Every finding on record at Jag Healthcare Mansfield

Based on resident interviews, staff interviews, review of the Facility Assessment (FA) and review of staffing reports, the facility failed to have sufficient staff to meet resident needs as identified in the FA. This had the potential to affect all 57 residents in the facility. The facility census was 57. Findings include: Interview with Resident #43 on 06/23/25 at 12:07 P.M. revealed the facility had several call offs over the weekend resulting in him not getting a shower. Observation on 06/23/25 at 12:07 P.M. revealed Resident #43 had body odor and oily hair. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included Diabetes Mellitus II, complete traumatic amputation at level between left hip and knee and right hip and knee, chronic kidney disease stage three and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #43 required partial/moderate assistance with personal hygiene and substantial/maximal assistance from staff for showers and bathing. Review of the functional abilities prior functioning dated 05/23/25 revealed Resident #43 needed some help, and he used a manual wheelchair. Review of the plan of care dated 05/21/25 revealed there were only two care plans for Resident #43 and neither pertained to hygiene care, bathing or showering. Review of the staffing tool with the Administrator on 06/26/25 at 11:26 A.M., dated 06/16/25 through 06/22/25 revealed on Saturday 06/21/25 and Sunday 06/22/25 the facility staffing fell below the 2.50 minimum staffing requirement and had 2.37 hours of care per resident per day on both 06/21/25 and 06/22/25. A second interview with Resident #43 on 06/25/25 at 8:11 A.M. revealed he washed up in his room. He wanted to shower over the weekend but due to Certified Nursing Assistant (CNA) call-offs, he did not get a shower. Interviews with CNA's #227 and #231 on 06/26/25 at 1:10 P.M. and 1:29 P.M. respectively revealed sometimes there are call offs and we do the best we can. Sometimes showers are not given due to lack of sufficient staff. Interview on 06/26/25 at 11:26 A.M. with the Administrator confirmed the facility failed to meet the 2.50 minimum required staffing on 06/21/25 and 06/22/25 resulting in the Administrator coming in and working as a CNA, still leaving the facility short staffed. The facility sent out a mass text for volunteers to work. A bonus was offered to get staff to work when there are call-offs. The facility does not use agency workers to fill vacant shifts in the schedule. Review of the Resident council dated 03/26/25 revealed call lights were not being answered in a timely manner. Resident council dated 02/26/25 revealed call lights were not being answered timely. Resident council dated 01/29/25 revealed the nursing/CNA care is not satisfactory and residents are waiting long periods of time to get care. Review of the 12/26/24 Resident Council revealed residents as a whole are complaining about staff not being available and those who are working seem to be exhausted. Review of the FA dated 06/18/25 revealed there are 31 residents who are dependent on staff for bathing. These Residents are: #3, #4, #5, #10, #12, #13, #14, #16, #17, #20, #21, #23, #24, #25, #26, #27, #29, #31, #32, #33, #34, #36, #37, #38, #39, #47. #48, #50, #55, #160 and #163. There are 28 residents who require assistance of one to two staff for bathing and they are Residents #1, #2, #6, #7, #8, #9, #11, #15, #18, #19, #22, #28, #30, #35, #40, #42, #43, #45, #46, #51, #52, #53, #54, #57, #110, #161, #162 and #164. The staffing plan revealed the facility will remain staffed without the use of third party supports (I.E. agency staff or state supported temporary staffing) in direct care. The facility has increased cross-training and leadership/frontline staff duty integration to ensure the delivery of care and services. Direct care staff members, specifically Certified Nursing Assistants (CNAs) plan is for three to five full-time employees on days 6:00 A.M. to 6:00 P.M. shift and one to two full-time employees on night shift from 6:00 P.M. to 6:00 A.M. Note that in the event of CNA unavailability, licensed staff will be substituted as necessary. Direct care staffing per patient day (PPD's) remain consist with an average PPD of 2.5; current staff are stable and most are tenured.

Based on observation and interviews, the facility failed to serve an appropriate amount of meat (protein) with the lunch meal. This had the potential to affect all residents at the facility. The facility census was 57. Findings include: Observation on 06/25/25 at 11:33 A.M. of the food service tray line revealed [NAME] #245 was serving residents meals. Observation revealed there were noodles in one pan and gravy with small chunks of beef in another pan. Observation revealed [NAME] #245 was placing the noodles with a four ounce scoop on each residents plate. The beef and gravy was served with a six ounce scoop. Observation revealed when [NAME] #245 placed the meat with gravy on each plate, some plates received one piece of stew meat, some had two and some had three pieces of meat. The pieces of meat varied in size from approximately one inch by one inch size pieces to 1/2 inch by 1/2 inch size pieces. [NAME] #245 confirmed the sizes of the pieces of meat and revealed, We are given two little bags of beef stew meat for all the residents. [NAME] #245 revealed the pieces of meat were added to the gravy before serving. Dietary Manager (DM) #236 entered the area and revealed each piece of meat was one ounce serving and each resident should receive three pieces of meat. DM #236 confirmed there was no scale to weigh the meat to confirm they were each one ounce and [NAME] revealed they were not each one ounce and confirmed residents randomly received one to three small pieces of meat per serving. Observations and or interviews on 06/25/25 between 11:46 A.M. and 1:12 P.M. with Residents #2, #3, #4, #6, #9, #23, #26, #27, #28, #46, #51, #53, and #25 revealed they received a small amount of meat, one to two pieces each resident. Telephone interview on 06/26/25 at 9:49 A.M. with Dietitian #325 revealed with beef and noodles, the recipe called for six ounces of beef and gravy and revealed the recipe should include how much meat each resident should receive. Dietitian #325 revealed each resident should receive at least three or four pieces of the meat with each serving.

Based on observation, interview, and review of the facility policy, the facility failed to ensure expired food items were disposed of and not stored with other food items used for resident meals. This had the potential to affect all 57 residents residing at the facility. Findings include: Observation on 06/23/25 at 8:10 A.M. with Dietary Manager (DM) #236 revealed in walk in cooler labeled #1 there were two metal containers, one with a bulk amount of sliced ham with an expiration date of 06/11/25 that was opened and partially used. A second bag that was in the container had a bulk amount of sliced salami, partially used with an expiration date of 06/14/25. A third bag had a bulk amount of sliced roast beef, partially used with an expiration date of 06/14/25. The second metal container had a second bag of sliced ham unopened with an expiration date of 06/19/25. Observation of the dry food storage area revealed a large container of barbeque sauce with approximately 1/4 container left with an expiration date of 05/19/25. DM #236 verified all expired foods. Review of the facility policy titled, Food Receiving and Storage undated revealed all foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their used by date, frozen or discarded.

Based on review of Quality Assessment and Assurance (QAA) meeting sign-in documentation, staff interview, and facility policy review, the facility failed to have required Quality Assessment and Assurance quarterly meetings with required members. This had the potential to affect all residents. The facility census was 57. Findings include: Review of the QAA sign in sheets revealed the facility had no documentation of QAA meetings for the first, second, and third quarters of 2024. The facility allowed viewing of fourth quarter QAA meeting documentation for 12/17/24 but there was no sign-in sheet for required members. Further review of the QAA sign-in sheets revealed the facility had a QAA meeting on 01/31/25 not attended by the Medical Director and another meeting on 02/28/25 not attended by the Director of Nursing or Infection Preventionist. Interview on 07/01/25 at 8:53 A.M. with the Administrator verified the facility had no documentation of quarterly QAA meetings prior the fourth quarter of 2024. The Administrator revealed the building was under new ownership beginning 11/01/24. The Administrator verified there was no documentation all required members were present during the 12/2024 fourth quarter meeting. Further interview with the Administrator revealed required members were not all present together for a QAA meeting for the first quarter of 2025. Review of the undated policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership revealed the following individuals serve on the committee: administrator, or a designee who is in a leadership role, director of nursing services, medical director, infection preventionist, and representatives of the following departments as requested by the administrator: pharmacy, social services, activity services, environmental services, human resources, and medical records. The committee would meet at least quarterly.

