Every finding on record at Indian Lake Rehabilitation Center

Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to report an allegation of abuse to the state agency. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the incident. The first time the facility took the information, the complainant informed the facility it was agency STNA #170 who works for an agency. Community Member #1 stated she called 3 weeks ago and was told by the Director of Nursing (DON); the facility took care of it. Community Member #1 could not identify the resident's name. Interview on 10/23/23 at 10:56 A.M., with the Social Services Designee #105 revealed the DON did receive a call from an anonymous caller about an agency nurse taking pictures of a resident and posting them on social media. Interview on 10/23/23 at 11:00 A.M., with the DON confirmed she received an anonymous call about Agency STNA #170. The anonymous caller accused STNA #170 of taking a picture of a blind black lady while smoking in her wheelchair and posted it on social media. The DON explained, because they do not have a blind black lady in the facility, she did not investigate the allegation. She interviewed the seven smokers and they all denied getting their picture taken. She reported the incident to the contracted staffing agency. The DON stated the Human Resources Manager #120 confirmed the agency also received the same complaint and will address the situation. The DON confirmed she did not report the abuse allegation to the state agency, file a Self-Reported Incident or investigate the allegation of abuse. She has no documentation of any interviews with her residents who smoke. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #64, who smokes, stated witnessing Resident #63, as the person who was in a wheelchair and a STNA let go and Resident #63 slid down the little ramp into the parking lot, but the STNA stopped her. Resident #64 denied knowing if anyone took a picture of it. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #61 stated recalled the incident when a female resident was in her wheelchair and the STNA let go of the chair and it wheeled down the ramp into parking lot. She could not recall the resident's name or if anyone took a picture. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #63, (who matched description provided by Community Member #1) revealed the resident is cognitively impaired and gets people and times confused. Resident #63 stated she does go out to smoke in a wheelchair; however, she could not recall if she was pushed in her wheelchair by an STNA down a ramp while smoking. Interview on 10/23/23 at 12:18 P.M., with the Human Resource Manager #120, from the contracted staffing agency, confirmed she received a call from the facility's DON about STNA #170 taking pictures while working. She confirmed her agency also received a call from an anonymous person who identified STNA #170 as taking pictures of a resident at the facility. Human Resource Manager #120 stated the agency followed up with STNA #170, who wrote a statement on 09/18/23 at 2:45 P.M., explaining she would never take a picture of a resident, make fun of them, or post it on social media. Human Resource Manager #120 stated she believes family members have made falls accusations about STNA #170. STNA #170 was educated over the phone on the agency use of cellphones, taking pictures and social media. Review of the policy titled, Ohio Resident Abuse Policy, dated 08/30/23, revealed it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. Facility must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. For this policy nursing home staff includes employees, consultants, contractors, volunteers, and other care givers who provide care and services to the residents on behalf of the facility. Abuse includes mental abuse, including abuse facilitated or enabled using technology. This deficiency represents noncompliance investigated under Complaint Number OH00147011.

Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to investigate and an allegation of abuse. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the incident. The first time the facility took the information, the complainant informed the facility it was agency STNA #170 who works for an agency. Community Member #1 stated she called 3 weeks ago and was told by the Director of Nursing (DON); the facility took care of it. Community Member #1 could not identify the resident's name. Interview on 10/23/23 at 10:56 A.M., with the Social Services Designee #105 revealed the DON did receive a call from an anonymous caller about an agency nurse taking pictures of a resident and posting them on social media. Interview on 10/23/23 at 11:00 A.M., with the DON confirmed she received an anonymous call about Agency STNA #170. The anonymous caller accused STNA #170 of taking a picture of a blind black lady while smoking in her wheelchair and posted it on social media. The DON explained, because they do not have a blind black lady in the facility, she did not investigate the allegation. She interviewed the seven smokers and they all denied getting their picture taken. She reported the incident to the contracted staffing agency. The DON stated the Human Resources Manager #120 confirmed the agency also received the same complaint and will address the situation. The DON confirmed she did not report the abuse allegation to the state agency, file a Self-Reported Incident or investigate the allegation of abuse. She has no documentation of any interviews with her residents who smoke. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #64, who smokes, stated witnessing Resident #63, as the person who was in a wheelchair and a STNA let go and Resident #63 slid down the little ramp into the parking lot, but the STNA stopped her. Resident #64 denied knowing if anyone took a picture of it. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #61 stated recalled the incident when a female resident was in her wheelchair and the STNA let go of the chair and it wheeled down the ramp into parking lot. She could not recall the resident's name or if anyone took a picture. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #63, (who matched description provided by Community Member #1) revealed the resident is cognitively impaired and gets people and times confused. Resident #63 stated she does go out to smoke in a wheelchair; however, she could not recall if she was pushed in her wheelchair by an STNA down a ramp while smoking. Interview on 10/23/23 at 12:18 P.M., with the Human Resource Manager #120, from the contracted staffing agency, confirmed she received a call from the facility's DON about STNA #170 taking pictures while working. She confirmed her agency also received a call from an anonymous person who identified STNA #170 as taking pictures of a resident at the facility. Human Resource Manager #120 stated the agency followed up with STNA #170, who wrote a statement on 09/18/23 at 2:45 P.M., explaining she would never take a picture of a resident, make fun of them, or post it on social media. Human Resource Manager #120 stated she believes family members have made falls accusations about STNA #170. STNA #170 was educated over the phone on the agency use of cellphones, taking pictures and social media. Review of the policy titled, Ohio Resident Abuse Policy, dated 08/30/23, revealed it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. Facility must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. For this policy nursing home staff includes employees, consultants, contractors, volunteers, and other care givers who provide care and services to the residents on behalf of the facility. Abuse includes mental abuse, including abuse facilitated or enabled using technology. This deficiency represents noncompliance investigated under Complaint Number OH00147011.

