jeopardy began on [DATE] when the facility failed to comprehensively and adequately assess and monitor Resident #91, who was a Full Code, after he showed serious changes in condition on [DATE] at 10:05 A.M. Despite signs like pallor, confusion, vision changes, lung congestion, and a high pulse, there was no documented follow up assessment until 3:30 P.M., when the resident was found unresponsive with no pulse. EMS arrived shortly after and confirmed the resident had already developed rigor mortis and was deceased . The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions:- On [DATE] from 4:00 P.M. until 10:00 P.M. the Director of Nursing (DON) and designee assessed all in-house residents for a change in condition by completing a full set of vital signs to identify any abnormal vital signs. Any negative findings were addressed immediately. All findings would be brought to the facility Quality Assurance and Performance Improvement (QAPI) committee.- On [DATE] from 4:00 P.M. until 10:00 P.M. the DON and designee completed an audit of in-house residents by reviewing progress notes, orders and assessments for the last 48 hours, to ensure that all changes of condition were appropriately monitored by staff. Any negative findings were addressed immediately. All findings would be brought to QAPI. - On [DATE], the DON and designee reviewed residents who expired or were transferred to the hospital for the past 30 days to determine if those residents received necessary care and monitoring. All findings were brought to QAPI. - On [DATE] from 4:00 P.M. until 10:00 P.M. RDCS #391 reviewed the facility Change in Condition Policy. - On [DATE] from 4:00 P.M. until 10:00 P.M. the DON and Human Resources Manager (HRM) #330 completed education for all facility licensed nurses on Change in Condition Policy for recognizing, evaluating, and monitoring resident changes in condition.- On [DATE] RDCS #391 and HRM #330 completed education with all licensed nursing staff regarding appropriate documentation of monitoring of change of condition. Education consisted of monitoring a change in condition per policy and as needed to include vital signs. - On [DATE] the DON and designee completed education with Certified Nursing Assistant staff regarding timely reporting of any change of condition to the charge nurse. - On [DATE] from 5:30 P.M. through 6:00 P.M. a QAPI meeting was held regarding the facility Abatement Plan addressing the documentation of the continued monitoring of residents' change of condition. In attendance were the DON, the Administrator, RDCS #391, Assistant Director of Nursing #306, HRM #330, and Medical Director #395 (participated via telephone). - Beginning [DATE] the facility implemented a plan for the DON/designee to audit five residents, five days a week for three weeks, who were experiencing a change in condition to ensure they were monitored, evaluated and treated timely, by reviewing progress notes, vital signs, orders and assessments. All negative findings would be brought to QAPI. - On [DATE] the DON and designee completed a comprehensive head to toe assessment on all in-house residents. - On [DATE] the Administrator and designee conducted interviews with 59 alert and oriented in-house residents to identify if they had concerns with not properly being monitored or treated after a change of condition. - Beginning on [DATE] the DON and designee would complete three comprehensive head-to-toe assessments a week for three weeks to ensure compliance. All findings would be brought to QAPI - Beginning on [DATE] the Administrator and designee will conduct five interviews a week for three weeks with alert and oriented residents to identify if they had any concerns with the timely reporting of change in condition. All findings would be brought to QAPI - Beginning on [DATE]/26 the DON and designee would audit all hospital discharges and expired residents' charts for three weeks for proper monitoring and treatment of a change of condition. - Beginning on [DATE] the DON and designee would audit hospital discharges and expired residents' charts randomly for proper monitoring and treatment of a change of condition.Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing implement corrective action and ensure ongoing compliance. Findings include: Review of Resident #91's closed medical record revealed an admission date of [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, schizophrenia, bilateral conductive hearing loss, and legal blindness. Resident #91 expired at the facility on [DATE]. Review of Resident #91's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had moderate cognitive impairment. The assessment revealed Resident #91 required set-up (staff) assistance for eating and required substantial to maximal assistance for toileting hygiene, bathing, the ability to move from lying on his back to sitting on the side of the bed, and chair/bed-to chair transfers. Resident #91 was dependent for lower body dressing and was always incontinent of urine and bowel. Resident #91 did not reject care during the seven-day assessment look-back period.Review of Resident #91's care plan edited [DATE] revealed Resident #91 had the potential for alteration in vision impairment related to legal blindness. Resident #91 was able to utilize a whiteboard to make needs known due to hearing loss. Resident #91 would maintain current vision ability as evidenced by no injuries and feeling safe and secure in the environment through next review. Interventions included Resident #91 would utilize a communication board; use large print materials with Resident #91.Review of Resident #91's nursing progress notes dated [DATE] at 5:43 P.M. through [DATE] at 10:05 A.M. did not reveal evidence progress notes were written regarding Resident #91's health status during this time period.Review of Resident #91's Weekly Observation dated [DATE] revealed Resident #91 had no new skin issues and did not have shortness of breath or trouble breathing when sitting at rest. Resident #91 was occasionally incontinent of bowel and bladder. Physical and verbal behavior symptoms were not exhibited in the last seven days.Review of Resident #91's vital sign record including temperature, pulse, respirations, blood pressure, oxygen saturation, blood sugar, meal intakes and snacks, urine output, emesis and bowel movement revealed from [DATE] at 10:49 P.M. through [DATE] at 10:05 A.M. no vital sign monitoring was completed or documentation of oxygen saturation, meal intakes, urine output or bowel movements documented. On [DATE] at 8:08 A.M., 9:55 P.M. and [DATE] at 8:43 A.M. Resident #91's pain was documented it was zero on a scale of 0 to 10, 0 being no pain and 10 being the worst pain. Review of Resident #91's nursing progress note dated [DATE] at 10:05 A.M. revealed Resident #91 appeared very drowsy and his skin color was pale. Resident #91's vital signs included a blood pressure of 112/87, pulse 102 (tachycardic), temperature 97.7 Fahrenheit and oxygen saturation of 98 percent. There was no assessment of the resident's respiratory rate documented. The note revealed Licensed Practical Nurse (LPN) #371 asked Registered Nurse (RN) #359 to assess Resident #91. RN #359 stated Resident #91's lung sounds were not clear, and he needed a chest x-ray, and laboratory testing including a Complete Blood Count (CBC) with differential and a Basic Metabolic Panel (BMP). The note included Nurse Practitioner (NP) #386 was contacted and stated the directive RN #359 gave was exactly what should be done. The assessment of the resident did not include a comprehensive assessment of the resident's mental status or neurological status. In addition, the note did not address and/or provide intervention related to the resident's new onset drowsiness.Review of Resident #91's progress notes dated [DATE] at 10:05 A.M. through [DATE] at 4:19 P.M. revealed on additional written evidence Resident #91 was monitored or re-assessed after the resident's change in condition was identified. A chest x-ray (reported on [DATE] at 12:08 P.M.) revealed Resident #91 had new mild left lower lung airspace disease, possible atelectasis, though concerning for pneumonia in the clinical setting of infection.Review of a Prehospital Care Report Summary dated [DATE] revealed a call was received at 3:41 P.M. EMS was dispatched to the facility for Resident #91, who was unresponsive and not breathing with Cardiopulmonary Resuscitation (CPR) in progress. EMS was on the scene and had contact with Resident #91 at 3:47 P.M. The summary included Resident #91 was dead at the scene, and resuscitation was attempted without transport. The summary also included Resident #91 had obvious signs of rigor (According to National Institutes of Health (NIH) sources, rigor mortis generally begins to set in approximately two hours after death) and was cold to the touch. Resident #91 did not have a pulse and no pulse was evident. Resident #91 was placed on the monitor, and it showed asystole. With the obvious signs of death and asystole on the monitor the hospital was contacted, and EMS spoke with medical control for a time of death. Physician #390 gave a time of death at 3:53 P.M. EMS turned the scene over to the facility and returned to their quarters. Review of a police investigative report dated [DATE] at 3:42 P.M. revealed police were dispatched to the facility regarding an unresponsive resident (Resident #91). Upon arrival staff members were performing CPR on Resident #91. Resident #91 had no detectable pulse, his extremities were cold to touch, while his chest area remained warm. EMS initiated life-saving measures which were unsuccessful and they subsequently contacted medical control to obtain an official time of death. Resident #91 was pronounced deceased at 3:53 P.M. by hospital Physician #390. LPN #371 stated Resident #91 had been acting unusual throughout the day, describing him as off and noting a decreased appetite. Review of Resident #91's progress note dated [DATE] at 4:19 P.M. (after the resident had passed away) revealed a chest x-ray was completed at approximately 11:30 A.M. Resident #91 was cleaned up after the x-ray and placed in a semi-Fowlers position. The note included Resident #91 was monitored by staff. Resident #91's x-ray results were sent to NP #386 and new orders were received. Upon entering Resident #91's orders, Certified Nursing Assistant (CNA) #345 notified LPN #371 that Resident #91 had a change of condition. LPN #371 entered Resident #91's room and found him without a pulse. LPN #371 immediately started chest compressions, yelled out code blue, a code blue was initiated and EMS was contacted. Resident #91 was pronounced deceased after multiple rounds of CPR. Resident #91's family, provider and the Director of Nursing were contacted. The progress note did not include means of how the resident was being monitored during this time period, including any written evidence of the resident's vital signs or a comprehensive physical assessment being obtained/completed after 10:05 A.M. Interview on [DATE] at 7:55 A.M. with Registered Nurse (RN) #359 revealed on [DATE] LPN #371 was Resident #91's nurse and around 10:00 A.M. LPN #371 told her Resident #91 did not look well and she wanted a second opinion. RN #359 accompanied LPN #371 to Resident #91's room and assessed him. RN #359 revealed Resident #91 was hard of hearing, she called his name a few times, then tapped him. After RN #359 tapped him Resident #91 opened his eyes and she could hear junkiness in his lungs. RN #359 revealed LPN #371 took Resident #91's vital signs. RN #359 revealed she told LPN #371 to contact Nurse Practitioner (NP) #386 and have her order a chest x-ray and bloodwork. RN #359 revealed she was assigned to a different nursing unit and did not see Resident #91 again that day until she was called to his room when he coded and cardiopulmonary resuscitation was initiated. RN #359 revealed she was responsible for ventilating Resident #91 with the Ambu bag (during the code). RN #359 revealed LPN #371, LPN #385, and RN #326 were in Resident #91's room assisting with the code, and EMS arrived and care was transferred to them. RN #359 revealed Resident #91 was not taken to the ED but passed away at the facility.Interview on [DATE] at 8:06 A.M. with Certified Nursing Assistant (CNA) #345 revealed in the morning on [DATE] when she went in Resident #91's room to check on him she noticed he looked pale and his eyes were wandering to the outside. CNA #345 indicated she told LPN #371 something was wrong with Resident #91. CNA #345 revealed Resident #91 had a STAT chest x-ray and he had a cloud in his chest. CNA #345 stated Resident #91 was a check and change and she checked on him every two hours. Although not documented in the medical record, CNA #345 stated on [DATE] she checked Resident #91 at 9:00 A.M., 11:00 A.M., 1:00 P.M. and at around 3:25 P.M. when she checked him he was gone. CNA #345 revealed she had LPN #371 come to Resident #91's room and LPN #371 asked her to time when the compressions were started which was at 3:31 P.M. CNA #345 stated LPN #371 had been in and out of Resident #91's room. CNA #345 revealed every time she checked on Resident #91 during the day he did not look like he was feeling well and she was nervous that when she went into his room he would be gone. CNA #345 revealed Resident #91's normal skin tone was pink and that day he was white, he was coughing a lot and he mumbled. Resident #91 loved coffee and CNA #345 knew something was wrong because he did not drink his coffee. CNA #345 revealed she took care of Resident #91 before [DATE], knew him and on [DATE] he was different and his eyes did not focus on her. Resident #91 did not throw up or have a bowel movement.Review of a late entry progress note dated [DATE] at 9:06 A.M., authored by NP #386, for [DATE] at 10:00 A.M. revealed Resident #91 was seen for chronic condition management at the facility (telehealth visit) and Resident #91's lungs had wheezing and rhonchi, and he was disoriented and confused. A STAT chest x-ray was ordered, and labs were to be drawn in the morning ([DATE]). Diagnostic tests reviewed for today's visit included the most recent labs and imaging results, and Resident #91's outside chart from the facility was reviewed. Discussed with nursing and patient (Resident #91). Interview on [DATE] at 12:02 P.M. with LPN #385 revealed she assisted with Resident #91's chest compressions during CPR. LPN #385 revealed she was close to Resident #91's room when the code was called, he was in bed, the head of the bed was lowered, and a board was placed underneath him. Resident #91 was pale, he was not responding and his skin was cold to the touch. LPN #385 revealed she did not know if Resident #91 was stiff, but stated he was definitely cold. LPN #385 revealed Resident #91 was a quiet man, was hard of hearing and staff had to write on a board to communicate with him. LPN #385 revealed sometimes Resident #91 went to activities or would wander around in the hall, but he was in bed the day he passed and did not get up.Interview on [DATE] at 9:29 A.M. with Paramedics #387, #388 and #389 revealed they responded to Resident #91's 911 call on [DATE] at 3:41 P.M. and when they arrived at the facility the staff were performing CPR, Resident #91 was unresponsive, he was not breathing and they took over CPR. Resident #91 did not have a pulse, he was cold to the touch, had mottled skin on his limbs and rigor was setting in. Paramedic #387 indicated a phone call was made to med control to get a time of death and CPR was stopped when they got the time of death. Paramedics #387, #388 and #389 indicated they were told the last time Resident #91 was seen by staff was an hour before, it seemed like longer than an hour, but they could not say. Paramedic #387 revealed Resident #91 had obvious signs of death and met their criteria for dead on arrival (DOA). Interview on [DATE] at 9:33 A.M. with LPN #371 revealed on [DATE] at 10:00 A.M. she went in to medicate Resident #91 and he was not himself. Resident #91 always drank his coffee, and his coffee was still in the cup. Resident #91 did not look good, but stated she felt his blood pressure and vitals were good, although his heart rate was a little high. LPN #371 revealed she asked RN #359 to come with her to Resident #91's room and assess him. After LPN #371 and RN #359 entered the room LPN #371 indicated she asked Resident #91 if he was okay, and while they were standing there he coughed and they could hear the mucous in his chest. LPN #371 revealed RN #359 told her she thought Resident #91 needed a STAT CXR, a BMP and a CBC, and she contacted NP #386, reported Resident #91's vital signs and NP #386 ordered the chest x-ray, and BMP and CBC. LPN #371 revealed she told CNA #345 that Resident #91 needed to be monitored and LPN #371 stated she kept going back and forth to his room. LPN #371 revealed staff checked on him periodically between their other duties and walked by his room and looked in. LPN #371 revealed she was very busy with passing medications to the residents, providing treatments, talking to physicians' (etc), but stated she checked on Resident #91 when she could. LPN #371 revealed she wasn't sure, she thought she took another set of vital signs but might not have written the vital signs in Resident #91's progress note. LPN #371 stated she was in the room when Resident #91's chest x-ray was completed at 11:13 A.M. LPN #371 revealed she did not have access to the system to check Resident #91's x-ray results and she asked RN #359 to check the results. While RN #359 was obtaining Resident #91's x-ray results around 3:30 P.M. CNA #345 called her into Resident #91's room and when she ran in the room she found him without a pulse. A code was initiated and CPR was started. EMS arrived and called it because Resident #91 had died. Resident #91's chest was warm, his hand was cold, and Resident #91 liked his room to be cold. LPN #371 stated during the interview she had last seen Resident #91 10 to 15 minutes before he coded. However, there was no indication provided during the interview or in the resident's medical record as to the condition of the resident at this time.Interview on [DATE] at 10:13 A.M. with NP #386 revealed Resident #91 was a paranoid schizophrenic, she knew him well and he had a history of non-compliance with his medical history and medications mainly due to paranoia. NP #386 revealed on [DATE] the nurse on duty called and reported that Resident #91 did not seem right. Resident #91's lungs were junky, his vital signs were stable and she ordered bloodwork. NP #386 revealed she did not think he needed sent to the hospital and if something changed she would expect Resident #91's vital signs to be checked and to be called with an update. NP #386 revealed the nurse knew how he was and would have kept an eye on him. NP #386 revealed the visit was a telephone visit, she did not see Resident #91 on [DATE] and the physical exam in her note came from discussion with the nurse. NP #386 revealed rigor would occur hours after death, and it would not happen if a resident expired in the past hour or so. NP #386 revealed she was not told the last time the staff saw Resident #91 prior to him being found unresponsive. Interview on [DATE] at 10:53 A.M. with Regional Director of Clinical Services (RDCS) #391 and the Administrator revealed on [DATE] at 10:00 A.M. Resident #91 was not feeling well but they stated they believed he was stable. RDCS #391 revealed [DATE] was a Sunday and there wasn't a manager present in the facility.Interview on [DATE] at 3:07 P.M. with the Administrator and RDCS #391 revealed Resident #91 was a long-term resident, and the facility was not required to document on him. RDCS #391 verified a weekly skin check was completed on [DATE] and the facility only needed to chart when he had a change of condition. RDCS #391 revealed Resident #91 had a change of condition, he had congestion and was drowsy. LPN #371 had RN #359 assess Resident #91. RDCS #391 revealed RN #359 sent Resident #91's x-ray report to NP #386 at 3:21 P.M. and received an order for an antibiotic. RDCS #391 revealed the nurses know to check for an x-ray result in about four hours, and that was the average time to get a report. Interview on [DATE] at 8:48 A.M. with RN #359 revealed on [DATE] she was not Resident #91's nurse and she went in his room with LPN #371 because LPN #371 asked her to. RN #359 revealed she did not do vital signs or neuro checks when she was in Resident #91's room; LPN #371 obtained vital signs but she stated she did not see her complete neuro checks. During this interview, the RN indicated she was not the assigned nurse for Resident #91 on this date; therefore, she did not follow up to re-assess Resident #91 following the identification in his change in condition at 10:05 A.M. or to ensure the resident was being comprehensively monitored by other staff prior to him being found unresponsive at 3:30 P.M.Review of the facility policy titled Resident Change in Condition Policy revised [DATE] included the licensed nurse would recognize and intervene in the event of a change in resident condition. A significant change of condition was a decline in the resident's status that impacts more than one area of the resident's health status and/or one that required interdisciplinary review and/or revision to the care plan. The nurse would address any emergency care required given the situation and then gather information prior to contacting the physician/provider. The physician/provider would discuss with the nursing staff and the resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or elsewhere as needed. If, after discussion with the physician/provider, the care or observation could not reasonably be provided in the facility, the physician would authorize transfer to the hospital or alternative facility. In the event of an emergency, 911 would be called immediately.Review of the Ohio Board of Nursing standards for a change of condition (OAC 4723-4-07) included the Ohio Board of Nursing standards required nurses to immediately assess, document and report any significant change in a patient's condition. Key standards for a change of condition included to collect and document comprehensive data regarding the change. Analyze the data and promptly report the change to the healthcare team. Modify the nursing care plan and implement new interventions and reassess the patient to determine the effectiveness of the interventions. All assessments, communications, and interventions must be documented in the medical record. The nurse must maintain competence and provide care that is current with professional standards. Review of a National Institute of Health article titled Methods of Estimation of Time Since Death dated [DATE] included rigor mortis was the post-mortem stiffening of muscles caused by the depletion of adenosine triphosphate (ATP) from the muscles, which was necessary for the breakdown of actin-myosin filaments in the muscle fibers. Rigor mortis appeared approximately two hours after death in the muscles of the face, progressed to the limbs over the next few hours, completing between six to eight hours after death.This deficiency represents non-compliance investigated under Complaint Number 2988794.