5. Review of the medical record for Resident #110 revealed an admission date of 06/13/25. Diagnoses included chronic pain, hemiplegia and hemiparesis, cerebral infarction, hypertension, atrial fibrillation, congestive heart failure, and narcissistic personality disorder. Review of the admission MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 06/20/25 revealed the resident had orders for contact precautions due to bilateral lower extremities wound infection. Review of a wound assessment report dated 06/20/25 revealed the resident had bilateral lower extremity venous ulcers. Review of a physician order dated 06/21/25 revealed to cleanse the bilateral lower extremities with wound cleanser, pat dry, apply ammonium lactate lotion to both lower leg topically, apply non-adherent dressing then a dry dressing over wounds, cover with tubular elastic dressing and wrap with elastic bandage daily and as needed for venous ulcer wound care. Observation on 06/24/25 beginning at 1:32 P.M. of wound care for Resident #110 with Licensed Practical Nurse (LPN) #259 revealed LPN #259 applied a gown and gloves when entering the resident's room. There was a sign on the resident's door indicating contact precautions required. LPN #259 removed the wound dressing from the resident's left lower extremity (LLE). LPN #259 then removed her gloves and applied new gloves without performing hand hygiene after removing the contaminated gloves. LPN #259 then removed the wound care dressing from the resident's right lower extremity (RLE). LPN #259 then removed the gloves, washed hands, and applied new gloves. LPN #259 cleansed the wound on the LLE then using the same contaminated gloves, cleansed the wound of the RLE. LPN #259 then removed the gloves without performing hand hygiene and applied a new pair of gloves. LPN #259 applied ammonium lactate topically to the LLE then using the same contaminated gloves applied ammonium lactate topically to the RLE. LPN #259 then removed gloves and washed hands. LPN #259 then dressed the wound to the LLE, removed gloves, used hand sanitizer, then went into the hallway outside the resident's room wearing a contaminated gown. LPN #259 returned and completed the wound dressing to the RLE. Interview on 06/24/25 at 2:12 P.M., LPN #259 verified using the same gloves for the RLE and LLE and not performing hand hygiene between glove changes. LPN #259 also verified not removing the contaminated gown before exiting the resident's room to obtain additional wound care supplies. Review of the undated facility policy Wound Care revealed to remove gloves and wash hands after removing a wound dressing then apply new gloves to apply wound treatment. Further review of the policy revealed no guidelines for staff when treating multiple wounds. Review of the undated facility policy Handwashing/Hand Hygiene revealed hand hygiene was required immediately after glove removal. Review of the undated facility policy Isolation-Categories of Transmission-Based Precautions revealed for resident's on contact precautions for staff to wear a disposable gown upon entering the room and remove before leaving the room. 3. Record review of the Legionella reduction plan revealed the facility did not have a text description of the building water systems and flow diagrams. Additionally the facility had no measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems based on nationally accepted standards. Interview with the Administrator on 06/30/25 at 11:30 A.M. revealed the facility was negative for Legionella. Interview with the Maintenance Director on 06/30/25 at 5:00 P.M. confirmed he did not have a description of the building water systems text and flow diagrams where Legionella and other opportunistic waterborne pathogens could grow and spread. He did not have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems based on nationally accepted standards. He did not have testing protocols with acceptable ranges to intervene when control limits were not met. He stated when he took over the job December 2024, all the Legionella tools and records were gone. Interview with the Administrator on 07/01/25 at 9:10: A.M. confirmed the facility did not have a facility specific risk assessment or a description of the building's water systems using text and flow diagrams including where Legionella and other opportunistic waterborne pathogens could grow and spread. The facility did not have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water system based on nationally accepted standards or a way to intervene when control limits were not met. Review of the undated facility policy, Legionella Water Management Program, revealed the facility was committed to the prevention, detection and control of water-borne contaminants including Legionella. The purpose of the water management program was to identify areas in the water system where Legionella bacteria could grow and spread and to reduce the risk of Legionnaire's disease. 4. Record review of Resident #15 revealed an admission date of 04/18/22. Diagnoses included end stage renal disease, dependence on renal dialysis, cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Record review for Resident #15 revealed physician orders dated 06/03/24 for Enhanced Barrier Precautions (EBP)due to a right chest hemodialysis palindrome. Review of the Minimum Data Set (MDS) 3.0 dated 06/05/25 revealed Resident #15 required substantial/maximum assistance for toileting. Review of the care plan dated 04/18/22 revealed Resident #15 required hemodialysis (HD) related to end stage renal disease and a new fistula, right arm hemodialysis, and had a palindrome in his right chest. Interventions included EBP precautions dated 06/24/25, monitor signs and symptoms of infection to the access site such as redness, swelling, warmth or drainage, and no blood pressures, needle sticks or laboratory draws from the arm with the fistula. Observation on 06/26/25 at 1:10 P.M. of the STOP See Nurse sign on Resident #15's the door indicated staff assisting this resident should wear gown and gloves when assisting with care. Observation on 06/26/25 at 1:10 P.M. revealed Certified Nursing Assistant (CNA) #227 walked past personal protective equipment (PPE) and the stop sign on Resident #15's door. She was observed assisting Resident #15 off the commode and into his wheelchair. Interview on 06/26/25 at 1:18 P.M. with CNA #227 confirmed she did not don PPE per the stop sign on Resident #15's door, and she assisted Resident #15 off the commode and into his wheelchair. Review of the undated facility policy, Enhanced Barrier Precautions revealed a gown and gloves were to be applied prior to performing a high contact resident care activity such as dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use and wound care. Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to maintain infection control practices during care including perineal care, foley catheter care, toileting, and meal service. The facility also failed to ensure a program was in place to prevent and stop the growth of water borne illness. The facility failed to maintain Enhanced Barrier Precautions (EBP)/Contact Precautions, and did not maintain proper infection control practices during wound care, medication administration, and glucometer cleaning. This had the potential to affect all residents residing at the facility. The facility census was 57. Findings include: 1. Record review for Resident #160 revealed an admission date of 05/28/25 with a diagnosis including neurogenic bladder. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired and dependent on staff for toileting hygiene and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Review of the care plan dated 06/23/25 revealed Resident #160 was at risk for infection and/or trauma related to the use of a foley catheter and neurogenic bladder. Interventions included EBP due to the use of a Foley catheter dated 06/23/25 and for a Foley catheter 16 French due to a neurogenic bladder. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 for a Foley catheter for oliguria, the order was not specific related to the size of the catheter or balloon. A revised order dated 06/19/25 revealed an order for a Foley catheter 16 french 10 milliliter (ml) balloon for a diagnosis of neurogenic bladder. Review of the physician orders for Resident #160 revealed an order dated 05/30/25 for Enhanced Barrier Precautions (EBP) due to Foley catheter use every day and night shift. Review of the Nursing Progress Note for Resident #160 dated 06/15/25 at 2:08 A.M. included Resident #160 complained of urgency, stating she felt like she had to urinate and she had increased agitation and confusion. The urine in catheter bag was cloudy and had a strong odor. The note included staff would speak with hospice for a urinalysis culture and sensitivity (UA C&S). Review of the Nursing Progress Note for Resident #160 dated 06/16/25 at 11:59 A.M. revealed the Certified Nursing Assistant (CNA) reported Resident #160's urine had a foul odor. Review of the Nursing Progress Note for Resident #160 dated 06/18/25 at 9:24 A.M. revealed a call was placed to hospice to obtain a urine sample to send to the laboratory for a UA C&S due to cloudy urine, a strong urine smell and increased confusion. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was scratching at her perineal area aggressively. The brief Resident #160 was wearing had been saturated with a red substance. Resident #160 was not responding to questions and continued scratching. Resident #160's husband placed Resident #160's call light on. Observation and interview on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. CNA #280 confirmed Resident #160 had blood inside her brief saturating the center perineal area of the brief. CNA #280 turned Resident #160 to her side. A moderate amount of blood was observed on the pad under Resident #160. The indwelling catheter was lying on the mattress next to Resident #160 with a fully inflated balloon. The catheter had blood on the tubing and balloon. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. There was blood with blood clots inside Resident #160's brief that CNA #226 and #280 removed. Observation during perineal care revealed neither CNA #280 nor #226 wore an isolation gown. CNA #280 then picked Resident #160's nasal cannula off the floor with her bare hands, placed it back in Resident #160's nares and turned on the oxygen concentrator. Upon exit of the room, CNA #280 confirmed Resident #160 did not have an Enhanced Barrier Precaution (EBP) and there were no Personal Protective Equipment (PPE) in or near the room. CNA #280 revealed Resident #160 was not on EBP and there was no need to wear an isolation gown or there would be a sign on the door. CNA #280 confirmed she picked up the oxygen tubing off the floor with her bare hands and placed it in Resident #160's nares then turned the concentrator on. Interview on 06/23/25 at 1:09 P.M. with Hospice Registered Nurse (RN) #321 revealed Resident #160 had an indwelling catheter due to urinary retention. Observation revealed Hospice RN #321 placed a pair of clean disposable gloves on and she did not don an isolation gown. Hospice RN #321 did not wash her hands prior to placing the clean gloves on. Hospice RN then place a pair of sterile gloves over the clean gloves. Hospice RN #321 then attempted to insert the indwelling catheter into Resident #160's urethra with no assistance. Resident #160 was morbidly obese and was not following direction. Observation revealed Hospice RN #321 was attempting to hold the catheter in one hand, spread Resident #160's legs with her arms while trying to separate the labia with the second hand to visualize the urethra. Hospice RN #321 then attempted several times inserting the catheter which was not visible due to positioning. Hospice RN #321 revealed Resident #160 was incontinent of urine on her brief. Hospice RN #321 turned Resident #160 to her right side. Hospice RN #321 pulled Resident #160's brief from under her ripping the brief into several pieces as she kept pulling on it, grabbing different areas of the brief. Surveyor suggested waiting for assistance to continue with the care. At 1:28 P.M., Licensed Practical Nurse (LPN) #261 entered the room to assist. LPN #261 never placed an isolation gown on. Observation revealed the indwelling catheter came out, the catheter the Hospice RN had just placed. Observation revealed perineal care was provided by Hospice RN #321 and LPN #261. Hospice RN #321 turned Resident #160 to her left side. While LPN #261 held Resident #160 on her left side, Hospice RN #321 bent her body down, while closely visualizing and pulling pieces of torn brief from under Resident #160, Hospice RN #321's hair was touching Resident #160's thigh and then the bed. Hospice RN #321 confirmed she bent her head down to the bed so low to see under Resident #160's side that her hair was touching Resident #321's body and bed. Hospice RN #321 stated, I usually put it up, I don't have anything to put it up with today. Hospice RN #321 confirmed she never washed her hands prior to putting on clean gloves then placing sterile gloves over the clean gloves. Both Hospice RN #160 and LPN #261 verified neither wore an isolation gown during the care. Interview on 06/24/25 at 4:45 P.M. with Director of Nursing (DON) revealed she called the lab and obtained the results of the UA C&S for Resident #160. Review of the lab results revealed Resident #160 had greater than 100,000 growths of both Escherichia coli and pseudomonas aeruginosa, indicating an infection. The DON further confirmed Resident #160 had an order for EBP and appropriate PPE was to be utilized for care. Review of the physician order for Resident #160 revealed an order dated 06/24/25 for Diflucan 200 mg by mouth for yeast for five days until finished. An additional order was written on 06/24/25 for Cipro 250 mg give one tablet orally two times a day for a urinary tract infection (UTI) for seven days. Review of the undated facility policy, Enhanced Barrier Precautions revealed a gown and gloves were to be applied prior to performing a high contact resident care activity such as dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use and wound care. 2. Observation and interview on 06/25/25 at 12:06 P.M. revealed the meal hall cart was delivered to the floor identified as Ford Hall with resident's meal trays. Observation revealed Certified Nursing Assistant (CNA) #227, CNA #231, and Dietary Manager (DM) #236 began passing the residents meal trays to their rooms along with drinks they prepared for the trays as they passed each tray. Observation revealed CNA #227 delivered the meal tray to Resident #14. A sign was on the entrance way to Resident #14's room revealing Resident #14 was on Enhanced Barrier Precautions (EBP). CNA #227 never donned any personal protective equipment (PPE). Observation revealed CNA #227 repositioned Resident #14 in bed then set up the meal tray. CNA #227 then left the room and returned to the meal cart and continued passing trays. CNA #227 never washed her hands or used hand sanitizer. DM #236 revealed there were 23 or 24 trays on the cart to be passed to residents. Residents on the hall included Resident #14, #15, #16, #30, #36, and #43 who were identified by the Director of Nursing (DON) as being on EBP. Residents #13, #29, #40 and #162 were identified by the DON as being on Contact precautions. Observation of the complete tray pass to Ford Hall residents revealed CNA #231 and DM #236 never washed their hands or used hand sanitizer before or after passing any of the meal trays. CNA #227 was observed using hand sanitizer on one occasion during the tray pass. CNA #227, and CNA #231 confirmed they passed trays to the residents including residents on EBP and Contact Precautions, repositioned residents and never wore PPE, washed their hands or used hand sanitizer with the exception of CNA #227 using hand sanitizer on one occasion. DM #236 also confirmed she passed several resident trays and never washed her hands or used hand sanitizer. Interview on 06/26/25 at 10:11 A.M. with DON revealed staff should be cleaning their hands between each meal tray passed. Review of the undated facility policy, Enhanced Barrier Precautions revealed a gown and gloves were to be applied prior to performing a high contact resident care activity such as dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use and wound care. 6. Review of Resident #14's medical record revealed an admission date of 07/15/24. Diagnoses include type two diabetes mellitus with neuropathic arthropathy, anemia in chronic kidney disease, dyspnea, and muscle wasting and atrophy. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition. Review of Resident #14's physician orders revealed an order for Sevelamer HCL oral tablet 800 milligrams (mg), three tablets by mouth before meals related to end stage renal disease. Observation on 06/25/25 at 7:30 A.M. revealed Registered Nurse (RN) #300 was preparing to administer medication to Resident #14. While preparing Resident #14's medication, RN #300 poured four pills into the medication container lid that he would transfer to Resident #14's medication cup. RN #300 placed his bare finger over a pill in the medication container lid and poured the other three pills into Resident #14's medication cup. Concurrent interview with RN #300 verified he should not have touched the pills when preparing the medications. Interview on 06/30/25 at 3:59 P.M. with the Director of Nursing (DON) verified it was not proper infection control to touch medications with your bare hand during medication administration. Review of the undated policy titled Administering Medications revealed staff were to follow established facility infection control procedures to administer medications in a safe manner. 7. Review of Resident #3's medical record revealed an admission date of 03/07/24. Diagnoses include type two diabetes mellitus, morbid obesity, osteoarthritis, hypertension, anemia, and chronic atrial fibrillation. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderately impaired cognition. Review of Resident #3's physician orders revealed an order for a Humalog per sliding scale. Give insulin subcutaneously before meals and at bedtime related to diabetes mellitus. Observation on 06/25/25 at 7:50 A.M. revealed Licensed Practical Nurse (LPN) #259 obtained a blood glucose reading from Resident #3 prior to administering insulin. After obtaining the blood glucose level, LPN #259 cleansed the glucometer with an alcohol swab. Interview on 06/25/25 at 7:59 A.M. with LPN #259 verified she used an alcohol swab to clean the glucometer. LPN #259 verified three residents use the same glucometer, Resident #3, #28, and #1. Interview on 06/30/25 at 11:20 A.M. with the Director of Nursing (DON) revealed staff should clean the glucometers per the manufacturers instructions. The DON stated staff usually cleaned the glucometers with a Sani-wipe, but staff were not supposed to use alcohol wipes to clean the glucometers. Review of the undated policy titled Glucometer Cleaning revealed all glucometers will be cleaned and disinfected using Clorox Germicidal wipes, EPA Reg. No. 67619-12, or equivalent. A 1:10 bleach solution is also acceptable (1 part bleach to 9 parts water).