Based on medical record review and staff interview the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 35. Findings include: Review of the medical record of Resident #180 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed no results of any BMP as ordered. Review of the progress notes revealed no documentation of the physician being notified the labs were not completed. Review of the medical record revealed no laboratory reports for the BMPs. Interview on 12/16/21 at 11:00 A.M. with Director of Nursing (DON) provided verification of the lack of BMP results. DON stated they had not been obtained as ordered. This deficiency substantiates complaint #OH 116.

Based on observations, staff and resident interview, review of the life enrichment (activities) program calendar and review of facility policy, the facility failed to have an life enrichment program that met the needs of the residents by ensuring the life enrichment calendars were posted, by ensuing life enrichment programs were conducted as scheduled and by ensuring activities were offered throughout the day and evening. This affected three (#6, #23 and #10) out of 19 residents reviewed for life enrichment programs. Facility census was 37. Findings include: Observation on 06/09/21 at 9:10 A.M., revealed the life enrichment program calendars hanging on the closet door of the resident rooms. These calendars were for May 2021 and no calendars were noted to be in any of the common areas. The calendars were printed on various colors of 11 by 13-inch paper. Interview on 06/09/21 at 9:16 A.M. with Licensed Practical Nurse (LPN) #201 provided verification of the life enrichment program calendars being for the previous month. LPN #201 stated residents are not afforded activities as often because the life enrichment staff do not report to work. Interview on 06/09/21 at 9:40 A.M. with Social Service (SS) #111 revealed due to Coronavirus Disease 2019 (COVID-19) life enrichment programs had been difficult to accomplish. The life enrichment Director left in November 2021 and the facility has not been able to fill that position. The administration has tried to fill in. Residents are offered a variety of puzzle pages and bingo as well as arts and crafts to do in their rooms. The staff has had all residents watch the same movie and get popcorn. Recently the residents go to the dining room for bingo and arts and crafts. Further observations on 06/09/21 at 10:15 A.M. revealed no activity being held. Resident #6 was seated in the dining room alone, waiting for coffee and a snack. Interview on 06/09/21 at 10:23 A.M. with Resident #23 revealed The girl just hung the new life enrichment program calendar pointing to the closet door. When asked whether she could read the small print, Resident #23 stated not really. Resident #23 stated the life enrichment programs don't always start on time. Interview on 06/09/21 at 10:30 A.M. with Activity Aide (AA) #322 confirmed music and body movement was not being done at this time as residents are still getting ready for the day. AA #322 was observed hanging new activity calendars in the rooms during the interview. The calendars were printed in small font on a plain white sheet of 13 by 8.5-inch paper. AA #322 verified the print size was difficult to read. Observation on 06/09/21 at 11:02 A.M. revealed six residents seated in the dining area. Resident #10 stated she is ready for exercise. At 11:05 AA #322 entered and started a video with two people instructing on movement while seated. The six residents participated in the movement. Interview on 06/09/21 at 2:46 P.M. with the Administrator and Director of Nursing (DON) provided verification the activity calendars were not current at the onset of this survey. The DON verified the first ones provide to the residents were a very small print and difficult for the residents to read. Review of the Life Enrichment Program Calendar for June 2021, provided on 06/09/21 at 10:00 A.M. to the surveyor, revealed only one program scheduled at 6:00 P.M. The other programs were scheduled at the latest time of 4:00 P.M. The Saturday 5:00 P.M. listing (turn in packets and recycling) was described as the residents simply turn in the weekly package to get bingo tickets for the prizes. The print on the calendar was small. The program indicated for 06/09/21 at 10:00 A.M. was Music and Body Movement. Review of the facility policy titled Life Enrichment Programming Policy dated 04/08/21 revealed evening (beginning after 6:00 P.M.) programs will be scheduled an average of twice per week Sunday through Saturday. The policy included the calendar of programs would be prepared in advance and posted for resident use by the first day of the month. This deficiency substantiates Complaint Number OH 728.