Based on observation, record review, hospital record review and interview, the facility failed to ensure adequate monitoring and treatment of urinary complications related to an indwelling catheter. Actual harm occurred on 04/27/26 to Resident #35 after an indwelling catheter was removed due to reported pain and burning, the resident's urine output was not thoroughly monitored, and when the catheter was re inserted the resident continued to have significant pain with no output, resulting in hospitalization where an acute kidney injury and approximately 1000 milliliters (mL) of urinary retention was identified. This affected one resident (#35) of two residents reviewed for urinary catheters. The facility census was 89.Findings include:Review of Resident #35's medical record revealed an admission date of 03/28/26 with diagnoses including obstructive uropathy, stroke and diabetes.Review of care plan dated 03/31/26 revealed Resident #35 had an indwelling Foley catheter related to diagnoses of obstructive uropathy. Interventions included assess for signs and symptoms of discomfort with urination or related to the catheter, assess/record/report signs and symptoms of urinary tract infection that included pain, burning, blood-tinged urine, and no output, check for wetness and change per routine as needed, record output amount every shift and as needed.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had intact cognition. The assessment revealed Resident #35 was dependent with toileting, had a urinary catheter and was incontinent of bowel.Review of Resident #35's current physician orders for April 2026 included pain assessment every shift, change Foley catheter as needed and record output every shift.Review of the recorded vital sign records from 04/24/25 to 04/26/26 revealed Resident #35 had zero pain on a scale of 0-10. On 04/24/26 at 6:21 A.M. Resident #35 had medium urine output (no actual amount of urine recorded, despite having a urinary catheter for accurate measurement of urine), on 04/24/26 at 6:18 P.M. Resident #35 had 200 milliliters (mL) of urine, on 04/25/26 at 2:05 A.M. 100 mL of urine, and on 04/25/26 at 2:10 P.M. medium urine output.Review of a progress note dated 04/24/26 timed 5:38 P.M. authored by Licensed Practical Nurse (LPN) #385 revealed Resident #35 had returned from an appointment had had complaints of burning pain when urinating. Recommendations for a urinalysis and culture were noted and orders were received from Nurse Practitioner (NP) #386 for the urinalysis and (urine) culture.Review of Medication Administration Record (MAR) revealed Resident #35 received Tylenol 325 milligrams (mg) three tablets on 04/24/26 at 8:40 A.M. No other Tylenol administration was recorded.Review of a progress note dated 04/25/26 timed 5:07 P.M. authored by LPN #348 revealed Resident #35 was having burning and discomfort from his catheter site and NP #386 was notified. NP #386 gave orders to remove the catheter and leave it out for a few days and monitor urine output. However, record review revealed no urine output was recorded in the medical record after the catheter was removed.Review of MAR revealed Resident #35received Tylenol on 04/25/26 at 2:05 A.M. and 12:20 P.M.Review of post fall huddle form, not included in the medical record, dated 04/26/26 timed 8:00 P.M. revealed Resident #35 had a fall due to attempting to self-transfer to use the bathroom. Resident #35 was without signs of injury and the form noted the resident's brief was noted to have been wet. Review of a progress note dated 04/27/26 timed 9:43 A.M. authored by Registered Nurse (RN) #359 revealed NP #386 was called and gave to reinsert Resident #35's catheter and continue to monitor urine output.Observation on 04/27/26 at 11:40 A.M. revealed an ambulance had arrived outside the facility. Emergency Services (EMS) had proceeded to Resident #35's room. At time of observation RN #359 had informed Regional Director of Clinical Services (RDCS) #391 that Resident #35 was being sent to the hospital due to low urine output over the weekend. Review of a progress note dated 04/27/26 timed 12:02 P.M. authored by RN #359 revealed Resident #35's catheter was reinserted with no urine output noted. The note included the resident had been bleeding from insertion site. NP #386 was called and orders were received to send Resident #35 to the hospital for further observation. Review of a progress note dated 04/27/26 timed 4:17 P.M. authored by RN #359 revealed Resident #35 was admitted to the hospital for an acute kidney injury and was being treated with antibiotics. Review of hospital paperwork dated 04/27/26 revealed Resident #35 had a past medical history of a chronic indwelling Foley catheter and had presented to the emergency department for inability to place a urinary catheter due to the facility had met resistance while trying to place the catheter and Resident #35 had bleeding. Upon arrival to the emergency department a bladder scan had been used and Resident #35 was noted to have more than 1000 milliliters (mL) of urine in his bladder. Lab work was completed and Resident #35 was assessed to have an acute kidney injury. Resident #35 was admitted to the hospital and as of 04/30/26 the resident had not returned to the facility.Interview on 04/28/26 at 7:45 A.M. with LPN #385 revealed she had cared for Resident #35 on 04/24/26 and he had an appointment. LPN #385 stated upon return from his appointment in the afternoon (couldn't recall time) Resident #35 had complains of pain and burning while urinating; however, the LPN stated it was mild. LPN #385 stated she did not recall administering any pain medication to Resident #35 at that time. LPN #385 further stated she had been made aware Resident #35 had low urine output over the weekend and stated RN #359 had contacted NP #386 and orders were received to reinsert Resident #35's catheter. LPN #385 stated upon reinserting Resident #35's catheter he had bleeding (the resident was on a blood thinner). LPN #385 stated RN #359 then had contacted NP #386 and orders were received to send Resident #35 to the hospital for evaluation. A telephone interview on 04/30/26 at 11:50 A.M. with NP #386 revealed she had received a text message from the facility (unable to state who sent the message) on 04/25/25 at approximately 5:00 P.M. that stated Resident #35 was having pain and discharge around his catheter site. NP #386 stated the text message had included asking if Resident #35's catheter could be left out for a few days and NP #386 stated she had agreed. NP #386 stated she had not been made aware of any concerns related to Resident #35's catheter until 04/27/26 when she had been advised Resident #35 was having a lot of bleeding and she had advised he be sent to the hospital. NP #386 stated she had not been aware of any concerns related to low urine output. During the interview NP #386 provided the text message for review. Review of text message dated 04/24/26 timed 3:12 P.M. (author unknown) included Resident #35 was having some discomfort and burning and had brown liquid and blood when the catheter was removed and asked if catheter could remain out for a few day to which NP #386 had replied ok. A telephone interview on 04/30/26 at 3:28 P.M. with LPN #348 revealed she had cared for Resident #35 on 04/25/26 from 7:00 A.M. to approximately 11:00 P.M. LPN #348 stated at approximately 5:00 P.M. Resident #35's brother had approached her and stated Resident #35 was having pain and discomfort from his catheter and had asked if it could be changed. LPN #348 stated she had checked Resident #35's orders and there were standing orders to change his catheter as needed. LPN #348 stated she proceeded to remove Resident #35's catheter, Resident #35 was having pain and there was brown discharge. LPN #348 stated as she proceeded to replace Resident #35's catheter Resident #35 had screamed in pain, there was no urine output and Resident #35 had asked her to stop. LPN #348 stated she had contacted NP #386 and had informed her of Resident #35 screaming in pain and the discharge and NP #386 had stated it was ok to leave the catheter out for a few days and to monitor his output. LPN #348 stated she had recalled administering Resident #35 Tylenol; however, could not recall if she had signed the medication off in the medical records. LPN #348 stated she had not been made aware of any complaints of pain previously. LPN #348 further stated upon removing Resident #35's catheter there was approximately 500 mL of urine in his catheter bag and stated she had relayed the amount to the aide for her to document. LPN #348 stated Resident #35 had no further complaints. LPN #348 stated she had returned to the facility on [DATE] and denied knowledge of the resident having complaints of pain during her shift. LPN #348 stated Resident #35 had a fall on the evening of 04/26/26 and she had assisted getting Resident #35 off the floor and she had observed his brief had been wet. LPN #348 stated she had since been asked to provide a statement due to her lack of progress note(s) to reflect Resident #35 having urine output between 04/25/26 and 04/26/26. This deficiency represents non-compliance investigated under Complaint Number 2988794.

Based on interview, record review, and review of the facility policy the facility failed to ensure facility staff notified Resident #90's responsible party of a change of condition. This affected one resident (Residents #90) out of three reviewed for notification. The facility census was 89.Findings include:Review of Resident #90's medical record revealed an admission date of [DATE] and diagnoses included acute and chronic respiratory failure, congestive heart failure, type two diabetes mellitus without complications, and end stage renal disease.Review of Resident #90's care plan dated [DATE] included Resident #90 had self-care and mobility deficits related to decline in functional abilities related to impaired gas exchange, shortness of breath upon exertion, debilitation and overall functional decline. Resident #90's needs would be met with staff assistance as needed. Interventions included Resident #90 required setup help for eating as tolerated; Resident #90 used a mechanical lift and required the assistance of two staff.Review of Resident #90's Quarterly Minimum Data Set assessment dated [DATE] included Resident #90 had moderate cognitive impairment. Resident #90 required setup or clean-up assistance for eating and required substantial to maximal assistance for toileting hygiene, bathing and lower body dressing. Resident #90 was always incontinent of urine and bowel. Resident #90 did not have a swallowing disorder. Review of Resident #90's progress notes dated [DATE] at 7:39 P.M. included Certified Nursing Assistant (CNA) #381 alerted Licensed Practical Nurse (LPN) #344 that Resident #90 was unresponsive. Resident #90 was sitting upright, unresponsive, with emesis noted on his gown. Resident #90 did not have a pulse or respirations, a code blue was initiated immediately, Resident #90 was repositioned and CPR was initiated per facility protocol. Emergency response was activated and EMS was notified. Oxygen was applied at 10 liters per minute (high flow) and the AED was applied with no shock advised. CPR was continued until EMS arrived and Resident #90 was transported to the ED for evaluation and management. Certified Nurse Practitioner (CNP) #392, Physician and facility management were notified. Resident #90's family was notified by insurance CNP #392. Subsequently, notification was received that Resident #90 expired at the hospital.Interview on [DATE] at 11:06 A.M. with CNP #392 revealed she was not present in the facility when Resident #90 coded, but she worked for an insurance company, and it was the facility policy that the insurance company was always the first call when a resident had an issue. CNP #392 revealed Registered Nurse (RN) #326 called her and asked her if she was comfortable calling the family and she agreed to notify the family. CNP #392 indicated RN #326 told her Resident #90 was found unresponsive, a code was initiated, CPR was started and EMS was called. CNP #392 revealed she told RN #326 to call her with updates, and she called 20 minutes later and said EMS arrived, Resident #90 was shocked three times and transferred to the local hospital ED. CNP #392 revealed RN #326 contacted her at 6:04 P.M. and she spoke to her at 6:20 P.M. CNP #392 indicated she called Power of Attorney (POA) #393 who was also Resident #90's niece at 6:38 P.M., she did not answer, then she texted her at 6:40 P.M. and said she needed to speak with POA #393 urgently. POA #393 called CNP #392 at 7:05 P.M. and was notified of Resident #90's change of condition.Interview on [DATE] at 11:24 A.M. with RN #326 revealed on [DATE] she called CNP #392 to notify her of Resident #90's code and she did not contact Resident #90's family or POA #393 because CNP #392 said she would contact the family. RN #392 revealed she did not remember if she asked CNP #392 to call the family or CNP #392 told her she would call the family. RN #326 indicated the insurance company was very specific about patient care.Interview on [DATE] at 11:57 A.M. of Regional Director of Clinical Services (RDCS) #391 revealed CNP #392 contacted POA #393 and notified her of Resident #90's change of condition and told her everything. RDCS #391 revealed CNP #392 knew everything the nurses knew and it was totally acceptable that she notified the family.Interview on [DATE] at 12:48 P.M. of RDCS #391 revealed CNP #392 often communicated directly with families regarding resident care and if there was a change of condition CNP #392 was notified right away. RDCS #391 revealed she was aware POA #393 was not happy the facility staff did not call her. Review of the facility policy titled Resident Change in Condition Policy revised [DATE] revealed the licensed nurse would recognize and intervene in the event of a change in resident condition. The Physician/Provider and Family/Responsible Party would be notified as soon as the nurse identified the change in condition and the resident was stable. In the event of an emergency situation, 911 would be called immediately and the Physician or Provider/Family/Responsible Party would be notified as soon as practicably possible. This deficiency represents non-compliance investigated under Complaint Number 2988794.

Based on record review, interview, review of relevant personnel records, and facility policy review, the facility failed to ensure timely incontinence care was provided to residents. This affected two residents (#23 and #24) of three residents observed and reviewed for incontinence care. The facility census was 76. Findings include: 1.Review of Resident #23's medical records revealed an admission date of 03/19/25. Diagnoses included muscle weakness and need for personal care assistance. Review of care plan dated 03/28/25 revealed Resident #23 was incontinent of bowel and bladder. Interventions included Resident #23 was to receive assistance with toileting.Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had intact cognition. Resident #23 was dependent on staff for toileting and was incontinent of bowel and bladder.Interview on 01/07/26 at 12:11 P.M. with Resident #23 revealed she had been soiled for several hours on occasions and staff had not assisted her with incontinence care which had lead to sores on her bottom. Resident #23 stated the previous evening she had used her call light for incontinence care and the light had remained on from 1:00 A.M. to 3:45 A.M. with no staff coming in to assist her. Interview on 01/07/26 at 12:58 P.M. with Certified Nursing Assistant (CNA) #233 revealed she had assisted Resident #23 with incontinence care at approximately 8:00 A.M. and had observed Resident #23 saturated in urine and she had required an entire bed change. CNA #233 stated she had observed residents who had been soiled many times when she arrived to start her shifts at 7:00 A.M. and stated management had been aware. Interview on 01/14/26 at 8:55 A.M. with Resident #23 revealed she had not been changed since approximately 5:00 P.M. the previous evening (01/13/26) until approximately 7:00 A.M. Resident #23 stated she had placed her call light on around 12:00 A.M. but no staff had come and she had fallen back asleep. Resident #23 stated when she had woken up again her call light was off, however she was still incontinent. Resident #23 stated she had started to bang on the wall for assistance and stated an aide had come in and said she could not provide her with incontinence care because there were not enough linens. Resident #23 stated she had informed the nurse about the situation and stated she had been left incontinent until approximately 7:00 A.M. when the day shift aide had assisted her. Resident #23 further stated she had been made aware of multiple other residents who had not received incontinence care that morning. 2.Review of Resident #24's medical records revealed an admission date of 10/03/23. Diagnoses included stroke with left sided weakness, and muscle weakness.Review of MDS assessment dated [DATE] revealed Resident #24 had intact cognition. Resident #24 was dependent with toileting and was incontinent of bowel and bladder.Review of care plan updated 11/10/25 revealed Resident #24 was incontinent of bowel and bladder. Interventions included provide incontinence care after each incontinence episode. Interview on 01/07/26 at 10:55 A.M. with Resident #24 revealed she was the [NAME] President of resident council and had residents who had complained about not receiving timely toileting assistance. Resident #24 stated residents' complaints included having been soiled for long periods of time without staff assisting them with toileting or incontinence care. Interview on 01/14/26 at 9:06 A.M. with Licensed Practical Nurse (LPN) #266 revealed she had been made aware of residents who had not been changed during the evening and night shift (01/13/26 into 01/14/26), however she had not been made aware until approximately an hour prior.Interview on 01/14/26 at 9:17 A.M. with Resident #24 revealed she had not been changed throughout the evening.Interview on 01/14/26 at 9:24 A.M. with CNA #216 revealed she had arrived at approximately 7:00 A.M. and had been made aware by Resident #23 she had not been changed throughout the evening. CNA #216 stated she had provided Resident #23 with incontinence care and had to change her entire bedding. CNA #216 further stated she had also been made aware Resident #24 had also been left incontinent during the evening and also had to provide her with an entire bed change as both residents were heavily soiled.Interview on 01/14/26 at 10:25 A.M. with Regional Registered Nurse (RRN) #301 revealed she had been made aware of residents who had not been changed during the evening shift and stated the Administrator had called the CNA who had been assigned both residents the evening and night prior. At 10:51 A.M., the Administrator entered and stated CNA #203 was the CNA who had been responsible for Residents #23 and #24, and CNA #203 had been terminated via phone for the lack of care provided to residents the night prior. The Administrator further stated CNA #203 was the aid assigned to Resident #23 on 01/06/26 when she had previously stated she had not been assisted with incontinence care. Review of CNA #203's separation form dated 01/14/26 revealed CNA #203 was terminated because she failed to check and change residents on her assignment the evening of 01/13/26.Review of facility policy titled Activities of Daily Living revised 08/12/20 revealed appropriate staff will perform ADL care for residents including but not limited to personal hygiene and toileting.This deficiency represents non-compliance investigated under Complaint Numbers 2669629 and 2648607.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left unattended in residents' rooms. This affected one resident (#19) of four residents observed for unattended medications. The facility census was 76.Findings include: Review of Resident #19's medical record revealed an admission date of 05/25/25. Diagnoses included dementia, mild cognitive impairments and hallucinations.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had impaired cognition. During an observation made on 01/14/26 at 12:38 P.M. upon entering Resident #19's room, a cup of medications were observed on a dresser underneath Resident #19's television that contained three white pills. Further observation revealed a second medication cup on Resident #19's night stand located next to her bed that contained a total of eight medications. Interview with Resident #19 at the time of observation revealed she was unaware of when the medications had been delivered and stated staff would sometimes bring in her medications while she was sleeping and she would be unaware they are there. Interview on 01/14/26 at 12:42 P.M. with Licensed Practical Nurse (LPN) #234 revealed she had administered Resident #19's morning medications between 8:00 A.M. and 9:00 A.M. LPN #234 stated she had observed Resident #19 consume her medications. Observation at time of interview revealed LPN #234 confirmed the medication cup with three white pills located in Resident #19's room as well as the medication cup with the eight medications. LPN #234 stated she was unaware of what the three white pills were as she had not administered those and confirmed the medication cup with the eight pills were Resident #19's morning medications. LPN #234 stated she thought the resident took her morning medications this morning and proceeded to remove both medication cups and exited Resident #19's room. LPN #234 confirmed medications should not be left unattended in resident rooms. Review of facility policy titled General Dose Preparation and Medication Administration revised 01/01/13 revealed facility should not leave medications or chemicals unattended and observe the residents consumption of medications. This deficiency represents an incidental finding identified during the course of the complaint investigation.

Based on interview, record review, review of communication documentation, and facility policy review, the facility failed to ensure private information had not been shared with individuals that had not been authorized. This affected one resident (#78) of two reviewed for privacy. The facility census was 76.Findings include: Review of Resident #78's closed medical records revealed an admission date of 07/11/25 and a discharge date of 08/04/25. Diagnoses included post surgical care, difficulty walking and need for personal care assistance.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had intact cognition.Review of Resident #78's demographics sheet revealed Resident #78 was listed as his own person and his emergency contact listed was a sister. No other contacts had been listed on Resident #78's demographics sheet.Review of a progress note dated 07/11/25 timed 6:57 P.M. authored by Registered Nurse (RN) #302 revealed Resident #78's daughter had called to discuss Resident #78's pain medications and RN #302 had provided information related to Resident #78's pain level and the use of as needed pain medication. The progress note further stated Resident #78's daughter had expressed concerns related to frequent rounding and daughter had been updated and informed she was more than free to call and update the facility daily.Review of a progress note dated 07/15/25 timed 4:28 P.M. authored by Social Services (SS) #223 revealed a care conference meeting was held in Resident #78's room with the daughter present and medications, orders, therapy goals, and discharge plans were discussed. Review of progress note dated 07/21/25 timed 4:54 P.M. authored by the Administrator revealed Resident #78's daughter had called and left a message for a return call from the Director of Nursing (DON). Due to the daughter not being a power of attorney (POA), Resident #78 was asked if it was ok to call her back and Resident #78 stated he would update his daughter and stated he would prefer that the facility not call her at that time. Review of communication documentation in the form of text messages dated 07/17/25 and 08/01/25 revealed communication between SS #223 and a family member of Resident #78. The text messages discussed Resident #78's care including the therapy appeal process, an upcoming appointment, his discharge plan, and home health care. Interview on 01/14/26 at 9:55 A.M. with SS #223 revealed a care conference was held in July 2025 with Resident #78 and his daughter. SS #223 stated at the time of the care conference Resident #78 had allowed his daughter to receive information, however after the care conference Resident #78 had asked that his daughter not receive any more information. SS #223 stated Resident #78 had given him permission to share the information with his family member. SS #223 confirmed there had been no documentation regarding Resident #78's permission to share information. Review of facility policy titled HIPPA 1 Privacy Policy-Overview and Definitions revised 01/08/26 revealed facility will treat Protected Health Information (PHI) in accordance with the policy and may not disclose PHI except as specifically permitted. This deficiency represents noncompliance investigated under Complaint Number 2648607.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure routine bathing care was provided to residents. This affected two residents (#23 and #31) of three residents reviewed for activities of daily living. The facility census was 76. Findings include:1. Review of Resident #23's medical records revealed an admission date of 03/19/25. Diagnoses included muscle weakness and need for personal care assistance. Review of the care plan dated 03/19/25 revealed Resident #23 had self care deficits. Interventions included assist with activities of daily living (ADL) care that included grooming, and dressingReview of the MDS assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 was dependent for bathing, personal hygiene and toileting. Review of physician orders for January 2026 revealed Resident #23 was ordered a shower on Tuesdays and Fridays on day shift.Review of Resident #23's plan of care documentation for November 2025, December 2025, and January 2026 to date revealed the resident had only one documented shower on 01/13/26.Interview on 01/12/26 at 11:56 A.M. with Resident #23 revealed she had not received a shower in several months and had only had two showers since she was admitted . Resident #23 stated the staff had wiped her down in bed, however when she had asked for a shower the staff had often given her an excuse as to why they couldn't give her a shower. At time of interview, Certified Nursing Assistant (CNA) #233 had entered and stated she was unaware Resident #23's showers were scheduled for Tuesdays and Thursdays and stated she had been aware Resident #23 had complained about not receiving her showers. 2. Review of Resident #31's medical records revealed an admission date of 08/25/24. Diagnoses included muscle weakness and need for personal care assistance. Review of the MDS assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 required moderate assistance with bathing, personal hygiene and bed mobility and was dependent with transfers. Review of the care plan updated 11/30/25 revealed Resident #31 required assistance with ADL care. Interventions included allow extra time to complete ADL's.Review of physician orders for January 2026 revealed Resident #31 was ordered showers on Tuesdays and Fridays. Review of Resident #31's plan of care documentation for December 2025 and January 2026 to date revealed the resident had only one documented shower on 01/11/26.Interview on 01/07/26 at 2:54 P.M. with Resident #31 revealed she had not been assisted out of bed or received a shower in about a month. Resident #31 stated since she had changed rooms the staff had told her she wasn't on a list and they had not gotten her out of bed. Observation of Resident #31 at time of interview revealed hair appeared to be matted and greasy and resident had a slight odor.Interview on 01/14/26 at 1:04 P.M. with Regional Registered Nurse (RRN) #301 reviewing Resident #23 and #31's shower documentation revealed Resident #23 had no documented shower for November 2025 or December 2025 and one shower documented on 01/13/26. RRN #301 confirmed Resident #31's shower documentation revealed the resident had no showers documented in December 2025 and only one shower documented on 01/11/26.Review of facility policy titled Activities of Daily Living revised 08/12/20 revealed appropriate staff will perform ADL care for residents including but not limited to personal hygiene and transferring.This deficiency represents noncompliance investigated under Complaint Number 2669629.