Based on review of the medical record, staff interview, and facility policy review, the facility failed to ensure residents on psychotropic medications were monitored for effectiveness and adverse consequences. This affected five (#47, #51, #19, #161, and #1) of five residents reviewed for unnecessary medication. The facility identified 52 residents receiving psychotropic medications. The facility census was 57. Findings include 1. Review of the medical record for Resident #47 revealed an admission date of 09/04/24. Diagnoses included depressive disorder, dementia, anxiety, mood disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a physician order dated 03/28/25 revealed orders for Zyprexa (antipsychotic) 2.5 milligrams (mg), one tablet twice a day by mouth for bipolar depression. An order dated 05/03/25 for Sertraline (antidepressant) 50 mg, two tablets by mouth in morning for vascular dementia with psychotic disturbance. An order dated 03/20/25 for Lorazepam (antianxiety) tablet 0.5 mg, give two tablets by mouth every eight hours as needed for anxiety and restlessness for six months. Review of the medication administration record (MAR) and nurse's notes dated 05/01/25 through 06/24/25 revealed no documentation the resident was monitored for adverse effects or effectiveness of the psychotropic medications. Interview on 06/26/25 at 10:59 A.M., the Director of Nursing (DON) verified there was no documentation of monitoring for medication adverse effects or effectiveness. 2. Review of the medical record for Resident #51 revealed an admission date of 01/27/25. Diagnoses included Alzheimer's disease, bipolar disorder, mood disorder, major depressive disorder, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the physician orders revealed an order dated 01/27/25 for Escitalopram (antidepressant) 20 mg daily for depression. An order dated 04/22/25 for Buspirone (antianxiety) five mg twice a day for anxiety. An order for Lorazepam (antianxiety) one mg by mouth every eight hours as needed for anxiety with no stop date. An order dated 05/03/25 for Aripiprazole (antipsychotic) 10 mg by mouth in the morning for major depressive disorder. Review of the nursing assessments dated 05/03/25 through 06/24/25 revealed no documentation the resident received an abnormal involuntary movement assessment (AIMS) for the use of the antipsychotic medication Aripiprazole. Review of the MAR and nurses notes dated 05/01/25 through 06/24/25 revealed no documentation the resident was monitored for medication effectiveness or adverse effects. Interview on 06/26/25 at 10:59 A.M., the Director of Nursing (DON) verified there was no documentation of monitoring for medication adverse effects or effectiveness. The DON verified there was no stop date indicated for the as needed Lorazepam. Further interview on 06/26/25 at 2:27 P.M., the DON revealed AIMS assessments should be completed on admission, quarterly, with medication changes, and changes in condition. The DON verified an AIMS assessment had not been completed for Resident #51. 5. Review of the medical record for Resident #1 revealed an admission date of 11/08/24, diagnoses included schizophrenia, schizoaffective disorder, major depressive disorder and anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #1 had intact cognition and little interest or pleasure in doing things and felt down, depressed or hopeless. He required supervision or touching assistance for oral hygiene, upper and lower body dressing and personal hygiene. He was dependent on staff for toileting. Review of Resident #1's care plan dated: 11/12/24 revealed Resident #1 had medications in high-risk drug classes used in their care which can place them at risk of side effects that can adversely affect their health, safety and quality of life. The resident was prescribed medications from the following high-risk drug class: antipsychotic. Interventions included: Resident #1 will be on the lowest dose required to achieve the desired therapeutic effect and minimize side effects, monitor for appropriate clinical indication for continued use of high-risk medication and periodic review of resident's medication profile to assess the possibility of a dose reduction of the elimination of unnecessary medications. Review of the monthly physician orders for Resident #1 revealed the resident has order for Olanzapine (antipsychotic) 20 mg give one tablet by mouth in the morning related to schizophrenia form disorder active since 11/30/2024, Lurasidone HCl (antipsychotic) 20 mg give one tablet by mouth in the morning related to schizophrenia active since 11/30/2024. Interview and record review on 06/30/25 at 4:00 P.M. with DON of Resident #1's medical record confirmed Resident #1 was not monitored every shift by the nurses for potential side effects and effectiveness of the high risk medications including antipsychotics. DON confirmed monitoring Resident #1 every shift by the nurses for potential side effects and effectiveness was not initiated by the staff until 06/27/25. Review of the undated facility policy Psychotropic Medication Use, revealed psychotropic medication management included adequate monitoring for efficacy and adverse consequences. Review of the undated facility policy Antipsychotic Medication Use revealed staff would observe, document, and report to attending physician information regarding the effectiveness of antipsychotic medications and monitor and report side effects and adverse consequences on antipsychotic medications. Review of the facility policy titled, Behavioral Assessment, Intervention and monitoring, undated revealed if psychotropic medications (mind altering medications including antidepressants and antianxiety medications) are used to treat behavioral symptoms, documentation includes monitoring for efficacy and adverse consequences related to psychotropic medications. 3. Record review for Resident #19 revealed an admission date of 01/01/25. Diagnoses included altered mental status, dementia severe with psychotic disturbances, and major depressive disorder recurrent. Record review of the quarterly MDS dated [DATE] revealed Resident #19 was moderately cognitively impaired. Resident #19 received antianxiety medication and antidepressants. Review of the care plan for Resident #19 dated 01/22/25 revealed Resident #19 had medications in high-risk drug classes used in their care which can place them at risk and can adversely affect their health, safety, and quality of life. The resident was prescribed medications from the following high-risk drug class: antidepressant medications. Interventions included to administer medications as ordered by the practitioner, monitor for appropriate clinical indication for continued use of high risk medication, and monitor resident for adverse effects of medications. Review of the physician orders initiated 01/02/25 for Resident #19 revealed an order for Paroxetine HCL (antidepressant) 40 milligrams (mg) give one tablet by mouth one time a day for depression. Buspirone HCL (antianxiety) five mg give one tablet by mouth two times a day related to major depressive disorder was initiated 04/22/25. Interview and record review of Resident #19's medical record for June 2025 on 06/30/25 at 3:59 P.M. with the Director of Nursing (DON) confirmed Resident #19 did not have monitoring every shift by the nurses for potential side effects and effectiveness of the high risk medications used in their care. DON confirmed monitoring Resident #19 every shift by the nurses for potential side effects and effectiveness was not initiated by the staff until 06/27/25. 4. Record review for Resident #161 revealed an admission date of 05/28/25. Diagnosis included major depressive disorder, single episode, mild. Review of the admission MDS dated [DATE] revealed Resident #161 was severely cognitively impaired. Resident #161 received antidepressant medication. Review of the care plan dated 06/22/25 revealed Resident (#161) had medications in high-risk drug classes used in their care which can place them at risk of side effects that can adversely affect their health, safety and quality of life. The resident was prescribed medications from the following high-risk drug class: antidepressant medications. Interventions included to administer medications as ordered by the practitioner, monitor for appropriate clinical indication for continued use of high risk medication, and monitor resident for adverse effects of medications. Review of the physician order dated 05/29/25 for Resident #161 revealed an order for Bupropion HCl (antidepressant) oral tablet extended release 12 hour 150 mg. Give two tablets by mouth in the morning for anxiety. Review of the physician order dated 05/28/25 for Resident #161 revealed an order Celexa (antidepressant) oral tablet 10 mg. Give one tablet by mouth in the evening related to major depressive disorder, single episode, mild. Interview and record review on 06/30/25 at 4:00 P.M. with DON of Resident #161's medical record confirmed Resident #161 was not monitored every shift by the nurses for potential side effects and effectiveness of the high risk medications including antidepressants. DON confirmed monitoring Resident #161 every shift by the nurses for potential side effects and effectiveness was not initiated by the staff until 06/27/25.