Based on personnel file record review, staff interview and review of the facility's [MEDICAL CONDITION] risk assessment, the facility failed to complete [MEDICAL CONDITION] (TB) skin testing or questionnaire was completed upon hire and/or annual. This affected eight of eight employees reviewed for TB testing. This had to the potential to affect all 36 residents residing in the facility. Findings include: Review of the personnel file for State tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19. There was no documentation that a [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for STNA #109 revealed a hire date of 02/01/19. There was no documentation that a [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for STNA #110 revealed a hire date of 12/01/16. There was no documentation that a annual [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for STNA #111 revealed a hire date of 12/01/16. There was no documentation that a annual [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for STNA #112 revealed a hire date of 06/12/18. There was no documentation that a [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for Director of Nursing (DON) #113 revealed a hire date of 04/22/19. There was no documentation that a [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for Assistant Director of Nursing (ADON) #102 revealed a hire date of 02/11/19. There was no documentation that a [MEDICAL CONDITION] skin test or questionnaire was completed. Review of the personnel file for Maintenance Supervisor #114 revealed a hire date of 04/10/19. There was no documentation that a [MEDICAL CONDITION] skin test or questionnaire was completed. Interview with the Administrator on 05/02/19 at 11:35 A.M. verified there was no documentation of [MEDICAL CONDITION] skin tests or questionnaires being completed for STNA #108, STNA #109, STNA #110, STNA #111, STNA #112, DON #113, ADON #102, and Maintenance Supervisor #114. Review of facility TB Risk Assessment Worksheet completed 04/23/19 revealed the facility was considered to be at a low risk for [MEDICAL CONDITION].

Based observation, staff interview, and review of facility policy, the facility failed to ensure medications were stored in a safe and secure manner for one (#90) resident residing in the facility. This had the potential to affect 15 (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) cognitively impaired mobile residents in the facility. The facility census was 36. Finding include: On 05/02/19 at 2:35 P.M., an open box was observed beside the telephone at the nurse's station. The box was labeled with the name of Resident #90 and contained five individual blister dose packs of an anticoagulant medication (Eliquis 2.5 milligrams (mg.)) and one blister pack of an [MEDICAL CONDITION] medication ([MEDICATION NAME] 30 mg. half tablet). The nursing station had two entry points without doors or other type of barrier, and there was no barrier to prevent residents or the public from reaching over the top of the desk. There was no staff present at the nursing station at the time of the observation. When questioned, Registered Nurse (RN) #102 and #106 stated Resident #90 was being discharged and needed the medications called into the pharmacy. The box had been placed by the phone and not returned to the medication storage room. Observations from 04/29/19 through 05/02/19, during each day of the survey, cognitively impaired mobile Residents #3 and #32 had been observed standing or sitting in a wheelchair respectively at the nurse's station at various times daily. Interview with the Director of Nursing (DON) on 05/02/19 at 2:40 P.M. verified the box with Resident #90 was left at the nurse's unsecured without any staff present. The DON verified there were 15 cognitively impaired mobile residents (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) in the facility. Review of the facility policy titled Storage and Expiration, Dating of Medications, Biologicals, Syringes and Needles, dated (MONTH) (YEAR), revealed under the heading General Storage Procedures, the policy stated the facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors.

Based on review of the facility's Antibiotic Use Tracking Sheet, staff interview and policy review, the facility failed to ensure eight residents (#2, #4, #8, #10, #14, #20, #21 and #29) of 28 residents reviewed for antibiotic stewardship had active signs and symptoms of infection prior to prescribing antibiotics. The facility census was 36. Findings include: Review of the facility's (MONTH) 2019 Antibiotic Use Tracking Sheet revealed Resident #29 had a dry scaly scalp with no date of onset. The physician prescribed Bactrim DS (antibiotic ) for 14 days. Four residents (#2, #10, #14 and #20) displayed symptoms of a cough without any other signs and symptoms. There was no diagnostic testing completed for these four residents. Three of the residents (#2, # 10 and #20) were placed on a Z- Pack ( [MEDICATION NAME] antibiotic) for four days. Resident #14 was placed on [MEDICATION NAME] 875-125 milligrams (mg.) for seven days. The tracking sheet stated Resident #21 had a possible urinary tract infection. The signs and symptoms were listed as increased urination , increased confusion, and increased episodes of incontinence. There was no urinalysis or urine culture. The resident was placed on [MEDICATION NAME] one gram (antibiotic) to be given intramuscularly (IM) for three days. The tracking sheet stated Resident #8 had a urinary tract infection. There was no signs or symptoms listed, no urinalysis, and no urine culture completed . The resident was given Keflex 500 mg. (antibiotic) for seven days. Review of the facility's (MONTH) 2019 Antibiotic Use Tracking Sheet revealed Resident #20 had an upper respiratory infection with signs and symptoms of a cough. There were no diagnostic test performed. The resident received [MEDICATION NAME] 100 mg. (antibiotic) for seven days. Three additional residents (#14, #4 and #20) were listed as having urinary tract infections. The tracking sheet stated three residents (#14, #4 and #20) had urinary tract infections with with the signs and symptoms being discolored urine and increased confusion. There was no urinalysis or urine culture was completed on these three residents. Resident #14 and #20 were [MEDICATION NAME] mg. (antibiotic) for seven days. Resident # 4 was given [MEDICATION NAME] one gram (antibiotic) for five days. Resident #3 was treated with an antibiotic [MEDICATION NAME] 250 mg. for five days for abnormal lung sound with no diagnostic tests. Review of the facility's (MONTH) 2019 Antibiotic Use Tracking Sheet revealed Resident #8 was placed on Keflex 500 mg. (antibiotic) for 10 days. A urinalysis was completed without a culture to identify an organism. Interview with Regional Director of Clinical Services #104 on 05/02/19 at 10:30 A.M. verified there was no Infection Prevention Control Committee. She stated infections were discussed in a weekly meeting with the Interdisciplinary team. She verified Resident #2, #4, #8, #10, #14, #20, #21 and #29 appeared on the Antibiotic Use Tracking Sheet in January, February, and (MONTH) of 2019 and did not have the indications needed to prescribe antibiotics. Review of the facility's policy on Antibiotic Stewardship Program, dated 04/16/18, revealed the Infection Prevention and Control Committee is to meet monthly to oversee the tracking of antibiotic of prescribing.