Based on record review, interview, review of self reported incident (SRI) and corresponding investigation, and facility policy review, the facility failed to ensure pain was comprehensively assessed and pain medications was administered timely after resident complaint of severe pain. This affected one resident (#18) of three residents reviewed for pain management. The facility census was 76. Findings include:Review of Resident #18 ' s medical records revealed an admission date of 04/25/24. Diagnoses included muscle weakness, need for personal care assistance and left femur fracture (diagnoses updated 11/16/25).Review of physician orders for November 2025 revealed Resident #18 was ordered Tylenol (an over the counter mild pain reliever) 650 milligrams (mg) every six hours as needed for pain and Methocarbamol (anti-spasmodic) 500 mg twice a day as needed.Review of care plan dated 10/10/24 and updated 11/28/25 revealed Resident #18 was at risk for pain related to osteoarthritis. Interventions included administer medications as ordered and evaluate and record effectiveness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. Resident #18 was dependent with toileting, bathing and personal hygiene and required maximum assistance with bed mobility. Review of a progress note dated 11/15/25 timed 7:28 P.M. authored by Licensed Practical Nurse (LPN) #297 revealed an aide had alerted her that Resident #18 ' s left leg did not look normal at 6:30 P.M. and Resident #18 was screaming in pain when being repositioned to be changed. LPN #297 had assessed Resident #18 ' s leg and noted it to be rotated in and left hip had yellow-tinged skin. LPN #297 had asked Resident #18 where the pain was and Resident #18 stated it was coming from her left groin area. Physician had been notified and an x-ray had been ordered. Continued review of Resident #18's record revealed no evidence a comprehensive pain assessment, including a pain rating and description of the quality of the pain, had been completed on 11/15/25. Review of a progress note dated 11/16/25 timed 7:17 A.M. authored by LPN #204 revealed x-ray results had suggested Resident #18 had a left hip fracture.Review of a progress note dated 11/16/25 timed 7:50 P.M. authored by LPN #297 revealed Resident #18 was ordered to be sent to the hospital for treatment. Review of the Medication Administration Record (MAR) for November 2025 revealed Tylenol only been administered on 11/05/25 and only one dose of Methocarbamol had been administered on 11/15/25 at 9:00 P.M. for pain. Review of a self reported incident form dated 11/16/25 revealed Resident #18 had complained of left hip pain and pain medications had been offered and given as ordered.Interview on 01/08/26 at 7:44 A.M. with Resident #18 revealed she had been sent to the hospital a few months ago for a broken leg as a result of having been placed back in bed too hard after a transfer. Resident #18 stated the pain in her leg had gotten worse a few weeks later and that is when she went to the hospital. Resident #18 stated she had pain but could not recall when she had received pain medication. Interview on 01/12/26 at 1:31 P.M. with Certified Nursing Assistant (CNA) #233 revealed CNA (#284) had asked her to come into Resident #18's room on 11/15/25 to observe Resident #18's leg. CNA #233 stated she had observed Resident #18's leg to have been turned outward, her hip was protruding out and Resident #18 was yelling out in pain. CNA #233 stated CNA #284 had immediately informed the nurse and the nurse had assessed the resident. Interview on 01/12/26 at 2:37 P.M. with CNA #284 revealed on 11/15/25 she had entered Resident #18's room to assist her with incontinence care and repositioning and she had observed Resident #18's left leg was turned outward and was yelling in pain when she had attempted to move her. CNA #284 stated she had asked CNA #233 to look and also assist with moving Resident #18 and she had also informed the nurse immediately. CNA #284 stated the nurse had come in and assessed Resident #18.Telephone interview on 01/12/26 at 3:06 P.M. with LPN #297 revealed at approximately 6:30 P.M. on 11/15/25 an aide had alerted her Resident #18's leg did not look right. LPN #297 stated she had immediately went and assessed Resident #18 and had observed Resident #18's leg was rotated inward and had a large yellow bruise on her left hip. LPN #297 stated Resident #18 had been yelling out in pain when being moved. LPN #297 stated she could not recall if she had medicated Resident #18 at that time. Review of SRI on 01/12/25 at 3:24 P.M. with Regional Registered Nurse (RRN) #301 confirmed investigation had included pain medication had been administered, however Resident #18's MAR had indicated Methocarbamol had not been administered until 9:00 P.M. and Resident #18 had been yelling out in pain at approximately 6:30 P.M. Resident #18 was not recorded to have received any doses of Tylenol, for which she had an as-needed order, between when the pain was identified and when the resident was transferred to the hospital for evaluation. Review of facility policy titled Pain Management Protocol revised 10/24/22 revealed when determined the residents pain will need pharmacological intervention, documentation of medications will be located in the electronic medication record. This deficiency represents non-compliance investigated under Complaint Numbers 2669629 and 2648607.

Based on observations, interviews and policy review, the facility failed to maintain a sanitary area surrounding the garbage dumpsters. This had the potential for affect all residents residing in the facility. The facility census was 77. Findings include:Observations on 09/15/25 at 5:40 A.M. of the dumpster area noted several large bags of garbage filled with soiled briefs, latex gloves, wipes, plasticware, and food were located on the ground surrounding the three dumpsters. The doors and lids of the dumpsters were left open allowing racoons to enter and pull out the garbage. Interview on 09/15/25 at 5:39 A.M., [NAME] #208 verified the opened garbage bags on the ground. Interview on 09/15/25 at 9:40 A.M., Licensed Practical Nurse (LPN) #200 verified the findings and stated the racoons come from the woods and tear open the bags all the time. Review of facility policies noted no policy provided created/implemented by the facility related to maintaining a sanitary dumpster area. This deficiency was an incidental finding identified during the complaint investigation.

Based on observations, interviews, and policy review, the facility failed to maintain a sanitary homelike environment for residents. This had the potential to affect all residents residing in the facility. The facility census was 77. Findings include: Observations on 09/15/25 from 5:00 A.M. to 5:40 A.M. noted miscellaneous items and debris on the floor in the halls throughout the facility. The debris included silverware and plastic utensils, latex gloves, paper straws, and linen on the floor. There were dinner trays full of food located on carts in resident halls and in the dining room. A medication cart located on the 300-hall had miscellaneous debris (powder like) substance along the entire bottom of the medication cart. Interview on 09/15/25 at 5:05 A.M., Licensed Practical Nurse (LPN) #201 verified the debris and items on the floor and went back to work. Interview on 09/15/25 at 5:10 A.M., LPN #203 verified the findings stating staff just cleaned out the drawers of the medication cart a few days ago. Review of facility policies noted no policy provided created/implemented by the facility related to staff maintaining communal areas daily. This deficiency represents non-compliance investigated under Complaint Number 1396690 (OH00165974).

Based on closed medical record review, hospital record review, review of a police and Emergency Medical Service (EMS) report, social media review, review of the Food and Drug Administration online medication information, policy review and interviews, the facility failed to timely respond and take appropriate action (e.g., suspending administration of an anticoagulant) in regard to an elevated International Normalized Ratio (INR) for Resident #11, who was receiving Warfarin (Coumadin) for atrial fibrillation. This resulted in Immediate Jeopardy and the potential for serious harm on 05/20/24 when the resident's INR, per laboratory testing, was abnormally high at 4.9 and staff failed to notify the physician or stop the administration of the medication, Coumadin. Staff continued to administer Coumadin 7.5 milligrams on 05/20/24 and 05/21/24 despite the high laboratory value, indicating the resident's blood was too thin and requiring a greater length of time to form a blood clot. On 05/22/24, Resident #11 reported he was having nose and gum bleeding. The resident subsequently called 911 for transport to the hospital for medical care. Upon Emergency Medical Service (EMS) arrival, EMS staff noted a large amount of bloody paper towels on the resident's bedside table. Upon arrival at the hospital (on 05/22/24 at 9:25 P.M.) the resident's chief complaint included nose and gum bleeding. Hospital emergency laboratory testing revealed the resident's PT was elevated at 63.4 seconds (reference range 9.7-13.0) and the INR was abnormally high at 7.2 (therapeutic range 2-3 with an anticoagulant planned INR of 2.5). The resident required treatment with Vitamin K (used to counteract the anticoagulant medication) intravenously and was hospitalized until 06/03/24 for ongoing care and treatment. This affected one resident (Resident #11) of five residents reviewed for Coumadin use. On 06/12/24 at 10:25 A.M. the Administrator, Director of Nursing (DON) and Regional Registered Nurse (RRN) #979 were notified Immediate Jeopardy began on 05/20/24 when the facility failed to monitor physician ordered laboratory results (INR) to ensure Resident #11's Coumadin was effective (by not allowing the resident's blood to clot too quickly or too slowly) and failed to notify the physician of an abnormally elevated INR result (4.9) to suspend the administration of Resident #11's Coumadin. Nursing staff continued to administer the Coumadin despite the elevated INR results placing the resident at significant risk for bleeding/continued blood loss. Resident #11 contacted EMS for emergent transport to the hospital for evaluation, received intravenous Vitamin K to counteract the effects of Coumadin and was subsequently admitted to the hospital for ongoing care and treatment. The Immediate Jeopardy was removed on 05/23/24 when the facility implemented the following corrective actions: Resident #11 was discharged to the hospital on 5/22/24 at 9:00 P.M. On 05/23/24 at 11:00 A.M. the Director of Nursing (DON), Assistant Director of Nursing (ADON) #918 and Registered Nurse (RN) Unit Manager (UM) #922 reviewed Resident #11's medical record, medication administration record (MAR), progress notes and laboratory results (labs) to identify the root cause related to the bleeding incident on 05/22/24. The facility identified the root cause as nursing staff including Licensed Practical Nurse (LPN) #883 and LPN #963 failed to check Resident #11's PT/INR level prior to administering Coumadin 7.5 mg to Resident #11 on 05/20/24 and 05/22/24 and failed to notify medical doctor (MD)/Certified Nurse Practitioner (CNP) #980 of Resident #11's abnormal INR level in a timely manner. On 05/23/24 at 11:30 A.M. the DON, ADON #918, RN UM #922 and Regional RN (RRN) #979 completed an in house audit and confirmed four residents resided in the facility who receive Coumadin including Residents #38, #44 #76 and #82. Resident records for Residents #38, #44, #76 and #82 were reviewed which included the lab reports, medication administration records (MARs), progress notes and care plans to ensure that abnormal labs were reported to Nurse Practitioner (NP) #980 in a timely manner and that Coumadin was not administered to residents with a PT/INR greater than 3.0, without negative findings. T On 05/23/24 at 12:00 P.M. the DON, RN ADON #918, RN UM #922 and Regional RN #979 completed assessments/skin checks on Residents #38, #44, #76 and #82 (receiving Coumadin) to ensure the residents did not have signs of bleeding or bruising. On 05/23/24 at 1:00 P.M. RRN #979 completed competencies, in person with return demonstration, with the DON, ADON #918 and RN UM #922 to review PT/INR blood work prior to administering Coumadin and education was provided on reporting of abnormal labs to CNP #980 of the specific resident by the end of the shift. On 05/23/24 at 2:00 P.M., LPN #883 and LPN #963 (two nurses who were out of compliance related to the Immediate Jeopardy) were educated (in person) by the DON, with return demonstration, on checking residents PT/INR blood work prior to administering Coumadin and on reporting of abnormal labs to CNP #980 of the specific Resident by end of shift. On 05/23/24 beginning at 2:00 P.M. through 4:35 P.M., RRN #979 completed an audit of the lab work for Residents #38, #44, #76 and #82. NP #980 was notified of all lab results. The audit revealed Resident #76's PT/INR lab work dated 05/23/24 had an INR of 3.6 and the NP was notified on 05/23/24 and ordered to hold the Coumadin dose and repeat the INR on 05/24/24. On 05/23/24 at 2:15 P.M., the DON, ADON #918 and RN UM #922 completed competencies with LPN #883 and LPN #963, in person with return demonstration, on checking residents PT/INR prior to giving Coumadin and to ensure that the lab results are reported to CNP #980 of the specific Resident by end of shift. On 05/23/24 at 3:30 P.M. the facility held an emergency Quality Assurance Performance Improvement (QAPI) meeting. The QAPI meeting was held to review the root cause, reviewed the facility abatement plan due to the nurses administering Coumadin prior to checking Resident #11's PT/INR labs and not notifying NP #980 responsible for Resident #11's care, by the end of the shift. Medical Director #669, the Administrator, the DON, ADON #918, Environmental Services Director (ESD) #805, Pharmacist #1012 (participated over the phone), RRN #979, Social Services Designee (SSD) #931, Activity Director (AD) #930 and Rehab Director #1024 participated in the QAPI meeting. On 05/23/24 at 6:00 P.M. the DON developed and implemented a PT/INR Coumadin flow sheet. ADON #918 and RN UM #922 were educated on the form, how to implement the form, when to use the form and what to do for abnormalities identified on the form. Both nurses would print Coumadin lab reports five days a week at Clinical Morning Meetings to review any changes in orders due to any abnormal lab results & to ensure the CNP of the specific resident was notified of the results by the end of the reporting shift. On 05/23/24 at 6:30 P.M. the Coumadin flow sheet was implemented by ADON #918 and RN UM #922. The form would be completed each time a blood draw was ordered with results received for each resident on Coumadin. The abnormal results would be reported to CNP #980 of the specific resident by end of the reporting shift. On 05/23/24 at 11:45 P.M. the DON, ADON #918 and RN UM #922 completed education in person and via phone to all 17 staff LPNs and all six staff RNs on checking residents' PT/INR results prior to giving Coumadin and to ensure that the lab results were reported to NP #980 of the specific resident by the end of the reporting shift. In addition, all 37 staff State tested Nursing Assistants (STNA) were educated on observing for abnormal effects of Coumadin including bleeding, bruising and black tarry stools and reporting abnormalities to the nurse. The facility also used agency staffing including four agency RN's (to be educated from 05/23/24 to 06/04/24), eight agency LPN's (to be educated from 05/27/24 to 06/11/24) and five agency STNA's (to be educated from 05/24/24 to 06/09/24) who work as needed in the facility. RRN #979 confirmed the agency staff members were educated over the phone and would not work in the facility from 05/23/24 to 06/14/24, unless they had received the education prior to their next scheduled shift. The facility indicated all new hires would receive the education during orientation. On 05/23/24 at 11:45 P.M. the DON, ADON #918 and RN UM #922 completed competencies to ensure 17 LPNs and six RNs were checking residents PT/INR prior to giving Coumadin and to ensure that the lab results are reported to NP #980 in a timely manner. To ensure ongoing compliance, the DON/ADON/UM/Designee would audit PT/INR lab results and timely notification of the residents' NP four times a week for three weeks. The audits would be completed beginning on 06/06/24 and the facility would then continue a monthly audit for the next two months, during clinical morning meetings, for verification the PT/INR results were reviewed and reported to the residents' NP as needed. The results of the audits would be forwarded to the facility QAPI committee for additional review and recommendations. Although the Immediate Jeopardy was removed on 05/23/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #11's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pain in the left leg, end stage renal disease with dependence on renal dialysis and paroxysmal atrial fibrillation (intermittent irregular heartbeat in the upper chambers of the heart). The resident was transferred to the hospital on 05/22/24 and did not return to the facility. Review of Resident #11's baseline care plan dated 05/15/24 revealed the resident would be monitored for abnormal bleeding due to anticoagulation treatment. The care plan revealed the resident would receive anticoagulant therapy as ordered; would be observed for any signs and symptoms of abnormal bleeding including bruising, tarry stools, nose bleeds, bleeding gums and/or hemorrhage; would receive education on the risks and benefits of anticoagulant therapy if needed; be monitored as ordered for lab tests to monitor coagulation factors and have any abnormal findings reported to the provider including the physician, nurse practitioner or physician assistant. Review of Resident #11's physician orders revealed an order dated 05/16/24 for Warfarin (Coumadin) 7.5 mg one tablet to be administered orally once daily (scheduled to be administered between 7:00 P.M. to 11:00 P.M.); and an order dated 05/18/24 to obtain a Prothrombin Time (PT) and International Normalized Ratio (INR) (The INR is a standardized number that measures how long it takes blood to clot. It's calculated using the results of the PT test, which measures how quickly the liquid portion of a person's blood clots. The INR is used to monitor people who take blood thinners, also known as anticoagulants, like Coumadin, to help ensure the medication is working properly. The higher the INR, the longer it takes the person's blood to clot) two times per week on Monday and Thursday. Further review of the medical record revealed no specific parameters for changes to the resident's Coumadin dosage or parameters for contacting/notifying the physician related to the INR results. Record review (also dated 05/16/24) revealed nursing staff were to initial for anticoagulant monitoring every shift (ensuring the PT/INR results were reviewed/available and the daily dose of Coumadin was available in the medication cart for the evening/night administration). This was documented on the medication administration record for the respective dates and shifts during the resident's stay. Review of Resident #11's laboratory testing revealed the resident's bloodwork was collected on (Thursday) 05/16/24 at 7:10 A.M. and reported on 05/16/24 at 3:57 P.M. The results of the PT and INR dated Thursday, 05/16/24 revealed the PT was 19.3 seconds and the resident's INR was 1.9. There was no evidence of any changes to the Coumadin order at this time. Review of Resident #11's laboratory testing revealed a PT/INR was drawn on (Monday) 05/20/24 at 2:50 P.M. and reported on 05/20/24 at 5:47 P.M. The resident's PT was 47.1 seconds (elevated), and the resident's INR was 4.9 (elevated). This laboratory form indicated the standard anticoagulant was 2.0 to 3.0 range for the INR and aggressive anticoagulant treatment was 2.5 to 3.5 INR range. Record review revealed no evidence the physician, nurse practitioner or physician assistant were notified of this abnormally high laboratory test result on 05/20/24. Review of Resident #11's medication administration records (MAR) and treatment administration records (TAR) from 05/20/24 to 05/22/24 revealed on 05/20/24 during the dayshift, Licensed Practical Nurse (LPN) #935 documented on the MAR, the INR was not applicable (NA); on 05/20/24 during the nightshift, LPN #883 documented on the MAR that the INR was 1.9 (however, these were the INR results obtained in 05/16/24). On 05/21/24 during the dayshift, LPN #935 documented the INR on the MAR as NA; On 05/21/24 during the nightshift, LPN #963 documented the INR on the MAR as 4.9; and on 05/22/24 during the dayshift, RN #812 documented the INR on the MAR as 4.9. Review of Resident #11's MAR from 05/15/24 to 05/22/24 revealed the resident was not administered the ordered Coumadin 7.5 mg on 05/15/24 (date of admission). The comment indicated it was a new order. The MAR revealed the resident was administered Coumadin 7.5 mg on 05/16/24, 05/17/24, 05/18/24, 05/19/24, 05/20/24 and 05/21/24. The medication was scheduled to be administered daily from 7:00 P.M. to 11:00 P.M. The record noted the Coumadin was held on 05/22/24 because the resident was in the hospital. Review of Resident #11's medical record revealed no evidence the physician, nurse practitioner or physician assistant were notified of the PT/INR result of 4.9 on 05/20/24 or 05/21/24. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and the resident was on an anticoagulant. Review of Resident #11's progress note dated 05/22/24 at 7:32 P.M., authored by Registered Nurse (RN) #812, revealed the resident notified RN #812 that he blew his nose and blood clots were coming out of his nose and a small amount in his mouth. Vital signs were stable, and the nurse practitioner was notified of the resident's INR level with a new order to hold Coumadin dose until further notice. The resident was made aware. There was no indication an order was obtained to check the resident's PT/INR at that time. Review of an Incident/Offense Report form dated 05/22/24 at 8:48 P.M., authored by Police #506 and Police #507, revealed Resident #11 had called 911 due to bleeding from his mouth and nose. The resident stated he had been bleeding from his nose and gums all day. The resident reported he was on a blood thinner and was taken by stretcher to the hospital. Review of Resident #11's progress note dated 05/22/24 at 9:00 P.M., authored by LPN #963, revealed LPN #963 was exiting another resident's room when EMS staff were observed going into Resident #11's room with a stretcher. The note indicated the resident called them (EMS) himself without letting the nurse know. A face sheet and medication list were sent with the resident to the hospital. Review of Resident #11's social media (Facebook) posts/documentation dated 05/22/24 between 7:00 P.M. and 8:00 P.M. revealed the resident had posted information to the social media site related to his status and health care. This information included when the resident's blood was drawn a few days ago in dialysis, the resident personally delivered the tube of blood to the nurse for the lab to pick up (at the facility). The resident had a hard time clotting at the end of the (dialysis) treatment. Later in the evening, the resident asked LPN #983 if she had the results of the blood work because the resident was reluctant to take the 7.5 mg of Coumadin because he felt his blood was thin. The social media post revealed LPN #983 argued with the resident and said the INR was 1.8. The resident said that it was the bloodwork from 05/16/24 and LPN #983 stated it was the current bloodwork. An unidentified person responded on the resident's social media on 05/22/24 between 7:00 P.M. to 8:00 P.M. to call 911 and to tell them his bleeding would not stop, and his INR was 4.9. (The content of the social media/Facebook post was verified through telephone interview with Resident #11 on 06/13/24 at 3:05 P.M.) Review of a police report dated 05/22/24 (incident number 24-01975) revealed upon arrival, the police department observed a large amount of bloody paper towels on Resident #11's bedside table. The resident explained that since his arrival on 05/15/24, he had not received proper care and had documented the improper care on social media to keep track of the lack of care and keep a record to advocate for himself and others in the facility that may not be able to (advocate for themselves). Review of hospital documentation revealed the resident presented to the emergency room (on 05/22/24) with a chief complaint of spontaneous bleeding. The resident had called the squad himself for concerns of spontaneous bleeding. The resident reported he had been having nosebleeds and bleeding from the mouth for the past few days and was concerned about his INR being high. The resident had an admission diagnosis of coagulopathy (bleeding disorder; a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis) which may occur spontaneously or following an injury or medical and dental procedures. The resident received Vitamin K intravenously to counteract the effects of the Coumadin and assist in stabilizing his INR levels and was admitted to the hospital from 05/22/24 through 06/03/24 for continued medical care and monitoring. The resident did not return to the facility upon discharge from the hospital. On 05/29/24 at 6:36 A.M. interview with Licensed Practical Nurse (LPN) #963 revealed she was the nurse working and assigned to care for Resident #11 on 05/21/24 during the nightshift from 7:00 P.M. to 7:00 A.M. LPN #963 revealed she did not notice the PT/INR for Resident #11 was out of range until after she had administered Coumadin 7.5 mg on 05/21/24. The LPN verified she did not report the elevated lab to the NP or the fact she had administered the resident's Coumadin without checking the INR first during her nightshift 05/21/24. LPN #963 stated on 05/22/24 at 7:00 P.M., when she came on shift to work, she was notified in the nursing shift to shift report by RN #812 that the NP was made aware of Resident #11's nose and mouth bleeding and the NP then gave an order to hold the Coumadin. LPN #963 stated the resident called for an ambulance to go to the hospital (on 05/22/24) while she was in another room. She stated she was unaware of any concerns until she had observed the squad with a stretcher going into Resident #11's room. LPN #963 stated she printed a face sheet and orders to send with the resident to the hospital and let the NP know the resident requested to be transported to the hospital. LPN #963 stated she was busy on her shift and did not think to call the physician after administering the Coumadin on 05/21/24 when she found out the PT/INR was elevated. Interview on 05/29/24 at 10:02 A.M. with Registered Nurse (RN) #812 revealed she worked dayshift from 7:00 A.M. to 7:00 P.M. on 05/22/24. RN #812 stated she talked to Resident #11 close to shift change around 7:00 P.M. to 7:30 P.M. about his Coumadin dosage and the NP orders to hold the Coumadin on 05/22/24. RN #812 stated the resident did not have concerns when she left the room, and the resident did not request to be sent to the hospital during her shift. She also stated she was not aware of the resident's nosebleed until she went in the room around 6:30 P.M. to answer the resident's call light and had observed the resident's bloody nose and several bloody tissues on his overbed table along with a bloody tissue in his hands RN #812 stated she immediately called the NP at that time and received new orders to hold the Coumadin. The RN denied knowledge of the resident's INR level until he (the resident) reported the bloody nose, and she reviewed the INR value. RN #812 denied an increase in monitoring Resident #11's condition because she stated she was not aware of the resident receiving the Coumadin with a high PT/INR. Telephone interview on 06/04/24 at 6:42 P.M. with Nurse Practitioner (NP) #980 revealed she was not aware of Resident #11's high PT/INR until the resident had the nosebleed and she ordered to hold the resident's Coumadin. The staff notified her the resident had gone out to the hospital (on 05/22/24). She indicated staff did not call her about the resident's abnormally high PT/INR result and they should have notified her (on 05/20/24) so the Coumadin could have been adjusted or held as necessary. Telephone interview on 06/10/24 at 6:03 P.M. with LPN #883 revealed she had administered Resident #11's Coumadin dose on 05/20/24 during the nightshift based on the lab work dated 05/16/24 (and not the lab work from 05/20/24). The LPN indicated the dayshift nurse told her the 05/16/24 lab work was the current lab work available for the resident and stated she did not physically check the lab system to see what the PT/INR was on the lab work obtained on 05/20/24. Telephone interview on 06/10/24 at 6:31 P.M. with Resident #11 with the Administrator and RRN #979 present revealed on 05/22/24, he had reported to RN #812 between 2:00 P.M. and 3:00 P.M. that his nose and gums were bleeding. Resident #11 stated RN #812 assessed his mouth and stated that he must have broken one of his teeth which caused bleeding. She provided a saltwater rinse for the resident. Resident #11 stated between 6:30 P.M. and 6:34 P.M., RN #812 came in and told him that his PT/INR was 4.9 and that his Coumadin was to be held. He stated at that point, he called his friends at the fire department and decided to call EMS for transport to the hospital. He stated he was hospitalized from 05/22/24 to 06/03/24 to get his INR stabilized which included the administration of Vitamin K shots. The resident indicated the hospitalization would not have been necessary if the nursing staff had monitored his lab work closely and reported the abnormal labs to the physician before giving him his Coumadin. Interview on 06/12/24 at 10:30 A.M. with RRN #979 revealed the facility policy was for the dayshift nurses to check the medication cart to ensure Coumadin doses were available for resident administration and the nightshift nurses were responsible to check the PT/INR results and administer Coumadin as ordered. Telephone interview on 06/12/24 at 1:33 P.M. with Laboratory Staff (LS) #502 revealed their company did not call high labs and only called critical labs. When further questioned, she stated it was a different critical level result for each facility and their computer told them when to call the results to the facility. LS #502 revealed their company faxed Resident #11's lab results to the facility on [DATE] at 1:49 P.M., 4:49 P.M. and 5:54 P.M. When asked why the lab faxed the lab results three different times, LS #502 stated multiple lab staff members worked on the labs with high results and that was probably why the results were faxed to the facility three times. Interview on 06/14/24 at 7:11 A.M. with RRN #975 revealed the nurse who was assigned to care for a resident receiving Coumadin was responsible for calling in the lab work for the PT/INR to the physician/NP. She stated all residents on Coumadin had orders to monitor for signs and symptoms of bruising or bleeding and any adverse effects of anticoagulant therapy. RRN #975 stated the expectations of each physician of those residents on Coumadin were different but in general, all nurses should call immediately for a PT/INR of greater than 3.0 (standard 2.0 to 3.0). RRN #975 confirmed Resident #11's lab work results for his PT/INR were received by the facility (via fax) around 5:30 P.M. on 05/20/24 and LPN #935, who worked dayshift on both 05/20/24 and dayshift on 05/21/24, should have called the physician with the PT/INR results for Resident #11 as well as LPN #883, who worked nightshift on 05/20/24, and LPN #963, who worked nightshift on 05/21/24, should have called the physician/NP regarding Resident #11's elevated PT/INR results. RRN #975 stated Resident #11's NP was notified on 05/22/24 and did not indicate she wanted the resident transported to the hospital. RRN #975 stated the NP wanted the resident's Coumadin held on 05/22/24, but the resident did not feel comfortable with that order and requested his own emergency transport to the emergency room Interview on 06/14/24 at 8:18 A.M. with Fire Department #311 revealed he had responded to Resident #11's 911 call on 05/22/24 and their squad was on scene for 21 minutes. He stated he had observed Resident #11 with bloody towels on the table, bloody tissues, blood in cups and blood down the front of him. Fire Department #311 shared that upon arrival, three staff members were at the end of the hall laughing and talking on their cell phones while the squad team was in the building. No staff were present in the room helping Resident #11. Further interview revealed fire department staff asked the staff members for a mechanical lift to get the resident on a cot for transport and no staff members brought the mechanical lift or even talked to them and/or assessed the resident while the squad was in the room. He stated the resident's room was in deplorable condition with bloody towels/tissues and the floor was sticky (from the resident's blood). Fire Department #311 indicated the entire 21 minutes the squad was in the building, not one staff member had come in to assess, monitor or assist Resident #11 in any way. Fire Department #311 indicated he asked for Resident #11's resident information and the nurse handed him the form without talking to the squad about the resident or resident's care. Review of the undated facility Labs policy revealed the nightshift nurse was responsible for double checking the lab draw list and assuring all residents that were due for scheduled labs were on the requisition. Review of the facility Anticoagulation policy revised 05/27/21 revealed on admission, nursing would identify individuals who were currently anticoagulated. Residents would be monitored for possible complications associated with anticoagulation and providers would be promptly notified of any such complications. Anticoagulation therapy and monitoring would be included in the care plan. The nurse would obtain and verify anticoagulation orders from the provider. In the event there was a change in the dosage of the medication, all changes to the dosage would be made on the MAR. Supplemental orders for anticoagulated residents include antibiotic check, PT/INR frequency check, dose check, check (to verify the) dose in the medication cart was correct and monitor bleeding. Review of the Resident Change in Condition policy revised 11/10/20 revealed the charge nurse would notify the physician/provider/family of significant changes in condition. Review of Food and Drug (FDA) Highlights of Prescribing Information webpage www.fda.com revised 10/2011 revealed to adjust Warfarin (Coumadin) dose to maintain a target INR of 2.5 with an INR range of 2.0 to 3.0 for all treatment durations (related to treatment of atrial fibrillation). This deficiency represents non-compliance investigated under Master Complaint Number OH00154752 and Complaint Numbers OH00154261, OH00154253 OH00153950 and OH00153809.