Based on review of the medical record, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected four (#26, #6, #5, and #30) of 20 reviewed for accuracy of MDS assessments. The facility census was 57. Findings include 1. Review of the medical record for Resident #26 revealed an admission date of 07/29/24. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and Type two diabetes mellitus. Review of a Preadmission Screening and Resident Review (PASRR) Level Two assessment determination dated 12/15/22 revealed the resident met PASRR inclusion criteria for serious mental illness with a diagnosis of paranoid schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] Section A1500 revealed the resident was documented as not having a serious mental illness by the state level two PASRR process. Interview on 08/08/24 at 11:28 A.M., MDS Licensed Practical Nurse (LPN) #208 revealed Resident #26 transferred to the facility from another facility with a transfer level of care. LPN #208 revealed the PASRR completed at the previous facility would continue upon transfer. LPN #208 verified Section A1500 of the admission MDS dated [DATE] was incorrect and should have noted the resident had a serious mental illness per the PASRR Level Two assessment. LPN #208 revealed using the Resident Assessment Instrument (RI) manual to complete MDS assessments. Review of the RI manual Section A1500 PASRR revealed to code 1, yes if PASRR Level II screening determined the resident had a serious mental illness and continue to A1510, Level II PASRR Conditions. 2. Review of the medical record for Resident #6 revealed an admission date of 11/09/23. Diagnoses included schizoaffective disorder, dementia, and depressive disorder. Review of the admission MDS dated [DATE] revealed the resident's diagnoses of schizoaffective disorder had not been included in Section I Active Diagnoses. Review of the face sheet from the resident's previous facility dated 11/03/23 revealed the resident had been diagnosed with schizoaffective disorder on 07/17/20. Interview on 06/30/25 at 1:26 P.M., MDS LPN #208 verified the resident's diagnoses of schizoaffective disorder was present on admission and was not included in the resident's active diagnoses in the MDS admission assessment dated [DATE]. 4. Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), unspecified protein calorie malnutrition, hypothyroidism, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had weight loss of 5% or more in the last month or weight loss of 10% or more in the last six months. Documentation revealed Resident #30 was on a prescribed weight loss regimen. Review of the care plan for Resident #30 dated 05/07/25 revealed Resident #30 had a nutritional problem or potential nutritional problems which included low serum albumin levels, and protein-calorie malnutrition. Interview on 06/30/25 at 10:59 A.M. with Licensed Practical Nurse (LPN)/MDS Nurse #208 revealed Resident #30 was not on a prescribed weight loss regimen and stated, I don't know where I got that, I coded that in error. 3. Review of Resident #5's medical record revealed an admission date of 01/15/25. Diagnoses included chronic kidney disease, type two diabetes mellitus, pressure ulcer of sacral region, and cardiac pacemaker. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. Further review of Section K of the quarterly MDS assessment revealed Resident #5 was assessed as receiving parenteral/intravenous (IV) feeding. Review of the medication administration record and treatment administration record during the seven-day look back period revealed Resident #5 had not received parenteral or IV feeding. Interview on 06/25/25 at 9:05 A.M. with MDS Licensed Practical Nurse (LPN) #208 revealed Resident #5 had not received parenteral or intravenous nutrition in the seven day look back period and should not have been marked on the MDS assessment. Further interview with LPN #208 revealed she referenced the Resident Assessment Instrument (RAI) when completing MDS assessments. Review of the Resident Assessment Instrument (RAI) version 3.0 section K0520 revealed to only check the box for Resident #5 if it occurred in the last seven days.