Based on record review, staff interview and review of facility policy, the facility failed to have consistent documentation of Advanced Directive status across all medical records for Resident #1 and #29) and failed to have any documented evidence of Advanced Directive status for Resident #36. This affected three (#1, #29 and #36) of four residents were reviewed for Advance Directives. The facility census was 36. Findings include: 1. Medical record review for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the electronic medical record for Resident #1 on 04/30/19 at 9:25 A.M. reflected the profile page to be silent to any advance directive code status. Review of the physician orders [REDACTED]. Review of the hard medical record found a Do Not Resuscitate (DNR) form dated 01/08/19 that had been signed by both physician and resident and marked for Do Not Resuscitate Comfort Care (DNRCC). Interview with Registered Nurse (RN) #115 on 04/30/19 at 10:00 A.M. stated she would go to the electronic resident profile page to ascertain code status if on the floor, or she could check the hard paper chart for code status of a red paper stating DNRCC, or a green paper stating Full Code. Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 3:00 P.M. stated she would look at the electronic resident profile page and physician orders [REDACTED]. Interview with Social Service Designee (SSD) #101 on 05/02/19 at 8:54 A.M. stated SSD #101 stated when a resident was admitted , she determined the advance directive status and enters it on the care plan. She passes along this information to nursing and they were to enter it in the electronic record and flag the hard medical chart so they match. The DNR form was to be in the hard record and should also be in physician orders. The SSD #101 stated she was to review the code status for every resident quarterly. It was also her responsibility to audit medical records for accuracy of code status. She verified the electronic and hard chart for Resident #1 did not match. Interview on 05/02/19 at 2:30 P.M. with Regional Director of Clinical Services (RDCS) #104 verified theses findings. 2. Medical record review for Resident #29 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the electronic profile page for Resident #29 reflected the resident was a Full Code status. However, the hard medical record contained a DNR form, dated 10/05/18, which identified the resident as a DNRCC-A. Review of current physician orders [REDACTED]. Social service progress notes were silent to advance directive status. Review of the plan of care, initiated 02/09/17 with a revision date of 03/18/19, stated the resident has chosen a Full Code status. Interview on 05/01/19 at 2:30 P.M. with RDCS #104 verified the code status for Resident #29 was not consistent across all parts of the medical record. 3. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a physician order, dated 03/13/19, revealed the resident's advanced directive was a full code status. Review of the social service progress note, dated 04/03/19, stated Resident #36's advanced directives have been reviewed and were located on the chart. He has chosen to have a Full Code status. Review of the plan of care, revised on 04/17/19, revealed Resident #36 has chosen a full code status for his advance directive. The interventions included staff was to document his advance directive in the chart.Interview on 05/01/19 at 2:30 P.M. with Licensed Practical Nurse (LPN) #119 verified there was no code status listed on the electronic record face sheet. She stated if the resident was found unresponsive she would check the resident's code status on the electronic record . Since there was no code status in the electronic record, she would go to the resident's hard copy chart to check his code status. She verified there was no code status listed under advanced directives in the hard copy chart. Interview with Regional Director Clinical Services #104 she verified Resident #36 did not have a advance directive in the electronic record or in the chart. Review of an undated facility policy titled Advance Directive Policy revealed documentation, written or oral, of informed consent to withhold or withdraw treatment must be placed in the resident's medical record together with the attending physician's orders [REDACTED]. The physician's orders [REDACTED]. record.

Based on medical record review and staff interview, the facility failed to provide written notification to a resident's representative of a transfer to the hospital. This affected one (#22) of one resident reviewed for hospitalization . The facility census was 36. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall. The resident was transferred to the hospital and admitted for surgical repair of a left [MEDICAL CONDITION]. Review of the medical record revealed there was no evidence the resident's representative was given a written notice for the resident's transfer to the hospital on [DATE]. Interview on 05/02/19 at 3:40 P.M. with the Regional Director of Clinical Services #104 verified there was no written notice given to Resident #22's representative at the time of the resident's transfer to the hospital on [DATE].

Based on medical record review and staff interview, the facility failed to provide a bed hold notice to a resident's representative when the resident was transferred to the hospital. This affected one (#22) of one resident reviewed for hospitalization . The facility census was 36. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall. The resident was transferred to the hospital and admitted for surgical repair of a left [MEDICAL CONDITION]. Review of the medical record revealed there was no evidence the resident's representative was given a bed hold notice when the resident transferred to the hospital on [DATE]. Interview on 05/02/19 at 3:40 P.M. with the Regional Director of Clinical Services #104 verified there was no bed hold notice given to Resident #22's representative at the time of the resident's transfer to the hospital on [DATE].