Based on record review and interview, the facility failed to ensure resident care needs were adequately and timely met to decrease/prevent residents from contacting the local fire and police department for care including routine care and assistance. This affected eleven residents (#4, #11, #12, #13, #19, #42, #51, #54, #75, #79, and #98) of 83 residents who resided in the facility. Findings include: 1. Telephone interview on 05/30/24 at 9:48 A.M. with Detective #994 revealed ongoing concerns with calls coming into their police department from facility residents (from 01/10/24 through 05/30/24). He stated there were a lot of non-emergent calls from residents who wanted assistance from staff and staff were not answering the call lights timely. He stated this caused the residents to call 911 and request assistance unnecessarily. This included, but was not limited to at least 13 calls (not including calls for emergency squad or emergency medical services (EMS) involvement for hospitalization s: a. Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and other behavioral disturbances. Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #4's physician's orders revealed an order dated 07/28/23 to document pain every shift; and an order dated 07/28/23 for acetaminophen (Tylenol) 325 mg give two tablets by mouth every four hours as needed for pain (discontinued 01/16/24). During the interview, Detective #994 revealed an incident occurred on 01/10/24 when Resident #4 called the police because she had pain in her leg and no staff answered her call light. Detective #994 indicated the resident reported she put her call light on and no staff answered her call light to address the pain in her leg. Review of a police report dated 01/10/24 at 11:20 P.M. revealed Resident #4 stated she had stomach pain. The resident was subsequently transported to the hospital due to pain. Review of Resident #4's medication administration record (MAR) and treatment administration record (TAR) from 01/01/24 to 01/31/24 revealed staff failed to identify or document any complaints of pain for the resident for the dayshift or nightshift during this time period. There was no evidence the resident was administered any Tylenol for pain on 01/10/24. Review of Resident #4's progress notes from 01/09/24 to 01/10/24 revealed no evidence staff documented or assessed the resident for complaints of pain, including stomach pain during this time period. Review of Resident #4's progress note dated 01/10/24 at 9:30 P.M. indicated the resident called EMS and went to the hospital per her request. Review of Resident #4's progress notes dated 01/10/24 at 11:35 P.M. indicated an ambulance arrived at the facility and stated Resident #4 had called EMS for abdominal pain. The resident was transported to the hospital. Review of Resident #4's progress note dated 01/11/24 at 1:02 P.M. authored by the Director of Nursing (DON) revealed a call was placed to Resident #4's daughter to inform her that the nurse stated she had called her twice with no answer obtained to let her know the resident called EMS twice on 01/10/24. The first time she asked for the police to come and the second time for EMS to transfer her to the hospital for stomach pain. Review of Resident #4's hospital Internal Medicine History and Physical Examination dated 01/11/24 revealed the [AGE] year-old female who had a known history of old stroke and dementia recently moved to Ohio from California. She stated the SNF mistreated and neglected her; and she was sent to the hospital. She was admitted for further management. Review of Resident #4's hospital emergency room documentation dated 01/11/24 revealed the resident stated the nursing home had mistreated and neglected her. Review of Resident #4's progress note dated 01/13/24 indicated the resident returned to the facility on [DATE] at 9:15 P.M. via a stretcher. The resident had been admitted to the hospital with a diagnosis of COVID-19. Review of Resident #4's hospital Discharge Summary form dated 01/13/24 revealed the resident was admitted for COVID-19. The hospital documentation did not include evidence of stomach pain or leg pain. An attempted interview on 06/03/24 at 10:24 A.M. with Resident #4 revealed the resident was confused. During the interview, the resident could not remember calling the police department for anything. Record review revealed no evidence of interventions or measures being implemented to ensure the resident's care needs were adequately and timely met to decrease/prevent the resident from contacting the local police and emergency medical services for care including routine care and assistance. Interview on 06/05/24 at 2:03 P.M. with the Administrator confirmed the facility was aware multiple residents, including Resident #4 had called police or fire for resident care. b. Review of Resident #98's medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes, acute respiratory failure, and hemiplegia. Review of Resident #98's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. During the interview with Detective #994, the detective stated an incident occurred on 02/27/24 when Resident #98 called the police to report she needed help. Review of the police report dated 02/27/24 at 2:06 A.M. revealed Resident #98 called, and her speech was slow and lethargic. She stated she did not have an emergency and she was ok. The facility was contacted and stated the nurse would check on the resident. Review of Resident #98's progress notes did not reveal evidence the resident was assessed on 02/27/24 following the call to the police department. Record review revealed Resident #98 was transferred to the hospital on 05/31/24 for a critically low hemoglobin. The family was updated on the resident's departure. The resident returned to the facility on [DATE] at 2:38 P.M. Interview on 06/11/24 at 8:12 A.M. with Resident #98's sister revealed the resident had been verbal and able to communicate in February 2024 but was currently in the hospital and non-verbal. During the interview, the resident's sister revealed she was unaware the resident had called the police in February 2024. Interview on 06/05/24 at 2:03 P.M. with the Administrator confirmed she was aware multiple residents called the police for care while residents in the facility including Resident #98. Record review revealed no evidence of interventions or measures being implemented to ensure the resident's care needs were adequately and timely met to decrease/prevent the resident from contacting the local police for assistance. c. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, psychotic disturbance and anxiety. Review of Resident #19's care plans dated 03/23/23 revealed the resident had impaired cognitive function and impaired though processes related to dementia. Review of Resident #19's MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. During the interview with the detective, Detective #994 revealed an incident occurred on 03/05/24 when Resident #19 called police to report he could not get (staff) assistance when he had pushed his call light for help. The detective indicated a second incident occurred on 03/06/24 when Resident #19 called police because he could not get (staff) assistance when he had pushed his call light for help. Review of the police report dated 03/05/24 at 11:27 A.M. revealed Resident #19 stated he was unable to get help and needed a bed pan. The dispatcher called the facility and the phone line was busy. The dispatcher called the facility again and the resident was assisted. Review of the police report dated 03/06/24 at 10:28 A.M. revealed the resident was unable to get (staff) help and was vomiting. Staff were advised and checking with the manager if the resident should be sent to the hospital. A squad was requested due to a change in Resident #19's mental status and the resident was transported to the veteran's hospital. Review of Resident #19's progress note dated 03/07/24 at 1:11 P.M. revealed on 03/06/24 at 11:00 A.M. prior to transport to the hospital, the resident called the police and stated he could not stand up because of pain and the ceiling was spinning. The note indicated the resident was administered Tramadol (narcotic) for pain and stated he felt better immediately. The police arrived and asked the resident if he wanted to go to the hospital and he said yes and the ambulance company was called to transport the resident to the veteran's hospital. The resident was readmitted to the facility on [DATE] at 11:18 P.M. Interview on 06/05/24 at 2:03 P.M. with the Administrator confirmed she was aware multiple residents called the police and fire department for assistance including Resident #19. Record review revealed no evidence of interventions or measures being implemented to ensure the resident's care needs were adequately and timely met to decrease/prevent the resident from contacting the local police for assistance. d. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, essential hypertension and insomnia. Review of Resident #51's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. During the interview with the detective, Detective #994 revealed an incident occurred on 03/08/24 when Resident #51 called police to report no staff answered her call light for basic care. Interview on 06/06/24 at 9:46 A.M. with the Administrator and DON revealed Resident #51 had not called the police/fire on 03/08/24 but rather it was Resident #51's friend because the friend had not heard from the resident in a while. Review of the police report dated 03/08/24 at 8:44 A.M. revealed the caller requested a welfare check on Resident #51 who was at the facility. She stated the resident did not receive food and basic care and no one answered the resident's call light. The report revealed the police officer had observed a nurse exiting the resident's room following breakfast. The resident reported to the police officer that she did not have her oxygen or food. The DON was in the room with the police officer and verified the resident's oxygen was hooked up and working properly and the resident's food was sitting in front of her. The resident refused hospitalization and the police officer exited the facility. Interview on 06/06/24 at 10:01 A.M. with State tested Nursing Assistant (STNA) #837 revealed she remembered the police responding to Resident #51 but could not remember the exact date. Record review revealed no evidence of interventions or measures being implemented to ensure the resident's care needs were adequately and timely met to decrease/prevent the resident from contacting the local police for assistance. e. Review of Resident #79's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, diabetes and hyperlipidemia. Review of Resident #79's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and had impairment on one side of the upper and lower extremities. During the interview with the detective, Detective #994 revealed an incident occurred on 03/29/24 when Resident #79 called the police to report a staff member abused him by putting their weight on the resident during care. Review of the police report dated 03/29/24 at 6:05 A.M. revealed Resident #79 had reported the nurse was abusing him by putting all her weight onto him when she leans into the bed. Record review revealed no evidence of interventions or measures being implemented to ensure the resident's care needs were adequately and timely met to decrease/prevent the resident from contacting the local police related to reports of abuse without staff knowledge. f. Review of Resident #42's medical record revealed the resident was admitted on [DATE] with diagnoses including spinal stenosis, diabetes, depression and anxiety disorder. Review of Resident #42's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. During the interview, Detective #994 revealed an incident occurred on 04/14/24 when Resident #42 called the police to report his wallet had been stolen. There was no evidence the resident had first reported this to facility staff or that staff were investigating the incident. Review of Resident #42's witness statement authored by the Administrator on 04/08/24 at 5:00 P.M. revealed the resident indicated he last saw his wallet about a year ago at the movies. He stated he had always kept his wallet in his back pocket which had a picture of himself and $23.00. The resident denied credit cards were missing and denied he wanted to file and police report. Telephone interview on 06/11/24 at 8:05 A.M. with Resident #42's sister revealed the resident went to an appointment approximately two months ago and his wallet was missing. She stated the wallet contained a social security card, driver's license and bank card. When questioned, she stated no one had attempted to use the bank card but the facility could not find the wallet. She replaced the bank card. Interview on 06/12/24 at 8:56 A.M. with Resident #42 and the resident stated his wallet was missing. He could not report what was in the wallet or where he thought the wallet might have went. He stated his sister replaced his identification card and he was not missing any money. Record review revealed no evidence of interventions or measures being implemented to ensure the resident's care needs were adequately and timely met to decrease/prevent the resident from contacting the local police related to reports of theft/misappropriation without staff knowledge. g. Review of Resident #54's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, end stage renal disease and anemia. Review of Resident #54's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. During the interview with the detective, Detective #994 revealed an incident occurred on 04/17/24 when Resident #54 called the police to report missing money. Review of Resident #54's witness statement dated 04/17/24 revealed the STNA overheard the resident having a conversation about money with his son and nephew and the son and nephew bought snacks in for the resident. No money was observed. Interview on 06/12/24 at 8:58 A.M. with Resident #54 who stated he put $20.00 in his drawer and reported it as stolen. He stated the facility reimbursed him for the $20.00 and then he found the money in the drawer stuck in the back of the drawer and the cabinet. h. During the interview with the detective, Detective #994 revealed the police were called on 04/18/24 by Resident #12's daughter to report an STNA intentionally pulled out the PEG tube. Review of Resident #12's nursing progress note dated 04/18/24 at 4:56 A.M. indicated the resident's needs could not be met in the facility at the time due to PEG tube issues. The PEG was pulled out by the resident. The resident was transferred to the emergency room . The resident had been prepared for transfer. The physician was notified and the resident was discharged at 11:00 P.M. with the face sheet, medication list and code status. i. Review of Resident #11's medical record revealed the resident was admitted on [DATE] with diagnoses including pain in the left leg, end stage renal disease with dependence on renal dialysis and paroxysmal atrial fibrillation. Review of Resident #11's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. During the interview with the detective, Detective #994 revealed Resident #11 called the police and ambulance due to a nose bleeding and bleeding in his mouth . Review of Resident #11's MARS and TARS from 05/15/24 to 05/22/24 revealed the staff documented the resident's INR result on 05/20/24 on dayshift as not applicable (NA), on 05/20/24 on nightshift as 1.9; on 05/21/24 on dayshift as NA; on 05/20/24 on nightshift as 1.9; on 05/21/24 on dayshift as NA; on 05/21/24 on nightshift as 4.9; and on 05/22/24 on dayshift as 4.9. Review of Resident #11's Squad Report form dated 05/22/24 at 8:48 P.M. revealed the male who was bleeding from his mouth and nose. The resident stated he had been bleeding from his nose and gums all day. He stated he was on a blood thinner and was taken by stretcher to the hospital. Interview on 06/05/24 at 2:03 P.M. with the Administrator confirmed she was aware multiple residents had called the police and fire department including Resident #11. Telephone interview on 06/10/24 at 6:31 P.M. with Resident #11 with the Administrator and RRN #979 present revealed on 05/22/24, he had reported to RN #812 between 2:00 P.M. and 3:00 P.M. that his nose and gums were bleeding. Resident #11 stated RN #812 assessed his mouth and stated that he must have broken one of his teeth which caused bleeding. She provided a saltwater rinse for the resident. Resident #11 stated between 6:30 P.M. and 6:34 P.M., RN #812 came in and told him that his PT/INR was 4.9 and that his Coumadin was to be held. He stated at that point, he called his friends in the fire department and decided to call EMS for transport to the hospital. He stated he was hospitalized from 05/22/24 to 06/03/24 to get his INR stabilized which included the administration of Vitamin K shots. The resident indicated the hospitalization would not have been necessary if the nursing staff had monitored his lab work closely and reported the abnormal labs to the physician before giving him his Coumadin. 2. Interview on 06/04/24 at 8:31 A.M. with Assistant Fire Department Chief #995 revealed the fire department had received multiple phone calls from residents at the facility. During the interview Chief #995 provided examples including on 05/20/24 when three different residents called their office to report care concerns. Calls were received from Resident #75 on 05/20/24 at 10:12 A.M. who stated she requested a breathing treatment, and the nurse did not bring it, Resident #13 on 05/20/24 at 11:37 A.M. who stated staff were not answering his call light and Resident #19 on 05/20/24 at 2:15 P.M. who needed to use the bathroom and no staff answered his call light. Interview on 06/05/24 at 1:20 P.M. with Regional Registered Nurse (RN) #979 revealed she believed the facility had investigated concerns with residents calling the police and fire departments and the facility attempted to determine the root cause of the resident complaints to the police and fire departments on 04/30/24. She revealed the facility tried to determine which staff members might be involved, what shift might be involved, days of the week involved and why the residents called the police for fire departments. However, Regional RN #979 revealed the facility could not determine a pattern. She stated the residents were interviewed, staff were educated, and a Quality Assurance and Performance Improvement (QAPI) plan was implemented to try to mitigate residents calling the police or fire unnecessarily. Interview on 06/05/24 at 2:03 P.M. with the Administrator she began employment at the facility on 05/20/24. The Administrator revealed she was currently attempting to schedule an appointment (call placed on 06/03/24) with the police and fire departments to introduce herself and to mitigate concerns. There was no evidence provided to confirm the appointments were scheduled for the meeting between the Administrator and the fire department or police department as of this date. An additional interview on 06/06/24 at 10:19 A.M. with the Administrator revealed the facility had been unable to specifically identify a root cause regarding the increase in resident phone calls directly to the police and fire departments for routine care and assistance. The Administrator revealed she believed the resident phone calls to the fire/police departments had decreased from 04/28/24 to the current date because of the facility added weekend supervisory position. The Administrator revealed the three resident phone calls to the fire department on 05/20/24 were on a Monday during the dayshift and she was present in the building as was the DON. Telephone interview on 06/14/24 at 8:10 A.M. with Fire Department #995 indicated approximately two-thirds of their calls to the facility were from residents who said they could not obtain assistance. He stated from 06/01/24 to 06/14/24 multiple residents had called for assistance with care including on 06/09/24 at 2:47 P.M. Resident #53 stated no one would answer his light to take him to the bathroom. When the squad arrived, the nurse was taking the resident to the bathroom. Fire Department #995 indicated on 06/11/24 at 6:14 A.M. Resident #19 stated he had back pain and no one responded to his call light. When the squad had arrived, no nursing staff were aware the resident had called 911. Telephone interview on 06/14/24 at 8:18 A.M. with Fire Department #311 indicated he had responded to Resident #11's 911 call for assistance on 05/22/24 and their squad was on scene for 21 minutes. He stated he had observed Resident #11 with blood towels on the table, blood tissues, blood in cups and blood on the front of the resident. He stated three staff members were at the end of the hall laughing and talking on their cell phones while the squad team were in the building and no staff were in the room helping Resident #11. Further interview revealed he had asked the staff members for a Hoyer mechanical lift to get the resident on a cot for transport and no staff members brought the Hoyer mechanical lift or even talked to them and/or assessed the resident while the squad was in the room. He stated the room was in deplorable condition with bloody towels/tissues and the floor was sticky. Fire Department #311 indicated the entire 21 minutes the squad was in the building, not one staff member had come in to assess, monitor or assist Resident #11 in any way. Fire Department #311 indicated he asked for Resident #11's resident information and the nurse just handed him the form without talking to the squad about the resident or resident's care. He stated this was just one example and many residents from this facility called for assistance because the staff did not answer the call lights or respond to their requests for assistance. This deficiency represents non-compliance investigated under Complaint Number OH00154261, OH00153879 and OH00153809.