2. Review of the medical record for Resident #51 revealed an admission date of 01/27/25. Diagnoses included Alzheimer's disease, anxiety, depressive disorder, dementia, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the plan of care last revised 06/24/25 revealed the resident had no individualized interventions in place for bipolar disorder. Interview on 06/30/25 at 9:54 A.M., LPN MDS Nurse #208 verified Resident #51's care plan lacked interventions for bipolar disorder. 3. Review of the medical record for Resident #6 revealed an admission date of 11/09/23. Diagnoses included schizoaffective disorder, dementia, and depressive disorder. Review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment. Review of the plan of care last revised 06/24/25 revealed the resident had no care plan in place with individualized interventions for schizoaffective disorder. Interview on 06/30/25 at 4:02 P.M., LPN MDS Nurse #208 verified Resident #6's care plan was lacking interventions for the schizoaffective disorder diagnoses. 4. Review of the medical record for Resident #26 revealed an admission date of 07/29/24. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and type two diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of the plan of care last revised 05/19/25 revealed the resident had no care plan in place with individualized interventions for paranoid schizophrenia. Interview on 06/30/25 at 4:02 P.M., LPN MDS Nurse #208 verified Resident #26 should have a care plan addressing interventions for paranoid schizophrenia. Based on observation, record review, staff interview and facility policy review, the facility failed to ensure the comprehensive care plan was initiated and or individualized for the resident. This affected six residents (#6, #26, #43, #51, #56 and #160) of 27 reviewed during the annual survey. The facility census was 57. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included Diabetes Mellitus II, complete traumatic amputation at level between left hip and knee and right hip and knee, chronic kidney disease stage three and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 required partial/moderate assistance with personal hygiene and substantial/maximal assistance from staff for showers and bathing. Review of the functional abilities prior functioning dated 05/23/25 revealed Resident #43 required some help, and he used a manual wheelchair. Review of the plan of care dated 05/21/25 revealed there were only two care plans for Resident #43 one for the resident's risk for infection and/or trauma related to use of suprapubic catheter with appropriate interventions and the other for the risk for urinary tract infections active infection, poor toileting habits and presence of Foley catheter with appropriate interventions. There was no other care plan present in the medical record, there was no care plan which addressed the resident's need for assistance with hygiene care. Interview on 06/26/25 at 9:06 A.M. with the Director of Nursing (DON) confirmed Resident #43's care plan was not comprehensive to address all his needs. Interview on 06/30/2025 at 5:13 P.M. with Licensed Practical Nurse (LPN)/MDS Nurse #208 verified there were only two items in his care plan. The care plan for Resident #43 does not include goals upon admission and desired outcomes nor building on his strengths or reflecting current recognized standards of practice for problem areas and conditions. LPN MDS Nurse #208 stated the care plan should be based on the MDS assessment. Resident #43 should have a care plan that addressed the following areas or risk: falls, pressure ulcer, pain, need for assistance with activities of daily living (ADLs), dental health and possibly high risk medication use. Review of the facility policy, Comprehensive Person-Centered Care Plan, no date revealed the care plan should encompass all the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 5. Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Record review for Resident #160 revealed a comprehensive assessment was not initiated until 06/23/25. Interview on 06/24/25 at 2:31 P.M. with LPN MDS Nurse #208 confirmed Resident #160 did not have a comprehensive care plan initiated until 06/23/25. 6. Closed record review for Resident #56 revealed an admission date of 04/07/25 and a discharge date of 06/02/25. Diagnoses included pneumonia, acute respiratory failure with hypoxia, hypertension, heart failure, physical debility, retention of urine, and wedge compression fracture of thoracic (T) T7-T8 vertebra sequela, multiple myeloma, and abdominal aortic aneurysm. Review of the admission MDS dated [DATE] included Resident #56 was moderately cognitively impaired. Resident #56 had an indwelling catheter and was frequently incontinent of bowel. Resident had cancer and received antiplatelet medications. Resident #56 required assistants with activities of daily living. Review of the comprehensive care plan for Resident #56 revealed a comprehensive care plan was never completed for Resident #56 during his stay at the facility. Interview on 06/30/25 at 5:02 P.M. with LPN MDS Nurse #208 confirmed Resident #56 did not have comprehensive care plans completed. LPN MDS Nurse stated, I don't know why they were not done. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered undated revealed the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission.