Based on record review and staff interview, the facility failed to ensure a comprehensive person centered care plan was written for Resident #25 and the correct code status for Resident #29's care plan. This affected two (#25 and #29) of 17 residents reviewed for care plans. The facility census was 36. Findings include: 1. Medical record review for Resident #25 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the current physician orders, dated 03/05/19, revealed the resident had an order to receive an antianxiety medication named [MEDICATION NAME] five milligrams (mg.) twice daily. Review of a Minimum Date Set (MDS) assessment, dated 04/09/19, revealed the resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, initiated 01/05/19 and revised 04/09/19, revealed it was silent to the resident's [DIAGNOSES REDACTED]. Interview with MDS Coordinator #102 on 05/01/19 at 1:30 P.M. verified there was no care plan to address the [DIAGNOSES REDACTED]. 2. Medical record review for Resident #29 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the medical record revealed a Do Not Resuscitate (DNR) form, dated 10/05/18, which identified the resident as a Do Not Resuscitate comfort care arrest (DNRCC-A). Review of the comprehensive plan of care, initiated 02/09/17 with a revision date of 03/18/19, the resident has chosen Full Code status, which was not the correct code status. Interview on 05/01/19 at 2:30 P.M. with the Regional Director of Clinical Services (RDCS) #104 verified Resident #29's comprehensive care plans had not been accurately developed to reflect the resident's code status.

Based on medical record review, resident and staff interview, and policy review, the facility failed to have care conferences on a quarterly basis and invite a resident to attend a care conference. This affected one (#32) of two residents reviewed for care conference attendance. The facility census was 36. Findings include: Record review for Resident #32 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 04/05/19, revealed the resident has no cognitive impairments. He was assessed to have no delusion, hallucinations, or any behavioral symptoms. Review of the social service progress note, dated 01/23/19, stated Social Service Designee #101 approached the resident concerning a care conference and the resident refused stating no, he didn't want to go. He stated to just find him a place to live and get him out of the facility. Review of the progress notes, from 01/22/19 through the present date 04/30/19, revealed no documentation that a care conference was held to discuss the resident's care. During an interview with Resident #32 on 04/29/19 at 10:06 A.M., he stated he has not been invited to a care conference to discuss his plan care. On 04/30/19 at at 3:00 P.M., during an interview with Social Service Designee #101, she verified there was no care conference held following the annual comprehensive assessment on 04/04/19. She verified Resident #32 had not been invited to a care conference following the MDS assessment on 04/04/19. She verified the interdisciplinary team did not have a care conference following the 04/04/19 MDS assessment. Review of the facility's policy on Care Conference, dated 01/27/11, stated under the procedure, each resident shall be invited to participate in their care conference. The policy also stated a care conference should be held quarterly and annually.

Based on record review, staff interview, and review of hospice contracts, the facility failed to ensure collaboration and communication between the facility and hospice entities for two (#5 and #31) of two residents reviewed for hospice services. The facility identified four residents currently receiving hospice services. The facility census was 36. Findings include: 1. Medical record review for Resident #31 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. The medical record contained a Hospice contract signed by the resident's responsible party, dated 04/12/19. On 05/01/19 at 10:50 A.M. a Hospice nurse from Hospice Entity #105 was observed at the nurse's station writing orders and talking with staff Registered Nurse (RN) #106. After the hospice nurse left the nurse's station, an interview with RN #106 found that the hospice nurse speaks with facility staff during her visits, but leaves no progress notes in the medical record regarding her observations and interactions with the resident, or care rendered. There were also no care notes provided by hospice nurse aide assistants after their visits twice weekly. On 05/01/19 at 12:00 P.M., an interview with Regional Nurse #104 was conducted. She stated it was the facility expectation that Hospice should be leave progress notes of all visits with the facility as part of the medical record. She verified that the hospice entity had not provided their progress notes to the facility for continuity of care. Review of the contract titled Nursing Facility Agreement, dated 02/03/17, stated the agreement was between Hospice Entity #105 and the nursing facility. The document, under section 4.8 Medical Chart, reflected Facility and Hospice will prepare and maintain complete medical records for Hospice Patients receiving Facility services in accordance with this Agreement and will include all treatments, progress notes, authorizations, physician orders [REDACTED]. Documentation of care and services provided by Hospice will be filed and maintained in the Facility chart. 2. Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #5 was admitted to hospice services on 11/02/18 with Hospice Entity #120. Review of the hospice binder revealed no documentation of services provided by Hospice Entity #120's staff in (MONTH) 2019 and (MONTH) 2019. Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 2:39 P.M. revealed hospice staff does not leave progress notes detailing the care they provided prior to leaving the facility. Interview with Registered Nurse (RN) #104 on 05/01/19 at 12:30 P.M. revealed Hospice Entity #120's staff were supposed to leave progress notes in the hospice binder at the nurse's station. RN #104 verified the facility did not have documentation of services provided by Hospice Entity #120's staff in (MONTH) 2019 or (MONTH) 2019. Review of the facilities Hospice Agreement with Hospice Entity #120 revealed hospice shall promote open and frequent communication with the facility and shall provide the facility with sufficient information to ensure that the provision of services under this agreement is in accordance with the hospice plan of care, assessments, treatment planning and care coordination. Hospice will promptly inform the facility of any change in a hospice patient's condition which requires a modification to the hospice plan of care.