Based on record review and interview, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets were on duty and provided the necessary access to the resident's electronic health record to ensure medications were administered in a timely manner. This affected 15 residents (#5, #12, #29, #49, #53, #54, #55, #58, #59, #64, #67, #71, #72, #78 and #84's) assigned to Licensed Practical Nurse (LPN) #401 on 06/04/24. The facility census was 83. Findings include: Review of the staffing schedule for 06/04/24 for the 7:00 P.M. to 06/05/24 7:00 A.M. shift revealed four licensed nurses were scheduled for 83 total residents. LPN #897 was noted to report off for the shift on 06/04/24 at 6:30 P.M. The facility contacted a staffing agency, and LPN #401 reported to work (to replace LPN #897), arriving to the facility at 7:00 P.M. The LPN was assigned to provide care for twenty residents including Residents #3, #4, #5, #12, #29, #49, #53, #54, #55, #58, #59, #64, #66, #67, #68, #71, #72, #73, #78 and #84 on the 100/200 split. The 100/200 split included ten residents, Resident #4, #29, #49, #59, #64, #66, #67, #71 and #73 with diagnosis of dementia/cognitive impairment. Review of resident records on the 100/200 unit revealed 19 residents reside on the 100/200 split including Residents #3, #4, #5, #12, #29, #49, #53, #54, #55, #58, #59, #64, #66, #67, #68, #71, #72, #78 and #84's. Further review of Residents #3, #4, #5, #12, #29, #49, #53, #54, #55, #58, #59, #64, #66, #67, #68, #71, #72, #78 and #84's medical records, medication administration records (MARS) and treatment administration records (TARS) revealed Residents #4 and #66 were not scheduled nighttime medications and Residents #3 and #68 had received the medications as ordered on 06/04/24. Telephone interview on 06/10/24 at 12:27 P.M. with LPN #401 confirmed she worked on 06/04/24 during the 7:00 P.M. to 7:00 A.M. shift on the 100/200 unit split with approximately 19 residents. During the interview the LPN revealed she did not receive login information timely for the facility electronic health records (EHR) and was unable to start her medication administration pass until around 10:00 P.M. (for medications scheduled to be administered between 7:00 P.M. and 11:00 P.M. The LPN verified the medications were administered on this date due to the staffing issue and lack of access to the facility EHR system. a. Review of Resident #5's medical record revealed the resident had physician orders for medications scheduled to be administered between 7:00 P.M. and 11:00 P.M. which included Atorvastatin (for high cholesterol) and Travoprost eye drops. Record review revealed the medications were administered on 06/05/24 at 2:10 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. b. Review of Resident #12's medical record revealed the resident had physician orders for medications including Atorvastatin, Buspirone (antianxiety), Cyclobenaprine (treats muscle spasms), Docusate Sodium, Hydralazine, Hydroxyzine (antianxiety), Lactulose, Levetiracetam (for seizures), Paroxetine (antidepressant) and a stool softener which were scheduled to be administered between 7:00 P.M. and 11:00 P.M. The medications were administered on 06/05/24 at 2:16 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. Interview on 05/28/24 at 8:23 A.M. with Resident #12's family member indicated the resident was not provided timely care during the nightshift and she felt there was not enough staff in the building to provide care to the resident. c. Review of Resident #29's medical record revealed the resident had physician order for the anti-coagulant medication, Eliquis scheduled to be administered from 7:00 P.M. to 11:00 P.M. The medication was administered on 06/05/24 at 2:18 A.M. The medication was not administered as ordered due to LPN #401 not having proper access to the facility record system. d. Review of Resident #49's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Atorvastatin and Remeron. The medications were administered on 06/05/24 at 2:24 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. e. Review of Resident #53's medical record revealed the resident had physician orders for medications scheduled to be administered between 7:00 P.M. to 11:00 P.M. which included an albuterol inhaler, Atorvastatin, Divalproex (anticonvulsant), Pepcid, Hydroxyzine, Levetiracetam and Methocarbamol (treats muscle spasms). The medications were administered on 06/05/24 at 2:26 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system . f. Review of Resident #54's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Baclofen, Eliquis, Hydralazine (high blood pressure medication) Lantus insulin and Metoprolol. The medications were not administered as ordered and scheduled between 7:00 P.M. and 11:00 P.M. due to the LPN not having proper access to the facility record system. g. Interview on 06/12/24 at 8:50 A.M. with Resident #55 revealed there was not enough staff and staff kept administering her medications late. Review of Resident #55's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Atorvastatin, Baclofen, Buspirone, Divalproex, Eliquis, Iron, Melatonin, Metoprolol, Symbicort inhaler and stool softener. The medications were administered on 06/05/24 at 2:29 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. h. Review of Resident #58's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Atorvastatin, Iron, Gabapentin, Hydralazine, Lantus insulin, Melatonin and Oxycodone. The medications were administered on 06/05/24 at 2:32 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system . i. Review of Resident #59's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Atorvastatin, Lantaprost eye drops and Melatonin. The medications were administered on 06/05/24 at 2:35 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. j. Review of Resident #64's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Tylenol, Mirtazapine and Trazodone. The medications were administered on 06/05/24 at 2:34 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. k. Review of Resident #67's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Tylenol, Coreg (anti-hypertensive) and eye drops. The medications were administered on 06/05/24 at 2:36 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. l. Review of Resident #71's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Baclofen, Keppra (an anti-convulsant), Lactulose, Norvasc, Miralax, Propranolol (an antihypertensive), Senna and Vimpat (anti-epileptic). The medications were administered on 06/05/24 at 2:40 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system. Telephone interview on 05/28/24 at 11:49 A.M. with Resident #71's power-of-attorney (POA) confirmed she was in the building on 06/04/24 and the resident had received the nighttime medications after midnight. She stated she believed this was because of lack of staffing in the building. m. Review of Resident #72's medical record revealed the resident had physician orders for medications scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Aricept, Lantaprost eye drops and Lantus insulin. The medications were administered on 06/05/24 at 2:42 A.M. The medications were not administered as ordered due to LPN #401 not having proper access to the facility record system . n. Review of Resident #78's medical record revealed the resident had a physician order for medication scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Miralax. The medication was administered on 06/05/24 at 2:43 A.M. The medication was not administered as ordered due to LPN #401 not having proper access to the facility record system. o. Review of Resident #84's medical record revealed the resident had a physician order for medication scheduled to be administered from 7:00 P.M. to 11:00 P.M. which included Metoprolol. The medication was administered on 06/05/24 at 2:45 A.M. The medication was not administered as ordered due to LPN #401 not having proper access to the facility record system. Interview on 05/23/24 at 9:34 A.M. with Resident #26 indicated the staff did not check on her during the nightshift. She felt there were not enough staff to provide timely resident care. Telephone interview on 05/28/24 at 9:27 A.M. with Resident #26's power-of-attorney revealed the resident was not checked on during the nightshift and she felt staffing was an issue. Interview on 06/12/24 at 9:21 A.M. with RN Supervisor #922 confirmed LPN #401 did not administer Resident #5, #12, #29, #49, #53, #54, #55, #58, #59, #64, #67, #71, #72, #78 and #84's medications as ordered on 06/04/24 because the nurse did not have computer access to administer these medications as ordered. Telephone interview on 06/14/24 at 8:10 A.M. with Assistant Fire Department #995 revealed residents called their department on multiple dates due to the staff not answering their call lights to provide care. Telephone interview on 06/14/24 at 8:18 A.M. with Fire Department #311 indicated he felt the facility was short staffed. He stated he had responded to multiple calls at the facility. He stated on 05/22/24 he went to the facility to respond to Resident #11's call for assistance and he had observed three staff members at the end of the hall laughing and talking on their telephones for the entire 21 minutes he was in the building. He stated not one staff member was observed to come into Resident #11's room while their team was there and assist the resident or ask the resident if he needed anything. Additionally, he stated his team was called to the building on multiple occasions to respond to resident's calling and asking for assistance from their department and when the team arrived in the facility and walked down the hall, multiple residents would see their team and yell out for assistance because the staff members were not answering their call lights and responding to the resident requests. Review of the undated staffing policy named Policy revealed each nursing home shall have sufficient direct care staff on each shift to meet the needs of the residents in an appropriate and timely manner and have the following individuals provide a minimum of two and one-half hours of direct care and services per day including nurse aides, RN's and LPNs. Review of the Medication Administration policy revised 05/01/24 revealed the facility should ensure authorized personnel, as determined by applicable law, administer medications according to the times of administration as determined by the facility's pharmacy committee and/or physician prescriber. This deficiency represents non-compliance investigated under Master Complaint Number OH00154752 and Complaint Numbers OH00154261, OH00154253, OH00153953, OH00153950, OH00153879 and OH00153809.

Based on closed record review, hospital record review, policy review and interview, the facility failed to ensure Resident #11 was administered pain medications as ordered. This affected one (Resident #11) of four residents reviewed for medication administration. Findings include: Review of Resident #11's hospital documentation revealed the resident had a left foot and ankle charcot neuroarthropathy with status post left ankle fusion and application for external fixator on 05/02/24. Further review of Resident #11's hospital documentation revealed discharge orders dated 05/15/24 for oxycodone (narcotic pain medication) extended release (ER) 15 mg (milligram)12-hour tablet take one tablet by mouth every 12 hours for fourteen days; and hydromorphone (dilaudid narcotic pain tablet) 4 mg tablet take one tablet by mouth every four as needed for pain up to seven days. Review of Resident #11's closed medical record revealed the resident was admitted on [DATE] with diagnoses including charcot neuropathy status post left ankle fusion and application of external fixator on 05/02/24, pain in the left leg, end stage renal disease with dependence on renal dialysis and paroxysmal atrial fibrillation. Review of Resident #11's Baseline Care Plan dated 05/15/24 revealed the resident would be monitored for adverse reactions to high-risk medications. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was frequently in pain and received non-medication interventions for pain. Review of Resident #11's physician orders revealed an order dated 05/15/24 to monitor the pain level every shift; an order dated 05/15/24 for hydromorphone 4 mg every four hours for seven days (stop date 05/22/24); an order dated 05/15/24 (discontinued 05/21/24) for oxycodone ER 15 mg administer one tablet orally every twelve hours as needed for pain; and an order dated 05/21/24 to administer oxycodone ER 15 mg one tablet every shift. Review of Resident #11's medication administration records (MARS) from 05/15/24 to 05/22/24 revealed the resident was administered the hydromorphone narcotic pain medication on 05/15/24 at 11:35 P.M., 05/16/24 at 8:29 A.M., 05/17/24 at 9:49 A.M. and 05/18/24 at 3:48 P.M. Review of Resident #11's MARS from 05/15/24 to 05/22/24 revealed the resident was administered the oxycodone ER narcotic pain mediation on 05/16/24 at 5:02 A.M., 05/16/24 at 6:13 P.M., 0517/24 at 10:28 P.M., 05/18/24 at 9:26 P.M., 05/18/24 at 1:21 P.M., 05/20/24 at 5:03 A.M., 05/21/24 at 8:54 A.M. No concerns were identified. Review of Resident #11's medication administration records (MARS) and treatment administration records (TARS) from 05/15/24 to 05/22/24 revealed the resident's pain was monitored every shift with a pain level of 8 (one being least and 10 being the worst) on 05/15/24 during the nightshift, an 8 on 05/16/24 during the dayshift, a zero on 05/16/24 during the nightshift, a zero on 05/17/24 during the dayshift, a zero on 05/17/24 during the nightshift, a five on 05/18/24 during the dayshift, a 4 on 05/17/24 during the nightshift, a zero on 05/19/24 during the dayshift, a zero on 05/19/24 during the nightshift, a zero on 05/20/24 during the dayshift, a zero on 05/20/24 during the nightshift, a zero on 05/21/24 during the dayshift, a four on 05/21/24 during the nightshift and a zero on 05/22/24 during the dayshift. Review of Resident #11's progress note authored by Certified Nurse Practitioner (CNP) #980 with a service date of 05/21/24 at 12:00 P.M. indicated the resident had a history non-pressure chronic ulcer of the unspecified heel and midfoot with bone involvement without evidence of necrosis . The oxycodone narcotic was transcribed incorrectly and corrected with nursing for every 12 hours. Telephone interview on 06/04/24 at 6:42 P.M. with CNP #980 stated she assessed Resident #11 on 05/21/24 and the resident reported his pain was not as controlled as it had been, and they were not administering his narcotic pain medications as ordered. NP #980 revealed she reviewed the medical record and determined the staff had transcribed the hospital discharge orders incorrectly and did not administer the oxycodone ER as ordered. She stated Resident #11 was to receive the oxycodone ER scheduled with hydromorphone for breakthrough pain. NP #980 indicated this was corrected on 05/21/24 and he went out to the hospital on 05/22/24. Telephone interview on 06/10/24 at 6:31 P.M. with Resident #11 revealed the nursing staff did not administer his pain medications as ordered for the pain in his left leg. He stated they messed up his pain regimen. Review of the Medication Admin policy revised 05/01/10 revealed the facility should ensure authorized personnel, as determined by applicable law, administer medications according to times of administration and determined by the facility's pharmacy committee and/or physician prescriber. The facility was unable to provide a Pain Management Policy. This deficiency represents non-compliance investigated under Complaint Numbers OH00154752, OH00154253, OH00153950 and OH00153809.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than five percent (%). This affected one resident (Resident #33) of four residents reviewed for medication administration. A total of thirty medications were administered with two errors for a medication error rate of 6.66%. Findings include: Review of Resident #33's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, essential hypertension and depression. Review of Resident #33's physician orders revealed an order dated 01/23/24 for aspirin chewable 81 mg (milligrams) administer one tablet orally once per day; and an order dated 01/31/24 for vitamin c 500 mg administer two tablets orally once per day. Observation on 05/29/24 at 9:38 A.M. with Registered Nurse (RN) #855 of Resident #33's medication administration revealed ten medications were administered including aspirin 81 mg enteric coated (EC) tablet and vitamin c 500 mg one tablet. Interview on 05/29/24 at 11:36 A.M. with RN #855 confirmed she administered aspirin EC and the order was for aspirin chewable and also administered one vitamin c tablet instead of two as ordered. Review of the Medication Administration policy revised 05/01/10 revealed the facility should ensure authorized personnel, as determined by applicable law, administer medications according to times of administration and determined by the facility's pharmacy committee and/or physician prescriber. This deficiency represents non-compliance investigated under Master Complaint Number OH00154752 and Complaint Numbers OH00154253, OH00153950 and OH00153809.