Based on observations, interviews, record review, and review of the facility policy, the facility failed to ensure residents received proper assistance with personal hygiene and grooming tasks. This affected three residents (#43, #45 and #47) of 28 (#1, #2, #6, #7, #8, #9, #11, #15, #18, #19, #22, #28, #30, #35, #40, #42, #46, #51, #52, #53, #54, #57, #110, #161, #162 and #164) residents who required assistance from staff for activities of daily living. The census was 57. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included Diabetes Mellitus II, complete traumatic amputation at level between left hip and knee and right hip and knee, chronic kidney disease stage three and peripheral vascular disease. Review of the Minimum Data Set (MDS) admission revealed Resident #43 required partial/moderate assistance with personal hygiene and substantial/maximal assistance from staff for showers and bathing. Review of the functional abilities prior functioning dated 05/23/25 revealed Resident #34 needed some help, and he used a manual wheelchair. Review of the plan of care dated 05/21/25 revealed there were only two care plans and neither pertained to hygiene care. They were risk for infection and/or trauma related to use of suprapubic catheter with appropriate interventions and urinary tract infections active infection, poor toileting habits and presence of Foley catheter with appropriate interventions. Interview on 06/23/25 at 12:07 P.M. with Resident #43 revealed he does not get staff assistance for showers therefore does not get showers unless he is assisted by staff. He was observed to have body odor and oily hair. Interview on 06/25/25 at 8:11 A.M. Resident #43 revealed he washes up in his room because staff call off and he does not get a shower. Interviews with CNA's #227 and #231 on 06/26/25 at 1:10 P.M. and 1:29 P.M. respectively revealed sometimes there are call offs and we do the best we can. Sometimes showers are not given due to lack of sufficient staff. Review of the shower sheets for Resident #43 revealed he was showered 05/21/25, 05/28/25 and 05/31/25. There were no shower sheets for June 2025. Interview with the DON on 06/25/25 at 9:06 A.M. revealed she did not know Resident #43's scheduled shower days nor was there an order for his showers to be given on certain days. The DON also verified on 06/30/2025 at 4:00 P.M. there were no shower sheets for Resident #43 for the month of June 2025. Review of the facility policy, Activities of Daily Living (ADLs), Supporting, no date revealed appropriate care and service are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (eating, including meals and snacks; and e. Communication (including speech, language and other functional communication systems). 2. Record review for Resident #45 revealed an admission date of 02/23/24. Diagnosis included chronic obstructive pulmonary disease and age-related physical debility. Review of the Annual MDS dated [DATE] revealed Resident #45 was cognitively intact. Resident #45 required supervision or touch assist with chair/bed to chair transfers and showering/bathing. Review of the care plan dated 04/07/25 revealed Resident #45 required partial/moderate assist for tub/shower transfer and supervision/touch assist for shower/bathing self. Review of the shower schedule revealed Resident #45 was to receive showers on Tuesdays/Fridays 6:00 A.M. to 6:00 P.M. Interview on 06/23/25 at 2:40 P.M. with Resident #45 revealed Resident #45 had a strong body odor. Resident #45's hair appeared oily. Resident #45 revealed she hoped to get a shower soon, she had not had one in a while. Resident #45 stated, That's my concern, I need my showers and I'm not always getting them. Interview on 06/30/25 at 2:15 P.M. with the Director of Nursing (DON) revealed if a resident received a shower, the Certified Nursing Assistant (CNA) would complete the shower form titled Comprehensive Shower Review. Each resident was scheduled a shower/bath two days a week, when the shower/bath is complete, the CNA and charge nurse signs and dates the form. Review of the Comprehensive Shower Review forms for Resident #45 from 03/01/25 through 06/30/25 with DON confirmed on 03/07/25, 03/14/25, 04/07/25, 04/15/25, 04/20/25, 05/20/25, 05/23/25, 05/27/25, and 06/06/25 Resident #45 received or was offered a shower or bath. DON confirmed there were no additional shower forms for Resident #45 to confirm she was offered or received a bath/shower. Interview on 07/01/25 at 8:19 A.M. CNA #227 confirmed every resident has a scheduled shower or bath two times a week. CNA #227 revealed the electronic medical records for each resident had a section to document the assistants needed for showers/bathing. Some residents were documented daily in the shower section the amount of assistants needed but that did not mean the resident received a shower or bath that day, it was only the amount of assistants normally needed. When a resident received a bath or shower, a shower form was completed by the CNA verifying the shower/bath was given. CNA #227 revealed if there were call offs or the facility was short staffed, the CNA's would be unable to do resident showers. 3. Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), panic disorder, obesity, lymphedema, Chronic Obstructive Pulmonary Disease (COPD), pulmonary hypertension, and heart failure. Review of the quarterly MDS dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 used a walker/wheelchair for mobility, required set up/clean up assist with the ability to come from a standing position to a sitting position, supervision or touch assist with shower/bathing, personal hygiene and upper and lower body dressing. Review of the care plan dated 06/27/25 for Resident #30 revealed Resident #30 had an activity of daily living (ADL) self-care performance related to ESRD with dialysis, oxygen use, pulmonary hypertension, and heart failure. Interventions included set up or clean up assistants with shower/bathing. Review of the shower schedule revealed showers/bathing were scheduled Tuesdays and Fridays 6:00 A.M. to 6:00 P.M. Interview on 06/23/25 at 11:56 A.M. with Resident #30 revealed she cannot shower because of her dialysis port. Resident #30 revealed she just washed up in the bathroom. Resident #30 stated, They never help, they want me to do it by myself, I think I need more help with that. Resident #30 revealed sometimes she felt weaker than other times and felt she just did not have the strength and confirmed sometimes she was not able to wash herself as well as she would like. Interview on 06/30/25 at 9:42 A.M. with Certified Nursing Assistant (CNA) #231 revealed Resident #30 preferred to wash up in the bathroom, Resident #30 put her light on when she needed help with bathing. CNA #231 revealed, Sometimes we help if needed, she will put her light on to let us know if she needs help otherwise, she does it, we do encourage her to do as much as she can. Interview on 06/30/25 at 9:48 A.M. with Resident #30 revealed, When I put the call light on for help, they come in and tell me they will be back and don't come back or say I need to do it myself. Interview on 06/30/25 at 10:43 A.M. with DON revealed if a resident was asking for assistants with bathing, based off the care plan and MDS, staff should be helping. Review of the facility policy titled, Activities of Daily Living, Supporting undated revealed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The residents responses to interventions are monitored, evaluated and revised as appropriate. 4. Review of Resident #47's medical record revealed an admission date of 09/04/24. Diagnoses include dementia with agitation, major depressive disorder, anemia, repeated falls, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had severe cognitive impairment. Furthermore, the MDS assessment revealed Resident #47 was dependent for showering/bathing and personal hygiene. Observation on 06/23/25 at 2:26 P.M. revealed Resident #47's fingernails were long and appeared to have a black/brown substance underneath the fingernails. Interview on 06/23/25 at 3:12 P.M. with Resident #47's family member revealed she believed personal hygiene was not provided the best at the facility and she would like Resident #47 to have his fingernails trimmed and clean at all times. Interview on 06/24/25 at 2:45 P.M. with Licensed Practical Nurse (LPN) #259 verified Resident #47's fingernails were long and appeared to have a black/brown substance underneath the fingernails. Observation on 06/25/25 at 1:11 P.M. revealed Resident #47's nails remained long, and they appeared to have the same black/brown substance underneath the fingernails. Interview on 06/25/25 at 1:14 P.M. with Certified Nurse Assistant (CNA) #220 verified Resident #47's fingernails were long and appeared to have a black/brown substance underneath the fingernails. Review of the skin monitoring shower logs for Resident #47 revealed from 04/02/25 to 06/21/25 no documentation of fingernail care was provided. Review of the undated policy titled Activities of Daily Living (ADLs), Supporting revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, staff interview, review of the water temperature logs, and policy review, the facility failed to maintain safe water temperatures between 105 degrees Fahrenheit (F) and 120 degrees F. This had the potential to affect all residents except eleven residents (#5, #7, #10, #16, #20, #32, #33, #36, #39, #162, and #163) who the facility identified as dependent for mobility. The facility census was 57. Findings include: Review of the water temperature reading logs revealed on 02/11/25 the water temperature in resident room [ROOM NUMBER] was 121.8 degrees F. On 04/14/25 the water temperature in resident room [ROOM NUMBER] was 123.1 degrees F, the water temperature in the dining hall was 134.6 degrees F, and the water temperature in resident room [ROOM NUMBER] was 123.8 degrees F. On 04/28/25 the water temperature in the activities room was 123.3 degrees F. On 05/14/25 the water temperature in the dining hall sink was 130.9 degrees F and in resident room [ROOM NUMBER] the water temperature was 122 degrees F. On 05/27/25 the activities sink water temperature was 127 degrees F. On 06/03/25 the water temperature in the activities room was 122.4 degrees F and the water temperature in the dining hall was 131.4 degrees F. On 06/11/25 the water temperature in resident room [ROOM NUMBER] was 120.8 degrees F. Observation on 06/25/25 at 8:12 A.M. with Maintenance Supervisor (MS) #278 of the water temperature in Resident #2's room verified the water temperature to be 122 degrees F. Observation on 06/25/25 at 8:15 A.M. with MS #278 of the water temperature in the shower room by nurses' station #2 verified the water temperature to be 121 degrees F. Observation on 06/25/25 at 8:18 A.M. with MS #278 of the water temperature in Resident #51's room verified the water temperature to be 121 degrees F. Observation on 06/25/25 at 8:20 A.M. with MS #278 of the water temperature in the shower room by nurses' station #1 verified the water temperature to be 120.4 degrees F. Observation on 06/25/25 at 8:24 A.M. with MS #278 of the water temperature in Resident #39's room verified the water temperature to be 123 degrees F. Observation on 06/25/25 at 8:27 A.M. with MS #278 of the water temperature in Resident #42's room verified the water temperature to be 121.8 degrees F. Observation on 06/25/25 at 8:57 A.M. with MS #278 of the water temperature in the dining room sink verified the water temperature to be 141.4 degrees F. Interview on 06/25/25 at 8:57 A.M. with MS #278 revealed he was new to his position as Maintenance Supervisor, and he was not trained. MS #278 revealed he was not aware of what the water temperatures were supposed to be. Interview on 06/25/25 at 10:54 A.M., the Director of Nursing (DON) revealed there had been no resident burn incidents related to the hot water temperatures. Review of the undated facility policy titled Water Temperatures, Safety of revealed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation.