Based on record review, observation, and staff interview, the facility failed to ensure Resident #5 received tube feeding as ordered by the physician. This affected one (Resident #5) of one resident reviewed for tube feeding. This facility identified one resident who received tube feeding. Findings include: Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders, dated 08/28/17, revealed a diet order for nothing by mouth (NPO). Further review of the physician orders, dated 01/15/19, revealed Fibersource, a tube feeding formula, was to run at 65 milliliters per hour for a total of 22 hours each day and water was to run at 30 milliliters per hour while the tube feeding was running via gastrostomy tube (a tube used to provide nutrients and fluid into the stomach). Review of the Medication Administration Record [REDACTED].M. Observation on 04/29/19 at 10:38 A.M. revealed Resident #5's tube feeding was turned off. Observation on 04/30/19 at 11:00 A.M., 1:35 P.M., and 2:22 P.M. revealed Resident #5's tube feeding was turned off. Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 2:39 P.M. revealed Resident #5's tube feeding was to run for 22 hours each day from 6:00 P.M. to 4:00 P.M. and the tube feeding was supposed to be turned off for two hours from 4:00 P.M. to 6:00 P.M. Interview with LPN #103 on 04/30/19 at 2:39 P.M. verified Resident #5's tube feeding was turned off. LPN #103 was unable to provide an explanation as to why the tube feeding was turned off.

Based on record review and staff interview, the facility failed to act upon a physician's response to the pharmacist recommendation for a resident. This affected one (#33) of five residents reviewed for unnecessary medication. The facility census was 36. Findings include: Medical record review for Resident #33 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of current physician orders, dated (MONTH) 2019, revealed the resident had orders for the following psychoactive medications: [REDACTED]. at bedtime, and [MEDICATION NAME] 20 mg. daily. Review of a pharmacy medication regimen consultation report, dated 04/02/19, revealed the pharmacist noted Resident #33 was receiving three antidepressants concomitantly, and recommended the physician to consider discontinuing [MEDICATION NAME] while continuing [MEDICATION NAME] at bedtime and while monitoring for re-emergence of depression/[MEDICAL CONDITION] and/or symptoms. Review of the physician's response, dated 04/09/19, revealed the physician agreed with the pharmacist recommendation with the following modifications: Decrease [MEDICATION NAME] to 7.5 mg. at bedtime and was signed and dated 04/09/19 by the physician. Below the physician signature and date, the previous Director of Nursing (DON) (Registered Nurse (RN) #116) had signed and dated the form, 04/12/19, and written verbal order to leave at 15 mg. Further review of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. was never implemented. The resident continued to receive [MEDICATION NAME] at 15 mg. nightly, as of 05/01/19. On 05/02/19 at 12:32 P.M., an interview with Regional Director of Clinical Services (RDCS) #104 verified the medication dosage was never reduced as ordered, and the physician had never signed and authorized the verbal order written by RN #116.

Based on observation, resident and staff interview, the facility failed maintain three resident's wheelchairs in safe operating condition. This affected three (#18, #23 and #37) of 17 residents reviewed for safe operating equipment. The facility identified 20 residents dependent on wheelchairs for locomotion. The facility census was 36. Findings include: On 05/01/19 at 1:00 P.M., an observation of Resident #23 revealed the resident was propelling in his wheelchair in the hallway. On the medial side of the left arm rest, the covering was torn with jagged rough edges. The resident was wearing a short sleeve shirt. The resident stated the arm of his wheelchair was torn and needed repair. On 05/01/19 at 1:10 P.M., an observation of Resident #37 revealed the resident was in a wheelchair in the dining room. The covering of the right arm of his wheelchair was torn in multiple areas causing the covering to have rough edges. On 05/01/19 at 1:12 P.M., an observation of Resident #18 revealed the resident was in a wheelchair in the dining room. The covering of the left arm of his wheelchair was torn in multiple areas causing the covering to have rough edges. On 05/01/19 at 1:20 P.M., interview with the Regional Director of Clinical Services #104 verified the arms on Resident #23, #37, and #18's wheelchairs were in disrepair with tears in the covering of the arms causing rough edges, which could result in skin tears to the resident's arms.