Based on observation, record review, interview and policy review the facility failed to ensure Resident #40's non-pressure skin treatments were administered as ordered. This affected one (Resident #40) of three residents reviewed for skin alterations. Findings include: Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including osteomyelitis, diabetes, and anemia. Review of Resident #40's skin breakdown care plan, dated 02/08/24, revealed interventions including barrier cream/ointment after incontinence episodes as needed; small frequent shifts of body weight; turn and reposition as indicated; and elevate heels off the bed or use heel protectors. Review of Resident #40's Podiatry Note, authored by Podiatrist #982 and dated 04/01/24, revealed the resident's chief complaint was painful, dry skin on the bottoms of both feet for several months. The resident had painful, fissuring skin, plantar to the bilateral feet and diminished pedal pulses to the bilateral feet. The impression was xerosis (dry skin) to the bilateral plantar feet. The treatment included proper foot care and lac-hydrin 12% over the counter (OTC) cream (a hydrating cream) every morning to the bottom of both feet for six months. The podiatry visit was conducted in the facility during the morning of 04/01/24. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) from 04/01/24 through 05/23/24 revealed no documented evidence the lac-hydrin treatment to the resident's bilateral feet was completed per orders. Review of Resident #40's offsite Wound Care note, dated 04/01/24 at 1:00 P.M., revealed the resident was at risk for wounds to the right and left heels. Wound prevention interventions included padding and protecting the heels and free float from a pillow. Wound Care Treatments included to cleanse the left calcaneus with normal saline, apply skin prep to the peri-wound, apply an abdominal pad and kerlix every other day. Review of Resident #40's medication administration records (MARS) and treatment administration records (TARS) from 04/01/24 to 05/23/24 did not reveal evidence the wound intervention to the left calcaneus was completed as ordered. Review of Resident #40's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #40's Podiatry note, dated 05/13/24, revealed the resident had painful, dry skin on the bottom of both feet which was last assessed on 04/01/24. No new issues were identified and lac-hydrin continued. No pressure ulcers to the bilateral heels were identified. Review of Resident #40's physician orders revealed an order dated 05/13/24 for ammonium lactate cream 12% (lac-hydrin) topically to the bottom of both feet daily. Review of the MARS and TARS from 05/13/24 to 05/28/24 revealed the ammonium lactate was administered to Resident #40's bilateral feet except on 05/20/24 and 05/22/24 which were documented as the resident refused. Interview on 05/23/24 at 1:17 P.M. with Regional Registered Nurse (RRN) #979 indicated the facility did not have Resident #40's outside wound clinic visit note when he came back from the office visit and were unaware of the resident's new orders for the left heel dressing changes. Telephone interview on 05/28/24 at 1:36 P.M. with Wound Nurse #978 (outside wound clinic) indicated Resident #40 was in their office on 04/01/24 and again on 05/23/24 (per the resident's request). Wound Nurse #978 stated the resident's wound care dressing on his bilateral feet, when he came in for his wound care appointment on 05/23/24, was the same dressing their office placed on 04/01/24. She stated the facility did not change the dressings to the resident's bilateral feet. She stated Resident #40 had reported it was the same dressings that were applied from 04/01/24. Interview on 05/28/24 at 1:46 P.M. with Resident #40 indicated he could not move anything from the waist down and the wound clinic had cleaned his bilateral feet on 04/01/24. Resident #40 stated staff were supposed to do a treatment to his left foot, but they had not completed the treatment from 04/01/24 to 05/23/24 (after his second wound clinic visit) or administered the lac-hydrin cream to his bilateral feet from 04/01/24 to 05/13/24. He denied he had mentioned the dressings needed to be changed to the staff members . Interview on 05/29/24 at 2:40 P.M. with Registered Nurse (RN) Unit Manager #922 confirmed Resident #40's MARS and TARS did not have evidence the wound care treatment to the left calcaneus was completed from 04/01/24 to 05/23/24 or the lac-hydrin to the bilateral feet was completed from 04/01/24 to 05/13/24. Observations on 05/29/24 at 2:50 P.M. with facility Wound Nurse Practitioner (NP) #983 of Resident #40's wound care did not reveal any concerns. The resident had an air mattress and green prafo boots in place at the time of the observation. He was ordered to turn and reposition every two hours and offload heels. She stated the resident always had his prafo soft pressure prevention boots in place and he was non-compliant with care including turning and repositioning and showers. She stated the resident's bilateral feet wounds were vascular in nature (non-pressure) due to the resident's declining condition and extremely dry skin. Review of Wound NP #983's facility Wound Evaluation form dated 05/29/24 revealed the resident had a history of wounds to the bilateral heels that have remained intact with pink scar tissue. Preventative measures had been in place since the resident was initially evaluated in 11/22. The offloading boots were always worn and removed for hygiene care. The visit to the wound center on 05/23/24 revealed some concerns regarding the dressing from the original follow-up on 04/01/24 and had not been changed. Per podiatry documentation from both 04/01/24 and 05/13/24, the feet were examined and the dry, scaly area on the plantar aspect of the feet remained. The resident remained non-compliant with showers. Telephone interview on 05/30/24 at 8:57 A.M. with outside Wound Clinic RN #984 revealed Resident #40 reported his dressing on his bilateral feet were the same ones as 04/01/24. She stated the dressings looked old but were not dated or timed. She denied the resident had skin impairment to the right or left heels during the wound care visit on 04/01/24. Outside Wound Clinic RN #984 confirmed Resident #40 did not have pressure on either heel on 04/01/24 and had a very small open area on both heels on 05/23/24. Telephone interview on 05/30/24 at 9:32 A.M. with NP #985 revealed she assessed Resident #40 on 05/23/24 at the wound clinic and he had a lot of dry skin and poor hygiene. She felt all the new wounds identified on 05/23/24 were superficial and from cleaning the dry skin from the resident. She stated she was aware the resident was non-compliant with care including bathing and felt that was the major concern regarding the resident's wounds. NP #984 denied Resident #40's bilateral heel wounds were pressure and she felt the wounds were vascular in nature. She stated she felt these wound occurred when the outside wound clinic staff cleaned his legs and feet and peeled off all the dead skin. Review of Resident #40's outside Wound note dated 05/30/24 revealed the resident had a history of non-pressure wounds to the other part of left foot; chronic non-pressure ulcer of left heel and midfoot, right great toe, left great toe, chronic non pressure ulcer of right heel and midfoot, necrotizing vasculopathy, chronic multifocal osteomyelitis right humerus and sacrum. Review of the wound care policy revised 09/18/20 indicated wounds identified would be assessed initially and at least weekly thereafter, until healed. This deficiency represents non-compliance investigated under Master Complaint Number OH00154752 and Complaint Numbers OH00154253, OH00154260 and OH00153809.

Based on observation, interview, record review, and policy and procedure review, the facility failed to maintain a clean and sanitary kitchen and nursing unit areas, failed to ensure staff wore hairnets while in the kitchen, and failed to ensure scoops were not stored in the containers with the food items. This had the potential to affect all residents except three residents (#48, #66, and #69) who received nothing by mouth. The facility census was 88. Findings include: Observation on 03/18/24 from 6:15 P.M. through 6:27 P.M. during the brief kitchen tour revealed three dietary staff observed in the kitchen cleaning without wearing hair restraints. Attempt to wash hands at the hand washing sink across from the dry storage area revealed the hot water was not working. Attempt to wash hands at the handwashing sink near the dish machine, and the hot water was also not working. Observed small white Styrofoam bowls stored in the bulk cereal containers for the cheerios, fruit loops, and rice Krispies. Observed in the bulk flour was a large plastic cup with measurements that was stored in the container with the flour. The clear lids of the bulk sugar, flour, and breadcrumbs had various food crumbs, food debris, and appeared sticky. Interview on 03/18/24 between 6:15 P.M. and 6:27 P.M. with Dietary Cook (DC) #212 verified the above findings. DC #212 stated the sink near the dry storage was leaking so maintenance shut the hot water valve off and must have turned the hot water valve off at the sink near the dish machine as well. DC #212 stated they would use the other sinks to wash their hands that were not indicated as handwashing sinks. DC #212 stated they weren't wearing hairnets because they were able to take them off after meal service to clean. Observation on 03/20/24 at 3:27 P.M. of the nursing unit refrigerators with Regional Registered Dietitian (RRD) #302. RRD #302 stated the servery on the 400/500 hall was closed. Observation of the 400/500 hall servery revealed the refrigerator empty and within normal temperature but had dried spillage on the bottom portion of the inside of the refrigerator. RRD #302 verified the observation. Observation on 03/20/24 at 3:30 P.M. of the 300-hall nursing unit servery revealed a dried spillage on the inside bottom of the refrigerator and a moderate amount of dried food debris/spillage on the grills of the shelves. Observation of the freezer revealed various spillage, a cup of slushy with no name or label, turned on its side and an open Twix candy bar. Observation of the microwave revealed minimal dried spillage and food debris inside of the microwave, but the silver shelf that the microwave sat on had a large dried black/brownish substance with food debris. Interview at this time with RRD #302 verified the observation. Observation on 03/20/24 at 4:35 P.M. of tray line temperatures revealed the food was observed on the steamtable. Observed a large, black fan on and blowing toward the food on the steam table that was dirty with dust. Interview at this time with RRD #302 verified the observation. Review of the list of residents with their diet orders provided by the facility revealed three residents (#48, #66, and #69) who received nothing by mouth. Review of the facility policy titled Food Preparation Area Policy, revised 06/07/21, revealed the community facility will maintain a clean, sanitary, and safe food preparation area. Food preparation staff must use hand washing facilities, which will be available and will include hot and cold water with a soap dispenser, disposable towel rack, and trash can with step to open lid. Hand washing sinks will be separate from ware washing sinks and will be located near food preparation and clean dish areas. Hand washing sinks will not be used for food preparation. Review of the facility policy titled Storage of Dry Food Policy, revised 03/09/24, revealed bulk food scoops are not to be stored in bins but are kept covered and protected near containers. Scoops are to be washed, sanitized, and dried on a routine basis.

Based on observation and staff interview the facility did not ensure the laundry room was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 88. Findings include: Observation on 03/19/24 at 4:14 P.M. revealed accumulated lint under each of the three dryers. There was a substantial amount of lint coating the surfaces in the room behind the dryers. The eye wash station sink was coated with white substance. The washing machines were coated in a white fuzzy substance that adhered to the surface. The wall behind the washing machines was cracked open along the baseboard. Interview on 03/19/24 at 4:19 P.M. with Regional Director of Clinical Services #286 verified these findings.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure hand hygiene was completed during medication administration for Resident's #9, #57 and #64 and failed to ensure Resident #31's soiled linens and soiled incontinence brief was not placed on the floor during incontinence care. This affected three residents (#9, #57 and #64) out of seven reviewed for medication administration and one resident (#31) of three residents reviewed for incontinence care. The census was 88. Findings include: 1. Review of Resident #57's medical record revealed an admitted [DATE] with diagnoses including severe protein-calorie malnutrition, pain in the right and left knees, and hypertension. Observation on 03/21/24 at 8:56 A.M. of Registered Nurse (RN) #285 revealed she was standing at the medication cart preparing Resident #57's medications for administration. RN #285 finished preparing Resident #57's medications, placed them in a small plastic cup and walked in Resident #57's room. RN #285 took Resident #57's blood pressure then administered the medications. After administering Resident #57's medications, RN #285 walked out of the room and back to the medication cart. RN #285 did not wash her hands or use hand sanitizer before leaving Resident #57's room or after she returned to the medication cart. 2. Review of Resident #9's medical record revealed an admitted [DATE] with diagnoses including atherosclerotic heart disease, hypertension, and gastro-esophageal reflux disease. Observation on 03/21/24 at 9:09 A.M. of RN #285 revealed she was standing at the medication cart preparing Resident #9's medications for administration. RN #285 finished preparing Resident #9's medications, placed them in a small plastic cup and walked into Resident #9's room without using hand sanitizer or washing her hands. RN #285 administered Resident #9's medications and walked out of the room and back to the medication cart without using hand sanitizer or washing her hands. 3. Review of Resident #64's medical record revealed an admitted [DATE] with diagnoses including unspecified dementia, chronic kidney disease, stage three, and hypertension. Observation on 03/21/24 at 9:14 A.M. of RN #285 at 9:14 A.M. revealed she walked into Resident #64's room without using hand sanitizer or washing her hands. RN #285 took Resident #64's blood pressure and left the room without using hand sanitizer or washing her hands. Interview on 03/21/24 at 9:14 A.M. of RN #285 confirmed she did not use hand sanitizer or wash her hands during medication administration to Resident's #57 and #9 and did not use hand sanitizer or wash her hands before or after taking Resident #64's blood pressure. RN #285 stated you got me. 4. Review of Resident #31's medical record revealed an admitted [DATE] with diagnoses including dementia, anxiety, and hypertension. Review of Resident #31's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had severe cognitive impairment. Resident #31 was occasionally incontinent of urine and always incontinent of bowel. Observation on 03/21/24 at 8:34 A.M. of Licensed Practical Nurse (LPN) #216 revealed he was working in the role of a State tested Nursing Assistant and was preparing to provide incontinence care for Resident #31. LPN #216 stated Resident #31 had a bowel movement, needed her incontinence brief changed, and she needed to be dressed and assisted to the chair in her room so she could eat breakfast. Observation of Resident #31 revealed she was lying in bed on her left side and a pungent odor of bowel movement was noted. LPN #31 provided Resident #31's incontinence care and when her incontinence brief was removed a large brown bowel movement could be seen. Further observation revealed LPN #216 placed the soiled incontinence brief with a large amount of feces in it on the floor and placed the soiled washcloth and towel used during incontinence care on the floor beside the incontinence brief. LPN #216 stated he would clean it up later. LPN #216 did not remove the soiled gloves used for incontinence care and picked up Resident #31's clean pants and shirt and placed them on a chair in the room. Observation revealed LPN #216 took his soiled gloves off, did not wash his hands or use hand sanitizer and donned clean disposable gloves. LPN #216 proceeded to dress Resident #31 in a clean shirt and pants and assisted her to a chair. LPN #216 did not remove his gloves, use hand sanitizer, or wash his hands, picked up Resident #31's breakfast tray, placed it on a table in front of her and removed the lids from her breakfast items. LPN #216 removed his gloves, washed his hands, then returned to Resident #31, and finished assisting her with her meal tray. There was a pungent odor of bowel movement noted in the room, and when asked about the soiled incontinence brief and washcloth lying on the floor, LPN #216 stated he would clean them up after Resident #31 ate her breakfast. Review of the facility policy titled Incontinent Resident Care, revised 01/2014, included incontinent residents would be cared for by nursing personnel to ensure adequate skin care, control odor and provide personal hygiene. Further review included to remove soiled clothing and do not put linen on the floor, dispose of linen per exposure control policy and to wash hands.

Based on observation, interview, record review, and policy and procedure review, the facility failed to ensure residents received timely assistance getting dressed and hair shampooed per physician order. This affected one resident (#60) of three residents reviewed for activities of daily living (ADL). The facility census was 88. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, and morbid (severe) obesity due to excess calories. Review of the care plan revised 03/10/24 revealed Resident #60 required staff assistance with ADL functions, resident was generally continent of bowel and bladder, resident required staff assistance with toileting, hygiene, and transfers. Review of the physician orders for March 2023 revealed an active order for prescription ketoconazole shampoo 2%. Special Instructions: apply topically to scalp one time a week on Mondays at 12:30 P.M. Review of medication administration record (MAR) for March 2024 revealed the order had been signed off as completed per order. Review of the bath/shower sheets for Resident #60 dated 02/24/24 through 03/20/24 did not indicate if the resident hair was shampooed. Interview on 03/19/24 at 11:50 A.M. with Resident #60 stated he had to wait a long time to be cleaned up and dressed. Resident #60 stated he had been waiting since 8:00 A.M. Resident #60 stated State tested Nurse Aide (STNA) #301 had stopped in his room about an hour ago and stated she had one shower to do before getting to him. Resident stated he had issues getting assistance with his ADL including getting his hair shampooed as ordered. Resident #60 stated he only received his hair shampooed once in the past three weeks. Observation at this time of Resident #60 revealed he was sitting in his wheelchair, with only a sheet covering him, and hair appeared unkempt. Interview on 03/19/24 at 12:08 P.M. with STNA #301 stated it was her first day at the facility but stated he can do a lot on his own but was a one person assist. STNA #301 stated she had not had a chance to get to him yet and had been running around doing patient care. Follow-up interview on 03/21/24 at 9:48 A.M. with Resident #60 revealed he could not recall exactly when he his hair was shampooed but it had been early in the month. Resident #60 stated this past Tuesday, 03/19/24 an aide he had not seen before shampooed his hair. Resident #60 stated his hair had been shampooed twice since he had been at the facility. Interview on 03/21/24 at 10:46 A.M. with Licensed Practical Nurse (LPN) #219 stated a lot of times he had to help Resident #60 get up and dressed because he didn't always get the assistance in a timely manner. LPN #219 stated he was not sure if the aides washed Resident #60's on shower days or if it was getting done per physician order. Review of the MAR for March 2024 with LPN #219 verified he had signed off on 03/04/24 and 03/18/24 that Resident #60 hair was shampooed per physician order. LPN #219 stated he assumed the aides shampooed the resident's hair. Interview on 03/21/24 at 10:56 A.M. with Registered Nurse (RN) #300 stated Resident #60's hair could be shampooed during bed baths and when given a shower. RN #300 stated technically since the shampoo was a medication, the nurse should be doing it or making sure it was on the resident's hair and the aides could rinse it out. Review of the MAR for March 2024 with RN #300 verified she signed off on the order as completed on 03/11/24 and then stated she did not recall. Review of the facility policy titled Activities of Daily Living, revised 08/12/20, revealed provision of ADL (activities of daily living) care will include but not limited to staff to provide care in the following areas: this shall include, but not be limited to, eating, toileting, ambulation, bathing, dressing, and transferring.