Based on observation and interview, the facility failed to puree food items to a smooth texture with no chunks of food remaining. This had the potential to affect four residents, Resident #8, #20, #34, and #160, identified by the facility as receiving a pureed only diet. The facility census was 57. Findings include: Observation on 06/25/25 at 10:41 A.M. of processing pureed foods with [NAME] #247 revealed [NAME] #247 placed mixed vegetables in the food processor to puree the vegetables. When completed, [NAME] #247 placed the pureed vegetables in a metal pan and confirmed the vegetables were completed and ready to place on the steam table to serve. Observation revealed several visible small chunks throughout the pureed vegetables. Taste of the pureed vegetables revealed the chunks were the texture of several pieces of skin from the mixed vegetables that did not puree. [NAME] #247 confirmed the chunks of food in the pureed vegetables and confirmed that she was going to serve the residents the prepared pureed vegetables. Phone interview on 06/26/25 at 9:39 A.M. with Speech Therapist (ST) #326 revealed pureed foods should be smooth, no chunks or lumps of food should be present. ST #326 revealed chunks of food in a pureed item would not be acceptable. Telephone interview on 06/26/25 at 9:49 A.M. with Dietitian #325 confirmed the pureed foods should be completely smooth and confirmed there should be no chunks present in the pureed food items.

Based on observation, interview, and review of service provider quotes, the facility failed to maintain the function of the wheelchair automatic push pad door openers for the facility front entrance double doors. This affected 14 residents (#1, #6, #8, #15, #17, #19, #27, #28, #30, #37, #40, #43, #45, and #53) identified by the facility as independent with wheelchair mobility. The facility census was 57. Findings include Observations on 06/24/25 at 7:40 A.M., on 06/25/25 at 7:50 A.M., on 06/26/25 at 7:41 A.M., and on 06/30/25 at 7:45 A.M. revealed the wheelchair accessible push pads used to open the facility front entrance set of double doors were not in working order. Further observation revealed there was a doorbell outside of the facility by the outer set of exterior doors. Interview on 06/30/25 at 7:45 A.M., the Administrator verified the push pad buttons to open each set of the double doors were not working. Interview on 06/30/25 at 8:35 A.M., the Director of Maintenance (DOM) #278 revealed the openers for front door push pads were at the end of its life. DOM #278 revealed the push pads to the exterior set of doors may work one out of ten times. DOM #278 revealed the push pads had not been working on and off since December 2024 and residents had gotten stuck in the entrance space between the two sets of doors. DOM #278 revealed he had notified the owner in April and in May of 2025 of the push pads needing replaced. DOM #278 revealed he obtained quotes in May of 2025, then got the quotes updated in June of 2025, and continued to wait on approval to get the push pads replaced. Interview on 06/30/25 at 11:54 A.M. with Resident #1 stated the push pads to open the front doors had not been working for a few weeks. Resident #1 stated as soon as they get fixed, they break again. Resident #1 revealed it was hard to open the doors on his own when the push pads were not working. Interview on 06/30/25 at 11:58 A.M. with Resident #15 revealed the push pads on the front entrance doors had not been working regularly for the last two years. Resident #15 revealed the doors were hard to open without the push pads. Interview on 06/30/25 at 12:02 P.M. with Registered Nurse (RN) #300 revealed the push pads for the front doors had been working on and off for the past month. Interview on 06/30/25 at 12:05 P.M. with Resident #43 revealed he had to push the push pads multiple times and the door would only start to open. Resident #43 revealed he could get out each set of doors, but it was easier when the button worked. Interview on 06/30/25 at 12:07 P.M. with Resident #30 revealed the push pad buttons had not been working for a few weeks. Resident #30 revealed she had to use the wheelchair to push open the doors. Observation on 07/01/25 at 7:42 A.M. revealed the push pads continued to fail to open both the outer and inner exterior doors to the facility when pushed multiple times to activate. Review of the service provider quotes dated 05/01/25 and 06/04/25 revealed quotes to remove and install new handicap operator on the interior and exterior vestibule doors. The service provider noted current ADA operators (automatic door operator designed to meet the requirements of the Americans with Disabilities Act) were not designed for use on larger steel doors which had affected their longevity. Service ability was becoming difficult as the operators were at end-of-life and should be replaced for safety and reliability concerns.