Based on personnel record review, staff interview, and facility policy review, the facility failed to ensure reference checks were completed for new hires. This affected six of six employees reviewed for completion of reference checks. This had the potential to affect all 36 residents. Findings include: Review of the personnel record for State tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19. There was no documentation of reference checks being completed. Review of the personnel record for STNA #109 revealed a hire date of 02/01/19. There was no documentation of reference checks being completed. Review of the personnel record for STNA #112 revealed a hire date of 06/12/18. There was no documentation of reference checks being completed. Review of the personnel record for Director of Nursing (DON) #113 revealed a hire date of 04/22/19. There was no documentation of reference checks being completed. Review of the personnel record for Maintenance Supervisor #114 revealed a hire date of 04/10/19. There was no documentation of reference checks being completed. Review of the personnel record for Assistant Director of Nursing (ADON) #102 revealed a hire date of 02/11/19. There was no documentation of reference checks being completed. Interview with Administrator on 05/02/19 at 2:50 P.M. verified there was no documentation of reference checks being completed for STNA #108, STNA #109, STNA #112, DON #113, Maintenance Supervisor #114, and ADON #102. Review of the facility policy titled Ohio Resident Abuse Policy, last revised (MONTH) (YEAR), revealed prior to hiring a new employee, the facility will attempt to obtain references from two prior employers.

Based on observation, staff interview and policy review, the facility failed to ensure medications were prepared appropriately potentially affecting two (#8 and #23) randomly observed residents. Additionally, the facility failed to properly store medication in the refrigerator in the medication room potentially affecting all residents residing in the facility. The facility census was 32. Findings include: 1. Observation on 04/02/18 at 8:55 A.M. revealed Registered Nurse (RN) #203 entered Resident #23's room carrying two plastic medication cups with medications in them, one with applesauce, and an insulin syringe. She sat the medications down on the bedside table and picked up the plastic cup containing the medications in applesauce and administered those to Resident #23, the only resident in the room. She then picked up the other plastic medication cup and the insulin syringe and started to leave the room. When questioned as to whose medications those were RN #203 replied Resident #8, who was not in the room at the time. RN #203 verified she had prepared two residents medications at once. Review of the General Dose Preparation and Medication Administration policy dated 01/01/13 revealed facility staff should only prepare medications for one resident at a time. 2. Observation of the medication storage room on 04/05/18 at 12:38 P.M. revealed two vials of [MEDICATION NAME] purified derivative and one vial of influenza vaccine which were opened and undated. This was verified at the time with Licensed Practical Nurse (LPN) #204. The facility identified this could potentially affect all residents residing in the facility. Review of the Storage and Expiration of Medications, Biologicals, Syringes and Needles dated 10/31/16 revealed facility staff may record the date opened on the medication container.

Based on medical record review, staff interview and policy review, the facility failed to ensure influenza vaccines were appropriately offered to residents for the (YEAR)-2018 influenza season. This affected five (Resident #7, #15, #19, #24 and #25) of five residents reviewed for influenza vaccination. The facility identified 28 (#1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30 #82, and #131) total residents that had not being offered education and/or the influenza vaccine for the (YEAR)-2018 influenza season. Facility census was 32. Findings Include: 1. Review of the medical record of Resident #7 revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed there was no documentation of the influenza vaccine had been administered or refused for (YEAR)-2018 season. There was also no documentation of information given or consent received or refused for the vaccine. 2. Review of the medical record of Resident #15 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed there was no documentation of the influenza vaccine had been administered or refused for (YEAR)-2018 season. There was also no documentation of information given or consent received or refused for the vaccine. 3. Review of the medical record of Resident #19 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed there was no documentation of the influenza vaccine had been administered or refused for (YEAR)-2018 season. There was also no documentation of information given or consent received or refused for the vaccine. 4. Review of the medical record of Resident #24 admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. vein of left lower extremity, constipation seasonal allergic rhinitis, wedge compression fracture of lumbar vertebra. Further review of the medical record revealed there was no documentation of the influenza vaccine had been administered or refused for (YEAR)-2018 season. There was also no documentation of information given or consent received or refused for the vaccine. 5. Review of the medical record of Resident #25 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed there was no documentation of the influenza vaccine had been administered or refused for (YEAR)-2018 season. There was also no documentation of information given or consent received or refused for the vaccine. Interview on 04/04/18 at 3:50 P.M. with the Director of Nursing (DON) verified the lack of documentation of the influenza vaccine being offered, administered or refused for Resident #7, #15, #19, #24 and #25. During the interview the DON further verified there are 28 (#1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30 #82, and #131) total residents that the facility can not find documentation of the influenza vaccine being administered or refused for (YEAR)-2018 season. There was also no documentation of information/education being given or consent received or refused for the vaccine for these residents. Review of the facility policy titled Influenza Vaccine-Resident dated 08/04/17 revealed the influenza vaccine shall be offered to all residents between 10/01 and 03/31 and upon admission, unless contraindicated or refused.

Based on record review and staff interview, the facility failed to develop a care plan that addressed the [DIAGNOSES REDACTED].#9) out of five residents reviewed for unnecessary medications. The total facility census was 32. Findings include: Medical record review for Resident #9 found an admission date of [DATE] with Diagnoses: [REDACTED]. type II, cardiac arrhythmia, gastro-[MEDICAL CONDITION] reflux disease and peripheral artery disease. Review of current physician orders [REDACTED]. Review of the care plan revealed it to reflect the resident uses [MEDICAL CONDITION] medications, but was silent to any planned interventions related to the resident's [DIAGNOSES REDACTED]. The care plan was also silent to any planned interventions to address the use of the anticoagulant medication and possible side effects of the blood thinning medication. These findings were verified by interview with the care plan nurse (LPN) #201 on 04/04/18 at 4:07 PM.