Based on observation, interview and record review, the facility failed to ensure facility staff were provided education and Resident #53 was provided adequate treatment and monitoring for a potentially life threatening medical condition. Actual Harm occurred on 02/18/23 at 1:00 A.M. when Resident #53 developed a severe, throbbing headache, was sweating profusely, had hives and felt weak. The nurse did not understand Resident #53's medical condition and could not find Resident #53's medication used to treat the condition in the medication cart. Resident #53 requested to be transported the Emergency Department via 911. Upon return from the hospital, the facility failed to ensure medication to treat Resident #53's life threatening condition was available for administration. This affected one resident (Resident #53) of three residents reviewed for quality of care. The facility census was 80. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] and diagnoses included quadriplegia C (cervical) 5 through C7 incomplete, neuromuscular dysfunction of the bladder, bipolar disorder, and anxiety disorder. Review of Resident #53's physician orders dated, 12/23/21, revealed orders for Nifedipine capsule 10 milligram (mg), give one capsule by mouth every eight hours as needed for headache which occurred immediately after emptying bowel or bladder. Review of Resident #53's physician's orders revealed no order to discontinue this medication. Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 assessment dated , 01/06/23 revealed Resident #53 had intact cognition. Resident #53 required limited assistance from one staff member for bed mobility, extensive assistance from two staff members for transfers, and total dependence from one staff person for toilet use. Review of Resident #53's care plan, dated 01/11/23 included Resident #53 had the potential for pain due to history of headaches and immobility. The goal developed was for Resident #53 to express pain level within satisfactory limits. Interventions included to administer pharmacological interventions as indicated per physician and monitor the effectiveness; assess for verbal and nonverbal signs and symptoms relating to pain such as grimacing, guarding, crying, moaning, increased anxiety. Resident #53 had quadriplegia related to history of motor vehicle accident (MVA) with spinal cord injury. The goal developed was for Resident #53 to maintain optimal status and quality of life within limitations imposed by quadriplegia. Interventions included to give medications as ordered and assess, document for side effects and effectiveness; pain management per orders, provide alternative comfort measures as needed, contact the physician if ineffective. Further review revealed Resident #53 did not have a care plan related to autonomic dysreflexia. Review of Resident #53's progress notes dated 02/18/23 at 1:00 A.M., written by Licensed Practical Nurse (LPN) #304 included Resident #53's needs could not be met at this time due to autonomic dysreflexia after facility attempted to meet Resident #53's needs. The services at the local hospital could meet Resident #53's needs at this time. Resident #53 and her responsible party were made aware of the transfer to the hospital. Review of Resident #53's Change in Condition Evaluation, dated 02/18/23 at 1:17 A.M. included abnormal vital signs, other change in condition, and seems different than usual were marked on the form. Resident #53 had a severe headache, sweating, hives, and was weak which started on 02/18/23. Resident #53's vital signs taken on 02/18/23 at 1:00 A.M. were blood pressure was 103/59, pulse was 112, irregular, and new onset, respirations were 22 breaths per minute, temperature 96.6 Fahrenheit, oxygen saturation 98 percent on room air. Resident #53 had quadriplegia, C5 through C7, incomplete. Further review of the evaluation included Resident #53 had no changes in mental status, had general weakness, had general weakness without fever, change in level of consciousness, or other acute symptoms, had a severe headache, sweating, hives. Resident #53 had a severe headache at the front of her head and rated her pain a ten, on a scale of 0 to 10 (zero was no pain and 10 was excruciating pain). Review of Resident #53's Medication Administration Record (MAR) dated 02/18/23, revealed an order for Nifedipine capsule 10 mg, give one capsule by mouth every eight hours as needed for headache which occurred immediately after emptying bowel or bladder was not documented as given on this date. Review of Resident #53's Prehospital Care Report Summary dated, 02/18/23, included a call was received from the facility at 12:59 A.M. and Emergency Medical Services (EMS) were on the scene at 1:04 A.M. Resident #53's vital signs at 1:17 A.M. were blood pressure of 133/76 (sitting), pulse 123 and regular, respirations 18, oxygen saturation was 95 percent and pain was rate a five, on a pain scale of zero through ten. Resident #53's vital signs at 1:26 A.M. were blood pressure 100/72 (sitting), pulse 95, respirations 18 breaths per minute, oxygen saturation 97 percent. The report further revealed Resident #53 had a spinal cord issue and was experiencing an episode with this issue. Resident #53 stated she had autonomic dysreflexia and was having a flare up with this condition. Resident #53 stated when this happened she experienced pain, high blood pressure, and a high heart rate. Resident #53 stated she would like to be seen at the hospital because of this flare up. Resident #53 stated the flare up started about five minutes prior to EMS arrival. Resident #53's status remained the same throughout transport. Review of Resident #53's medical record including progress notes, physician orders, and care plans dated 11/28/19 through 02/28/23, did not reveal documentation Resident #53 had autonomic dysreflexia (abnormal, overreaction of the involuntary (autonomic) nervous system to stimulation. This reaction may include change in heart rate, anxiety, dizziness, blurred vision, excessive sweating, high blood pressure, severe throbbing headache). The medical record did not include instructions on how to provide care and monitor Resident #53 for the condition. Review of Resident #53's After Visit Summary dated, 02/18/23, included Resident #53 had an acute non intractable tension-type headache, nausea and vomiting, history of quadriplegia, acute cystitis with hematuria and autonomic dysreflexia. Resident #53 was administered Ceftriaxone (antibiotic medication), Ketorolac (pain medication), and Scopolamine (transderm-scop patch to stop nausea and vomiting). Resident #53's discharge instructions included Scopolamine (transderm-scop) (antiemetic) one mg over three days, apply patch as directed every 72 hours; Sulfamethoxazole-Trimethoprim (Bactrim DS antibiotic) 800-160 mg, take one tablet by mouth twice daily for seven days. Review of Resident #53's Order Audit Report dated, 02/18/23, revealed Nifedipine 10 mg capsule, give one capsule by mouth every eight hours as needed for headache which occurred immediately after emptying bowel or bladder was ordered from the pharmacy. Observation on 02/28/23 at 2:40 P.M. with Licensed Practical Nurse (LPN) #300 of Resident #53's medications located in the medication cart on the nursing unit Resident #53 resided on revealed Nifedipine 10 mg was not in the cart. LPN #300 stated Resident #53's Nifedipine which was ordered on 02/18/23 was on the way to the facility. LPN #300 stated she did not know why the Nifedipine was not delivered because it had been ten days since the order was placed. LPN #300 stated she called pharmacy, they could not tell her why the Nifedipine had not been delivered to the facility, but it would be delivered later today. LPN #300 indicated the pharmacy told her the prescription was current and there were no issues with it. Interview on 02/28/23 at 3:17 P.M. with LPN #300 revealed she was assigned to the nursing unit Resident #53 resided on most of the time when she worked. LPN #300 stated she did not know what autonomic dysreflexia was, but thought it had to do with the spine and affected the bowel and bladder. LPN #300 stated she did not know Resident #53 had autonomic dysreflexia. LPN #300 indicated about a year ago Resident #53 told her she had a spine injury and developed bad headaches, but did not specify what she did when she had the headaches and LPN #300 indicated she did not ask her. Interview on 02/28/23 at 3:52 P.M. with Nurse Practitioner (NP) #303 revealed she was aware Resident #53 had autonomic dysreflexia. NP #303 stated it was due to Resident #53's spinal cord injury. NP #303 stated autonomic dysreflexia could occur at the spur of the moment and was usually had an underlying cause such as a urinary tract infection. NP #303 indicated once the underlying problem was corrected the symptoms went away. NP #303 stated autonomic dysreflexia could be life threatening if it was not treated timely. NP #303 indicated medications which were classified as calcium channel blockers like Nifedipine were used to treat autonomic dysreflexia. NP #303 stated Resident #53 knew about autonomic dysreflexia and was aware of the symptoms and would let staff know if she had a problem. NP #303 stated she was aware Resident #53 was transported to the Emergency Department, Resident #53 had a severe onset of a headache and requested to go to the hospital. NP #303 stated if Resident #53's Nifedipine had been available it probably would have helped, and she was not aware the Nifedipine was not available on 02/18/23 when Resident #53 was taken to the hospital. NP #303 indicated she started working in the facility in May 2022 and as far as she knew Resident #53 had not taken the Nifedipine since that time. NP #303 stated it would be better if the trip to the Emergency Department was avoided, but the facility needed to abide by Resident #53's wishes. NP #303 stated Resident #53 was diagnosed with a urinary tract infection at the Emergency Department and placed on Bactrim. Observation on 02/28/23 at 4:44 P.M. of Resident #53 revealed she was sitting in a padded wheelchair in her room and had just returned to the facility from an appointment. Interview on 02/28/23 at 4:44 P.M. with Resident #53 revealed when she first moved into the facility on [DATE] her autonomic dysreflexia was documented and she was able to have Nifedipine when she had a trigger. Resident #53 stated she had no idea where it was documented but the facility and nurses were aware of the condition and had been educated on it. Resident #53 stated the nursing staff was aware of her condition, would check her for triggers, and knew to administer Nifedipine when she had a trigger. Resident #53 stated the nurses who knew about her condition had all resigned and did now work for the facility now. Resident #53 stated when she first moved to the facility, she was having frequent urinary tract infections which would cause a flare up. Resident #53 indicated the triggers started to slow down and her last flare up was at least eight months ago. Resident #53 stated she had a spinal cord injury and autonomic dysreflexia would always be something she had to pay attention to. Resident #53 revealed on 02/18/23 she was in her padded wheelchair her room, had a pounding headache, was profusely sweating, and she wheeled into the common area where the nurses and aides were. Resident #53 stated she asked an unidentified aide to take her socks off because that would sometimes help with the symptoms. Resident #53 indicated after her socks were removed her head continued to pound, she knew her bladder was empty, she had a bowel movement, and knew she needed help. Resident #53 stated she told Licensed Practical Nurse (LPN) #304 she was having an autonomic dysreflexia flare up and was having symptoms of panting, profusely sweating, and headache. Resident #53 stated LPN #304 did not know what was going on and checked her blood pressure, but the wrist cuff did not work and her blood pressure was unable to be obtained. Resident #53 revealed LPN #304 stated what do you want me to do?, I don't know what to do, and Resident #53 was able with difficulty to say the word Nifedipine. LPN #304 looked in the computer, saw the order for Nifedipine, looked in the medication cart, was not able to find Nifedipine and told Resident #53 there was no Nifedipine in the cart. Resident #53 stated her head hurt so bad, she had difficulty speaking, but was able to tell LPN #304 to call 911. Resident #53 stated it was extremely scary for her to be in that situation because if she was not able to tell the nurses what she needed she could have had a seizure or stroke. Resident #53 stated if she was in the middle of a flare up and the nurses did not know how to treat her that was really scary. Resident #53 stated if she could have been administered the Nifedipine, it was a calcium channel blocker, and she would not have needed to be transported to the hospital. Resident #53 stated she did not know what medications she was administered while in the Emergency Department because she was so out of it. Resident #53 indicated the Emergency Department staff told her the autonomic dysreflexia could have been triggered from a urinary tract infection or her pressure ulcer. Resident #53 stated after she returned to the facility from the Emergency Department, she told Regional [NAME] President of Operations (RVPO) #301 and Registered Nurse/Unit Manager (RN/UM) #305 about the issue with autonomic dysreflexia and RVPO #301 stated she would look into it. Interview on 02/28/23 at 4:17 P.M. with Regional [NAME] President of Operations (RVPO) #301 and Regional Director of Clinical Services (RDCS) #302 revealed they did not know why Resident #53's Nifedipine was not in the medication cart. RVPO #301 and RDCS #302 stated pharmacy was called and they were waiting for a call back to explain why the Nifedipine was not available for Resident #53. RDCS #302 stated Resident #53 was receiving Bactrim DS to treat a urinary tract infection. Interview on 02/28/23 at 4:20 P.M. with Nurse Practitioner (NP) #303 revealed Resident #53 was administered Scopolamine for dizziness related to autonomic dysreflexia. NP #303 stated autonomic dysreflexia could happen when a spinal cord injury was sustained. NP #303 stated she would like to see education for the staff regarding autonomic dysreflexia and how to react to it when it occurred. Interview on 02/28/23 at 4:45 P.M. with RDCS #302 revealed Nifedipine was stocked in the automated medication dispensing system. RDCS #302 did not know why LPN #304 was not aware Nifedipine was stocked in the automated medication dispensing system. Review of the automated medication dispensing system inventory revealed Nifedipine 10 mg capsule was available in the system for the residents. Interview on 02/28/23 at 5:04 P.M. with RVPO #301 revealed Resident #53 talked to her about situation involving Resident #53's autonomic dysreflexia. RVPO #301 stated Resident #53 asked if she knew she went to hospital and there was a medication ordered when she was first admitted that wasn't available in the medication cart when she was having symptoms. RVPO #301 stated she told Resident #53 she would look into it and would check with the Director of Nursing. RVPO #301 stated she asked the DON about the situation. RVPO #301 stated Resident #53 had been a resident in the facility for a few years, physicians could discontinue medications if they were not used, and Nurse Practitioner #303 was coming to the facility the day Resident #53 talked to her or the next day and could see Resident #53 then. Review of Physiopedia article titled Autonomic Dysreflexia, undated, included Autonomic Dysreflexia (AD) was a common life-threatening condition after a spinal cord injury (SCI), usually occurred if SCI was at or above the T6 level. AD was characterized by a sudden, exaggerated reflexive increase in blood pressure in response to a noxious stimulus, commonly bladder or bowel distension, arising below the neurological level of injury. Acute AD was characterized by severe paroxysmal hypertension associated with a throbbing headache, profuse sweating, flushing of the skin above the level of the lesion, bradycardia, cool, pale skin below the level of injury, and visual disturbances, dizziness, and anxiety, feeling of doom, which was sometimes accompanied by cognitive impairment. The most common initial complaint was a severe throbbing headache. Many patients with spinal cord injuries would have hypotension. Orthostatic hypotension was found in over 50 percent of patients with autonomic dysreflexia. This deficiency represents non-compliance investigated under Complaint Number OH00140467.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide necessary care and services to prevent one resident (Resident #11) from developing an unstageable pressure injury to the sacrum. Actual Harm occurred when Resident #11 complained of pain to his sacral area, and redness on the sacral area was observed by State tested Nursing Assistant (STNA) #134 and reported to a nurse on 08/17/21, and no interventions were implemented to prevent the redness from progressing to an unstageable pressure ulcer on 08/26/21. In addition, the STNAs did not ensure Resident #11's heels, which were already soft, red, and boggy, were elevated off the mattress when he was in bed. This affected one resident (Resident #11) of three residents reviewed for pressure ulcers. The facility census was 56 residents. Findings include: Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was placed on Hospice on 10/02/20. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment, dated 07/08/21, revealed the resident had moderate cognitive impairment, required extensive assistance and was a one person physical assist for bed mobility, transfers, and toilet use. Further review of the assessment included Resident #11 did not have a pressure injury or ulcer, but was at risk for developing one. Review of Resident #11's care plan dated, 10/13/20 included the resident had the potential for skin breakdown related to impaired balance and mobility along with incontinence, and the resident would maintain intact [NAME] through the review period. Interventions included to complete Braden Scale Assessment per protocol, complete skin assessment per protocol, elevate heels off bed as tolerated, and encourage repositioning and assist as needed. Review or Resident #11's Braden Scale Pressure Ulcer Risk assessment dated , 04/16/21 revealed the resident was low risk for developing a pressure injury or ulcer. There were no additional Braden assessments from 04/16/21 through 08/26/21. Review of Resident #11's Braden Scale Pressure Ulcer Risk assessment dated , 08/26/21 revealed the resident was at a moderate risk for developing a pressure injury or ulcer. The assessment indicated Resident #11's skin was occasionally moist, requiring an extra linen change approximately once a day, his ability to walk was severely limited or non-existent, and he could not bear own weight and/or must be assisted into chair or wheelchair. Resident #11 made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. Resident #11 required moderate to maximum assistance in moving. Complete lifting without sliding against sheets was impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Review of Resident #11's Weekly Skin Evaluation dated, 08/17/21 revealed Resident #11 had current skin issues, and no new identified skin issues. Review of Resident #11's Weekly Skin Evaluation dated, 08/24/21 revealed Resident #11 had no current skin issues, and no new identified skin issues. Observation on 08/26/21 at 10:18 A.M. of Resident #11 revealed he was laying supine in his bed, and his heels were resting directly on the mattress. There was no observation of heel protectors or elevation of his heels off the mattress. Observation on 08/26/21 at 10:18 A.M. of STNA #132 providing incontinence care for Resident #11 revealed Resident #11's incontinence brief was very wet. Further observation revealed a very dark red mark on the front of Resident #11's upper left thigh and extending around the inner thigh. The mark was about six inches long and about a half inch wide. STNA #132 stated the mark looked like it was from the incontinence brief fitting too tight or it was too small. STNA #132 rolled Resident #11 onto his left side, and observation of the left sacral area revealed an approximately three inch area was very dark red, did not blanche, and had a dime sized dark purple circle in the middle of the very dark, red area. Observation of Resident #11's right buttocks revealed red splotches over an approximately four inch area of skin. Interview on 08/26/21 at 10:18 A.M. with STNA #132 confirmed the dark red areas on Resident #11's left sacral area and left thigh did not blanche. STNA #132 stated she made rounds at around 7:00 A.M. when she arrived for work, with an unidentified night shift STNA and Resident #11's incontinence brief was not wet and not changed. STNA #132 stated she did not check Resident #11's incontinence brief again until 10:18 A.M.and had not turned and repositioned him. Interview after intervention of the surveyor on 08/26/21 at 10:33 A.M. with the Director of Nursing (DON) stated the dark red mark on Resident #11's thigh looked like it was from the leg of the incontinence brief fitting too tight. The DON confirmed Resident #11's left sacral area had a very dark red area with a dime size dark purple circle in the middle of it. The DON stated she wound have the wound nurse evaluate Resident #11's thigh and buttocks. Interview on 08/26/21 at 10:38 A.M. with Wound Nurse/Licensed Practical Nurse (WN/LPN) #133 revealed the dark red mark on Resident #11's left thigh did not blanche, and was from the incontinence brief fitting too tightly. The mark measured length 1.8 centimenters (cm), width 8.4 cm, and the depth was unable to be determined. Resident #11 cried out in pain while WN/LPN #133 measured the left inner thigh area and observation revealed the left side of the scrotum was red and excoriated. Interview on 08/26/21 at 10:38 A.M. with WN/LPN #133 confirmed Resident #11's left sacral area had a dark red area, there was a dark purple dime size area in the middle of the dark red area, and it did not blanche. WN/LPN #133 stated Resident #11 had a Deep Tissue Injury to the left sacral area. WN/LPN #133 measured the red area on the left sacral area revealing length 3.4 cm, width 4.2 cm, and depth was unable to be determined. WN/LPN #133 confirmed Resident #11's right buttock had an area of red splotches, and the area blanched. Observation on 08/26/21 at 10:38 A.M. of Resident #11's right and left heels with WN/LPN #133 revealed both heels were soft, red, and boggy. WN/LPN #133 stated Resident #11 was at a high risk for skin breakdown and his heels should not be resting dirctly on the bed, but should be elevated to relieve the pressure on them. WN/LPN #133 stated he needed heel protectors, and a low air loss mattress. Observation on 08/26/21 at 11:15 A.M., 1:00 P.M., 3:15 P.M. and 4:00 P.M. revealed Resident #11 laying supine in bed and his heels were resting directly on the mattress and were not elevated. There were no observations of staff encouraging Resident #11 to turn and reposition or to elevate the heels off of the mattress. Interview on 08/26/21 at 2:20 P.M. with STNA #134 revealed most of the time when she arrived for work she was assigned to the nursing unit Resident #11 resided on. STNA #134 stated on 08/25/21 Resident #11 had a red mark on his left leg from sitting in his urine, stated his incontinence brief was too tight and he told her his butt hurt. STNA #134 stated on 08/17/21 she told a nurse Resident #11 stated his butt hurt and it was red. STNA #134 stated she did not know the name of the nurse. STNA #134 stated the red mark on Resident #11's leg was not there on 08/17/21. Interview on 08/26/21 at 3:27 P.M. with Licensed Practical Nurse (LPN) #131 revealed skin assessments were done weekly and it was the responsibility of the nurse's on all shifts to make sure they were completed. LPN #131 stated the skin assessments were done on shower days, and she would glance at the residents skin during showers or bed baths to evaluate for any issues. LPN #131 stated Resident #11 had redness after incontinence. LPN #131 did not think redness after incontinence was a new issue and that was why she marked no on the 08/17/21 Weekly Skin Assessment to the question about any new identified skin areas. LPN #131 marked yes to the question asking if Resident #11 had current skin issues. LPN #131 stated Resident #11's redness to his bottom was the kind that could be resolved with barrier cream after incontinence. LPN #131 stated she did not go back and check Resident #11 to see if the redness went away. LPN #131 stated the STNAs did not report any skin issues and she did not know there was a problem. Interview on 08/26/21 at 5:07 P.M. with LPN #130 revealed she completed Resident #11's Weekly Skin Evaluation on 08/24/21. LPN #130 stated she marked no to the questions regarding any current skin issues and any new identified skin issues. LPN #130 stated Resident #11 was showing a little red on his bottom, she told the STNA to grease him up and the red would go away. LPN #130 stated she did not go back to check Resident #11 to see if the redness went away because he would be checked on his next shower day. Observation on 08/30/21 at 7:05 A.M. of Resident #11 with LPN #130 revealed a dark purple open area on the left sacral area approximately one to two cm wide with serosanguinous drainage. LPN #130 confirmed the dark purple area on the left sacral area had serosanguinous drainage. Further observation revealed Resident #11's heels were resting directly on the mattress and there was a blanket under his calves. LPN #130 confirmed the heels were directly on the bed and stated she was the only nurse on the nursing unit, did not have an STNA, and could not leave to find something to elevate Resident #11's heels. LPN #130 stated she used a blanket, but it was not working because the heels were still laying directly on the bed. Observation on 08/30/21 at 8:00 A.M., 11:00 A.M. and 1:43 P.M. of Resident #11 revealed he was laying supine and his heels were resting directly on the mattress. There were no observations of staff encouraging or assisting Resident #11 to turn and reposition or to elevate his heels off the mattress. Interview on 08/30/21 at 1:43 P.M. with STNA #107 revealed she had not turned or repositioned Resident #11 since she arrived for work at 7:00 A.M. STNA #107 stated she was too busy providing care and giving baths to other residents, to turn or reposition Resident #11. STNA #107 confirmed Resident #11's heels were resting directly on the bed. STNA #107 stated the dark red mark on his left leg was from the incontinence brief and there was no reason for that to occur. Interview on 08/31/21 at 10:17 A.M. with Wound Physician (WP) #135 revealed Resident #11's left sacral wound was a Deep Tissue Injury (DTI) and measured length 2 cm, width 2 cm, and depth was unable to be determined. WP #135 stated immobility, and not being turned and repositioned contributed to the development of the DTI. Review of the Wound Evaluation and Management Summary on 08/31/21 revealed Resident #11 had multiple wounds. Resident #11 had an unstageable Deep Tissue Injury to the coccyx, partial thickness and measured length 2 cm, width 2 cm and unable to determine depth. Resident #11 had a wound of the left posterior thigh, partial thickness and measured a length 0.4 cm, width 0.4 cm and depth was unable to be determined. Resident #11 had a wound to the left anterior thigh, partial thickness and measured length 0.4 cm, width 5 cm, depth unable to be determined. Review of Resident #11's nurse's progress notes on 08/26/21 revealed an unstageable pressue ulcer to the sacrum. Measurements were length 3.4 cm, width 4.2 cm, and depth unable to be determined. The notes stated the wound bed was black, the wound was a new wound, in-house acquired and skin impairment was not present on admission. Review of Resident #11's physician orders revealed an order on 08/26/21 to cleanse the left sacrum with normal saline, pat dry, apply Triad cream and cover with a foam dressing every night shift for wound care and as needed for soiled, lifting, or drainage. Review of Resident #11's physician orders revealed an order on 08/26/21 to cleanse the left inner thigh region with normal saline, pat dry, apply [MEDICATION(S)] every shift for wound care and as needed. Review of Resident #11's physician orders revealed on 08/26/21 for an air mattress to bed and check placement and function every shift. Review of Resident #11's physician orders on 08/26/21 revealed an order to leave his incontinence brief loosely open while in bed as tolerated Review of Resident #11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's nurse's progress notes from 08/01/21 through 08/30/21 did not reveal documentation Resident #11 refused to be turned and repositioned or to elevate his heels off of the mattress. The progress notes did not reveal documentation staff encouraged Resident #11 to turn and reposition and to elevate his heels off the mattress. Review of the facility policy titled, Pressure Injury Prevention and Treatment Policy, dated 07/17/13 included resident's will be assessed for pressure injury risk on admission, quarterly, and with significan change of condition using the Braden Scale for Predicting Pressure Ulcer Risk. wounds identified will be assessed initially and at least weekly thereafter, until closed to include the following elements: location and stage, size, exudate, pain, wound bed, appearance of surrounding tissue, and any evidence of infection. The facility will notify family/resident representatives and the provider of any newly acquired or worsening pressure injuries and any changes in treatments. This deficiency substantiates Complaint Number OH 851.