Based on medical record review, staff interview, Medical Director interview and review of information from Medscape drug reference, the facility failed to appropriately monitor [MEDICATION NAME] (anti-[MEDICAL CONDITION]) level which resulted in actual harm when Resident #25 had to be hospitalized with [DIAGNOSES REDACTED].#25. This affected one (#25) out three residents reviewed for unnecessary medication use. The facility census was 25. Findings include: Review of medical record for Resident #25 revealed an initial admission date of [DATE] current admitted d of current admission date of [DATE] with [DIAGNOSES REDACTED]. Review of facility admission orders [REDACTED]. Further review documented [MEDICATION NAME] level was to be done with the next laboratory work drawn. Review of [MEDICATION NAME] level completed 10/03/16 documented a level of 9.9 micrograms per deciliter which was low. The therapeutic range was 10.0 to 20.0 micrograms per deciliter. Review of physicians order dated 10/06/17 documented a new order for [MEDICATION NAME] 20 milligrams every day for acid reflux. Review of pharmacy recommendation dated 10/07/16 documented Resident #25 should be monitored for changes in response to [MEDICATION NAME] when [MEDICATION NAME] is added to or discontinued from therapy. Serum [MEDICATION NAME] should be monitored to assist in dosage adjustment. Further review documented the physician review the recommendation with a date of 10/10/17 and documented will check levels. There was no dated noted when to check the level. Review of physician orders [REDACTED]. Review of nurse notes dated 11/01/16 documented at 10:05 A.M. documented Resident #25 was lethargic most of the morning. At 1:05 P.M. the resident continues to be lethargic and difficult to arouse. At this time the medical director was notified and orders were received to send the resident to the emergency department for evaluation and treatment. Review of physicians order dated 11/01/16 documented to send the resident to the emergency room for evaluation and treatment for [REDACTED]. Review of laboratory report completed in the emergency room dated 11/01/16 documented Resident #25 had a [MEDICATION NAME] level of greater than 40 micrograms per milliliter. This was documented as critically high as with the reference units being 10.0 to 20 micrograms per milliliter. Further review documented results were rechecked by repeat sampling. Review of discharge summary from the Hospital dated 11/08/16 documented Resident #25 was discharge from the hospital due to poisoning by [MEDICATION NAME], [MEDICAL CONDITION] due to another medical condition, persistent, mixed level of activity. Review of Resident #25's Medication Administration Record [REDACTED]. Further review of nurses notes from 03/25/17 through 03/31/17 lacked any documentation of non- pharmacological interventions attempted prior to the use of an [MEDICATION NAME]. On 04/05/17 at 9:30 A.M. interview with Registered Nurse (RN) #105 revealed when Heartland owned the building at the time the [MEDICATION NAME] level was recommended she stated the process was to place pharmacy recommendations in a binder for the doctor's review. RN #105 stated it was the nurse working the floor responsibility to review the recommendations and write the order for what the physician wanted done based on his response to the recommendation. RN #105 is unsure what happened in this case of Resident #25 [MEDICATION NAME] level. RN #105 also verified there was no order written to recheck the [MEDICATION NAME] level for Resident #25 following the pharmacist recommendation. At this time RN #105 verified there was no follow up to what was written by the doctor on the pharmacist recommendation. On 04/05/17 at 11:46 A.M. interview with Medical Director verified he did review Resident #25's pharmacy recommendation to monitor the [MEDICATION NAME] level with the use of [MEDICATION NAME]. He also verified he review it on 10/10/17 as documented and wrote will check levels. He stated typically he will write a physician's orders [REDACTED]. He also revealed he seen Resident #25 the next day on 10/11/16 and referenced the level obtained on 10/03/17 of a serum [MEDICATION NAME] level of 9.9. He verified there was no additional information documented in regards to the pharmacy recommendation of when to check the level. He stated he feels the interaction between the [MEDICATION NAME] and [MEDICATION NAME] was minimal. He was unable to verify when the serum [MEDICATION NAME] should have been done in regards to the pharmacy recommendations and his note will check the level. On 04/05/17 at 4:15 P.M. interview with Corporate Nurse revealed the incident with the pharmacy recommendation regarding the [MEDICATION NAME] level happened prior to the new company taking over in December 2016. She stated the current policy in place for addressing pharmacy recommendation would not be the policy used. She stated the prior company took all the information with them and it was unavailable at this time. She did reveal all the staff members working were the same staff members at the time the incident occurred. The Corporate Nurse further confirmed non- pharmacological interventions were not attempted prior to the administration of [MEDICATION NAME] on the dates identified above. Review of drug reference information from Medscape revealed when [MEDICATION NAME] and [MEDICATION NAME] are taken together the [MEDICATION NAME] level should be monitored closely due to [MEDICATION NAME] increasing the level of [MEDICATION NAME] by affecting hepatic enzyme. It also documented to use caution and monitor. This deficiency substantiates Complaint Number OH 328.