Based on observation, interview and record review, the facility failed to administer medications to Resident #22 according to the physician's orders. Actual harm occurred when Resident #22 was admitted to the facility on [DATE] at 6:00 P.M. and did not receive anticonvulsant medication (seizures), experienced seizures and was transported to the Emergency Department via Emergency Medical Services (EMS) on 03/24/21 and admitted to the intensive care unit due to seizures. This affected one (Resident #22) of three residents reviewed for physician orders. The facility census was 69. Findings include: Review of Resident #22's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #22 had severe cognitive impairment and required extensive assistance with activities of daily living. Review of Resident #22's discharge summary from the hospital dated 03/21/21 at 8:57 A.M. included administer [MEDICATION(S)] ([MEDICATION(S)]) (anticonvulsant) 50 milligrams (mg) by mouth every Monday, Wednesday, and administer [MEDICATION(S)] ([MEDICATION(S)]) 150 mg by mouth two times a day. Review of Resident #22's physician orders on 03/23/21 at 9:37 A.M. (two days after admission) [MEDICATION(S)] 50 mg; give one tablet by mouth, one time a day, every Monday, Wednesday, and Friday for seizures for 30 days, take with [MEDICATION(S)] 150 mg to equal 200 mg, start 03/24/21 at 9:00 A.M. (Hospital discharge instructions did not state to take [MEDICATION(S)] 50 mg with [MEDICATION(S)] 150 mg to equal 200 mg), and [MEDICATION(S)] 150 mg ([MEDICATION(S)]); give one tablet by mouth, one time a day, every Monday, Wednesday, and Friday for seizures for 30 days, take with 5 mg to equal 200 mg, start 03/24/21 at 9:00 A.M. (Hospital discharge instructions were 150 mg two times a day). Review of Resident #22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (three days after admission), and [MEDICATION(S)] 150 mg ([MEDICATION(S)]); give one tablet by mouth, one time a day (the hospital discharge instructions were 150 mg two times a day), every Monday, Wednesday, and Friday for seizures for 30 days, take with 5 mg (order stated 50 mg) to equal 200 mg, start date 03/24/21 at 9:00 A.M. (three days after admission). Review of Resident #22's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #22 was transported to the hospital via EMS on 03/24/21. Review of Resident #22's discharge summary from the hospital dated 03/21/21 at 8:57 A.M. included to administer [MEDICATION(S)] ([MEDICATION(S)]) (sedative to treat seizures) 1.5 mg by mouth three times a day. Review of Resident #22's physician orders on 03/23/21 at 9:37 A.M. (two days after admission) revealed [MEDICATION(S)] tablet 0.5 mg ([MEDICATION(S)]); give one tablet by mouth three times a day for [CONDITION(S)], anxiety, and muscle spasms. (The hospital discharge instructions were 1.5 mg three times a day). Review of Resident #22's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (two days after admission). Documentation revealed the medication was administered 03/23/21 at 2:00 P.M. and 10:00 P.M., and 03/24/21 at 6:00 A.M. Observation on 03/24/21 at 10:38 A.M. of Resident #22 revealed while Licensed Practical Nurse (LPN) #304 was administering medications, State tested Nursing Assistant (STNA) #277 called for LPN #304 to come to Resident #22's room because he was having a [CONDITION(S)]. LPN #304 ran to the room, and Resident #22 was sitting in a padded wheelchair slumped to the side of the chair, jerking motions noticed from his arms and legs, jaw was moving, eyes rolling back, and clear material draining out of his mouth onto his chin. Resident #22 was wearing incontinence briefs, was diaphoretic, he threw up yellowish brown material, his foot jerked, hit the side of the wheelchair and his toe started to bleed. STNA #277 supported Resident #22 head so he would not choke or injure himself. Resident #22's vital signs included blood pressure 158/92, pulse 110, temperature 96.9 degrees Fahrenheit, and blood sugar was 151. The EMS crew arrived and took over care. Interview on 03/24/21 at 10:43 A.M. of LPN #304 stated she did not give Resident #22 his [CONDITION(S)] medications before he was taken to the hospital by EMS. Interview on 04/01/21 at 12:24 P.M. with Family Member (FM) #306 stated Resident #22 was doing so well at the hospital before he was readmitted to the facility on [DATE]. FM #306 stated he was walking with assistance and feeding himself. FM #306 stated she was called on 03/24/21 and notified Resident #22 had been transported by EMS to the emergency room because he was having seizures. FM #306 stated Medical Doctor (MD) #305 told her Resident #22 had been admitted to the intensive care unit for observation due to his many seizures. Interview on 04/01/21 at 1:58 P.M. with Medical Doctor (MD) #305 revealed MD #305 was a neurologist and cared for Resident #22 at the hospital. MD #305 stated Resident #22 was admitted to the hospital on 03/24/21 and was in the intensive care unit overnight for respiratory watch. Resident #22 was currently residing on a nursing unit in the hospital. MD #305 stated Resident #22 had quite violent breakthrough seizures and he was highly suspicious Resident #22 did not receive his [CONDITION(S)] medications [MEDICATION(S)] and [MEDICATION(S)] before he came to the Emergency Department on 03/24/21. MD #305 further stated if Resident #22 missed his [MEDICATION(S)] for one day he had breakthrough seizures and if missed two or three doses of [MEDICATION(S)] he had breakthrough seizures. MD #305 knew Resident #22 well and stated if he received his [CONDITION(S)] medications the way they were ordered he did not have breakthrough seizures. This admission Resident #22 did not have any other reason that could cause breakthrough seizures which was why he was very suspicious Resident #22 did not receive his [CONDITION(S)] medicine. MD #305 stated Resident #22 should receive [MEDICATION(S)] 150 mg two times a day, and every Monday, Wednesday, Friday should receive an additional [MEDICATION(S)] 50 mg as a booster dose after [CONDITION(S)]. Resident #22 should also receive [MEDICATION(S)] 1.5 mg three times a day. Interview on 04/01/21 at 10:20 A.M. with LPN #307 revealed she was working on 03/22/21 when Resident #22 was readmitted from the hospital. LPN #307 stated Resident #22 was admitted around 7:15 P.M., she took his vital signs, did a head to toe assessment, and was assisted by a STNA to get him settled into his room. It was time for LPN #307 to go home, and LPN #307 gave the admission paperwork, including medications needing ordered and verified with the physician to LPN #309 and told her this still needed to be completed for Resident #22. LPN #307 went home and when she arrived for work at 7:00 A.M. on 03/23/21, LPN #309 gave her the paperwork back stating she did not complete it and did not order and verify medications with the physician, and it still needed done. LPN #307 stated she was so upset this was not done and refused to take responsibility for completing the paperwork and ordering Resident #22's medications. Assistant Director of Nursing (ADON) #259 was notified about the situation. ADON #259 assigned LPN #308 to complete Resident #22's paperwork, verify the medications with the physician and order the medications. LPN #308 completed the admission for Resident #22 but did not have access in the electronic system to acknowledge the medications and have them uploaded and released because he was an agency nurse to. LPN #307 stated she had to do that for LPN #308 which was why her name showed up in the electronic system. LPN #307 stated she was very upset Resident #22 went so long without his medications. Interview on 04/01/21 at 5:16 P.M. with the Director of Nursing (DON) revealed pharmacy orders should be put in right away after residents were admitted to the facility. The nurse should call the physician and review residents medications and have them verified so they could be processed by the pharmacy and delivered to the facility. This deficiency substantiates Complaint Number OH 157.

Based on observation, interview, and record review, the facility failed to provide Basic Life Support (BLS) including Cardiopulmonary Resuscitation (CPR) timely to a resident who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) Also, the facility failed to have a consistent system in place to ensure staff could access accurate resident code status quickly and the facility was not equipped to provide full CPR as evidenced by failure to have ambu bags (self-refilling mask units used for artificial respirations) available to provide rescue breathing. Three of three crash carts did not have an ambu bag as required for the administration of CPR per the American Heart Association. The first responders report indicated that R11 died . Additionally, review of all residents' current code status revealed a discrepancy between the facility's systems where for one resident (R12) the code status was identified as Full Code in one system and Comfort Care (end of life care that provides relief of pain, discomfort or nausea but usually indicates no resuscitation efforts would be administered should the person's heart stop or the person stops breathing) in the other system used to identify code status. The facility's failures had the potential to affect any of the 120 facilitiy residents in the event of cardio/pulmonary arrest due to the likelihood staff would not correctly identify the person's code status and the likelihood that if CPR was indicated that rescue breathing would not be provided due to failure of the facility to have ambu bags available for use. The Immediate Jeopardy began on [DATE] when R11 did not receive timely and proper CPR due to RN3's actions of determining R11's code status, the ability to determine the resident was in cardiopulmonary failure, and the facility not being equipped with an ambu bag to deliver breaths during CPR. On [DATE] at 8:35 PM, the facility Administrator was notified of the Immediate Jeopardy at F678, Cardio-Pulmonary Resuscitation (CPR). The removal plan for the Immediate Jeopardy was validated on [DATE] through interviews and documentation reviews. Review of the facility's records revealed all Licensed Nurses were currently CPR certified and RN3 had been scheduled for a CPR class. Interviews were conducted with facility nursing staff and all had been educated on what to do if they found someone unresponsive including calling a code. Review of the facility's records revealed all staff had been called in and had demonstrated Mock Codes with competency check offs. Observation of all three crash carts revealed they now contained ambu bags. Review of the facility records revealed the nursing staff had been educated on ensuring the crash cart was restocked. Review of the updated Nurses Report Sheet, revealed R12's code status was correctly reflected. Interviews were completed with nursing staff to validate where they could quickly locate a resident's code status. The facility was notified that the Immediate Jeopardy was removed on [DATE] at 6:35 PM. After the Immediacy was removed, the noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy at a pattern until sustained compliance can be attained and verified. Findings include: 1. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) revised [DATE], revealed Licensed nurses .will hold active CPR certification for healthcare providers by an American Heart Association (AHA) approved provider .CPR will be provided to all residents/patients who experience cardiopulmonary arrest unless one or more of the following is present: A valid Advance Directive or POLST [physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Resuscitative efforts which have been initiated may be withdrawn if any of the documents listed above is discovered and efforts to that point have been unsuccessful .Activate the emergency response team: the resident should not be left alone, if you are alone with the victim, call out for help, if someone is nearby, instruct them to dial [DATE] immediately, in the event help is not available, call 911 prior to starting CPR, return as soon as possible . Review of the American Heart Association's website titled, What is CPR, revealed .Immediate CPR can double or triple chances of survival after cardiac arrest .For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths. https://cpr.heart.org/en/resources/what-is-cpr Review of R11's undated Admission Record, located in R11's electronic medical record (EMR) under the profile tab revealed R11 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of R11's Admission Record revealed an Advance Directive (a written statement of the person's wishes regarding medical treatment) of Full Code. Observation on [DATE] at 9:35 AM revealed first responders of two Emergency Medical Service (EMS) personnel with a stretcher and one police officer going down the 400 hall to R11's room. Observation on [DATE] at 9:37 AM revealed the EMS personnel performing CPR on R11. Interview on [DATE] at 9:50 AM with Nurse Practitioner (NP)1 revealed she was the one who initiated CPR on R11; however, she was not the person who discovered R11 unresponsive. Continued interview with NP1 revealed she received a call on her cell phone from RN3 who stated R11 was unresponsive. NP1 stated she went directly to R11's room. NP1 also stated RN3 had not started CPR. When asked if RN3 should have started CPR before calling her on her personal cell phone, NP1 stated, Yeah, she probably should have. Interview on [DATE] at 10:05 AM with RN3 revealed she discovered R11 unresponsive at approximately 9:15 AM when she entered R11's room to obtain her blood sugar. Continued interview with RN3 revealed she then exited R11's room to go check R11's code status. RN3 stated on her way to check R11's code status, from her personal cell phone, she called NP1. RN3 also stated while checking R11's code status, she called 911 from the nurses' station and reported the problem and room number and then on her way back to R11's room got the crash cart and returned to R11's room. Further interview revealed when she returned back to R11's room, NP1 had already initiated CPR. A subsequent interview on [DATE] at 10:40 AM with RN3 revealed that the medication cart with R11's EMR was outside R11's room; however, she did not remember if she used the computer on the medication cart or the computer at the nurses' station to look up R11's code status. When asked what assessment she used to determine if R11 was unresponsive, RN3 stated R11's chest did not rise, no response to stimuli, no radial pulse, and absence of heart tone and breath sounds. RN3 stated she did not check for a carotid pulse. RN3 also stated R11 was warm to touch and had normal color. Continued interview with RN3 revealed she seen that the Director of Rehab was in the hallway and she had asked her to come stay with R11 while she obtained the resident's code status. When asked why she called the NP1, RN3 stated she wanted to make sure R11 was unresponsive and was in need of CPR. RN3 stated she did not provide any CPR to R11. RN3 stated she called NP1 at 9:17 AM per her call log on her cell phone. RN3 also stated using the facility's phone she called 911 immediately after hanging up with the NP1. RN3 stated she was not sure if her CPR certification was current. During interview on [DATE] at 10:56 AM with the Director of Rehab, she stated she was not CPR certified. Continued interview revealed that RN3 stepped out in the hallway and asked her to come in R11's room because she did not know if R11 was breathing or not. The Director of Rehab stated she witnessed RN3 assess R11 for breaths, stated she needed to make a phone call, and then RN3 exited the room. The Director of Rehab stated the RN3 was gone for approximately one minute before NP1 came into the room. Interview on [DATE] at 1:15 PM with NP1 revealed RN3 had called her personal cell phone and asked her to come to R11's room because the resident was unresponsive. NP1 stated she arrived to R11's room within 20 seconds of the phone call, donned full Personal Protective Equipment (PPE), and entered the room. NP1 also stated RN3 was waiting outside R11's room when she arrived. NP1 further stated the resident's mouth was open, R11 was not breathing, and she directed RN3 to find out what R11's code status was and to call 911. Continued interview with NP1 revealed RN3 brought back a crash cart and indicated R11 was a full code and she (NP1) then initiated CPR. NP1 stated no one else was in R11's room when she arrived. NP1 further stated the regional nurse arrived and took over CPR and the Director of Nursing (DON) brought in a second crash cart. Neither crash cart was equipped with an ambu bag to provide rescue breathing for R11. Review of the first responders Incident/Offense Report, dated [DATE] revealed RN3 called 911 at 9:30 AM, which was approximately 14 minutes after RN3 discovered R11 unresponsive. Continued review of the incident/offense report revealed .CPR protocols followed/unsuccessful, which indicated R11 had expired. Interview on [DATE] at 10:00 AM with the DON revealed it was her expectation that RN3 would have checked R11's code status and called a code (made an announcement over the facility intercom to alert staff to respond to an emergency such as need to administer CPR). The DON stated RN3 should not have called NP1 first. Interview on [DATE] on 1:30 PM with the Regional Director of Clinical Services (RDCS) revealed when she arrived the NP1 was performing CPR on R11. The RDCS stated NP1 was tired and complained of pain so she took over CPR. When asked, the RDCS stated to her knowledge no rescue breaths were given to R11. The RDCS stated when she arrived to R11's room, she looked in the crash cart for an ambu bag; however, the crash cart did not contain one. The RDCS also stated when the second crash cart arrived, she looked for an ambu bag in it and there was not one. The RDCS further stated rescue breaths should be given because that was part of the facility CPR protocol. Observation on [DATE] at 1:40 PM with the RDCS observation of the two crash carts revealed no ambu bags were in the carts. The RDCS stated there were only two crash carts in the facility. Interview on [DATE] at 10:50 AM with the RDCS revealed she had realized that the facility had a third crash cart. Observation and interview on [DATE] at 10:52 AM with RDCS of the third crash cart located outside the therapy gym, revealed there was no ambu bag located in the crash cart. Review of RN3's CPR certification records provided by the Administrator, revealed RN3's CPR certification expired on ,d+[DATE], which indicated the RN3 had been without a CPR certification for approximately 14 months. During an interview with the Administrator on [DATE] at 5:59 PM, the Administrator provided RN3's CPR card and verified the RN's CPR certification expired ,d+[DATE]. 2. All 61 of the facility residents EMR's were reviewed to assess code status. Thirty-one facility residents were documented to request to be a Full Code. Interview with the DON on [DATE] at 11:07 AM revealed, the process to verify a resident's code status by nursing was they could look in the resident's EMR or look at the Nurses Report Sheet. The DON stated, the Nurses Report Sheet was not a 'system' but every unit used them. The DON also stated there were no other mechanisms for nurses to use other than the EMR and the paper Nurses Report Sheet and they could use either to determine the code status of a resident. On [DATE] at 11:30 AM, the DON and the surveyor went to three of three nurse's stations to find the Nurses Shift Report sheet. On the 400 hall the DON found an undated nurse's shift report indicating R12 as CC (Comfort Care). Review of R12's EMR indicated Full Code on the first page of the record. During this review, the DON stated, We don't date them, these are old, but this is the one the nurses would use today to check current code status. I don't review them for accuracy. The nurse managers update them on the night shift. The DON agreed that the shift report had not been updated to show R12's current full code status. Interview on [DATE] at 6:10 PM with RN4 revealed the shift report was used by the nurses to identify a resident's code status. RN4 stated she did not go into the EMR on the computer to check for resident's code status, she would utilize the shift report sheet which had residents' code statuses on it.