Based on review of the medical record, staff interview, and facility policy review, the facility failed to ensure resident code status was consistent throughout the medical record. This affected two (#26 and #110) of 20 residents reviewed for code status. The facility census was 57. Findings include 1. Review of the medical record for Resident #26 revealed an admission date of [DATE]. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and Type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the electronic medical record (EMR) face sheet revealed the resident's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Further review of the EMR revealed no physician signed DNR form. Review of a physician order dated [DATE] revealed the resident's code status was DNRCC-A. Review of the care plan dated [DATE] revealed the resident/family had chosen a DNRCC-A order. Review of the paper chart revealed a handwritten note at the front of the chart stating the resident had full code (cardiopulmonary resuscitation) status. Interview on [DATE] at 9:34 A.M., Licensed Practical Nurse (LPN) #275 revealed in an emergency she would check the resident's code status in either the paper chart or the EMR according to which record was the closest. LPN #275 verified Resident #26 had no physician signed DNR form in the EMR or the paper chart. LPN #275 further verified the EMR face sheet stated the resident was a DNRCC-A and in front of the resident's paper chart was a sheet of paper stating the resident had full code status. Interview on [DATE] at 4:01 P.M., Social Service Designee (SSD) #305 revealed the resident had a signed DNRCC-A from his previous facility not uploaded in the medical record and it should have been updated during admission. SSD #305 revealed the resident's family now wanted the resident to be a full code status. 2. Review of Resident #110's medical record revealed an admission date of [DATE]. Diagnoses include chronic pain, mild cognitive impairment, major depressive disorder, morbid (severe) obesity due to excess calories, and hypertension. Review of Resident #110's care plan dated [DATE] verified Resident #110 wanted his code status to be a Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #10's physician orders revealed an order dated [DATE] for a DNRCC code status. Observation on [DATE] at 9:34 A.M. of Resident #110's advanced directives revealed he was a Do Not Resuscitate Comfort Care (DNRCC) in the Electronic Medical Record (EMR). Upon review of the physical paper chart there was no physician signed DNR form in the record. Interview on [DATE] at 9:47 A.M. with Licensed Practical Nurse (LPN) #275 revealed if a patient were to need Cardiopulmonary Resuscitation (CPR), she would reference the advanced directive that was physically closest to her. Interview on [DATE] at 9:51 A.M. with LPN #275 verified a signed DNRCC document was not present in Resident #110's physical chart or scanned into the EMR. Review of the undated policy titled Do Not Resuscitate Order revealed a DNR order must be completed and signed by the attending physician and resident and placed in the front of the resident's medical record.

Based on observation, interview, record review, and review of the facility policy, the facility failed to assure missing items were investigated and followed up on for one resident, (Resident #32), of three residents reviewed for missing items. The facility census was 57. Findings include: Record review for Resident #32 revealed an admission date of 01/13/23. Diagnosis included Alzheimer's disease with late onset. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was severely cognitively impaired. Resident #32 was dependent for bed mobility, chair/bed chair transfers, and wheelchair mobility. Telephone interview on 06/24/25 at 10:07 A.M. with Resident #32's family member revealed Resident #32 was missing blankets, clothing items, and stuffed animals. Resident #32's family member revealed it had been a while, between a month or two but they did let the staff know. Resident #32's family member revealed they could not remember the staff names. Interview on 06/25/25 at 9:25 A.M. with Social Worker Designee (SWD) #305 revealed she had not received any resident concerns or grievances since February 2025. SWD #305 revealed if a family or resident had a concern or grievance, they would fill out a concern log located at the front desk or a staff member could fill one out for them. If it was for missing laundry or items, she would look for the item then if she could not find it she would notify the Administrator and she would take over from there. SWD #305 revealed she never had a concern log for any missing items from Resident #32 or the family. Observation with SWD #305 revealed there were no concern logs located at the front desk. Interview on 06/26/25 at 10:46 A.M. with Laundry/Housekeeping Assistant #253 revealed the laundry department gets reports of missing clothing, all the time, at least three times a week. Laundry/Housekeeping Assistant #253 revealed that sometimes families, staff or residents just come tell the laundry department what is missing but most the time they give us something in writing, usually on plain white or scrap paper or we just write it on paper. Laundry/Housekeeping Assistant #253 revealed she does not keep the notes or papers with missing items, once she looks for the item, if she cannot find it, she tells the nurse and throws the paper away and that's it. Laundry/Housekeeping observation completed with Laundry/Housekeeping Assistant #253 of the laundry room revealed two racks of clothes hanging and three full large boxes of clothing items and slippers. Laundry/Housekeeping Assistant #253 revealed these were no name items and laundry did not know who they belonged to. Interview on 06/26/25 between 11:07 A.M. and 2:01 P.M. with Certified Nursing Assistant (CNA) #227 and #231 revealed they both frequently worked with Resident #32. CNA #231 revealed, About two months ago, the family said she was missing stuffed animals but there was another resident at the facility who would wander and take stuff but I don't know what ever happened with it. CNA #227 and #231 revealed when residents or families report missing items, they go to the laundry to look for it and if they cannot find it, they tell whoever is working in laundry to keep an eye out for it. Interview on 06/26/25 at 2:06 P.M. during Resident Council meeting with nine participants, Resident #3, #14, #15, #17, #22, #28, #37, #46, and #161 all confirmed verbally or with a head nod that they each had missing clothing items and this was considered by them a big problem. Resident #37 revealed they tell the laundry lady, she always says she will look into it but they never come back to follow up about the missing clothing items. Multiple residents stated out loud simultaneously they agreed with that statement and reiterated they felt it was a big problem. Resident #17 revealed twice a year they bring out all the clothes and put them in the activities room for residents to go through to see if any of their missing clothing is in there. Review of the Resident Council Meeting minutes dated 04/30/25 revealed room [ROOM NUMBER] was missing an Ohio State short sleeve shirt and woman's jean shorts. room [ROOM NUMBER] has been missing XXXL black shorts since last summer; Residents are complaining they are not getting socks back. Review of the Resident Council Minutes review dated 04/30/25 to Department Housekeeping/laundry revealed Plans of Corrections: Housekeeping was informed to look for residents missing items and follow up upon returning resident items to ensure needs were met. Administrator signed and dated 05/07/25. No follow up was documented as to finding or not finding the missing items or follow up with the residents. Review of the Resident Council Meeting minutes dated 05/28/25 revealed room [ROOM NUMBER] received clothes that did not belong to her. Review of the facility policy titled, Grievances/Complaints, Recording and Investigating undated revealed all grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievances. The Grievance Officer will record and maintain all grievances and complaints on the Grievance Report. The following information will be recorded and maintained in the log: a. The date the grievance/complaint received. b. The name and room number of the resident filing the grievance/complaint. c. The name and relationship of the person filing the grievance/complaint on behalf of the resident. d. The date the alleged incident took place. e. The name of the person investigating the incident. f. The date the resident or interested party was informed of the findings. g. The disposition of the grievance. h. The grievance/complaint form will be filed with the Administrator within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number OH00166248.

Based on record review, interview, and review of the facility policy, the facility failed to complete a baseline care plan for one, (Resident #160) of eight reviewed for baseline care plans. The facility census was 57. Findings include: Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Record review for Resident #160 revealed no baseline care plan was initiated until 06/18/25. Interview on 06/24/25 at 2:31 P.M. with Licensed Practical Nurse (LPN) MDS Nurse #208 confirmed Resident #160 did not have a baseline care plan initiated until 06/18/25. LPN MDS Nurse #208 revealed baseline care plans were to be initiated upon admission and completed within 72 hours of admission. Review of the facility policy titled, Care Plans-Baseline undated revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan.

Based on observation, resident interview, medical record review, review of the facility policy and review of the facility assessment, the facility failed to provide an individualized activity program designed to meet the interest and care needs of one resident (#16) of two residents reviewed for activities. The facility census was 52. Findings include: Review of Resident #16's medical record revealed an admission date of 04/02/25. Diagnoses included acquired absence of left leg below the knee, major depressive disorder, Diabetes Mellitus II with hyperglycemia and acquired absence of right foot. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #16 was cognitively intact. Resident #16 was dependent on staff for personal hygiene, lower body dressing, shower/bathing self and toileting. Review of Resident #16's care plan dated 04/07/25 revealed it did not have a care plan for activities. Interview and observation on 06/23/25 at 9:30 A.M. with Resident #16 revealed staff do not tell her what is going on. The other day, they had a parade and didn't tell anyone. I would have loved to go. I have never seen activities posted. It's hard for me to get around. Resident's room was observed and no calendar was observed indicating what activities were occurring on the days of the month. Interview on 06/30/2025 at 8:59 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #16 had a Peripherally Inserted Central Catheter (PICC) line placed and when she returned to the facility, she was too weak and tired to attend activities therefore declined to go to the Juneteenth parade. Interview on 06/30/25 at 11:58 A.M. with the Activity Director revealed activity calendars are passed out to all residents. Some residents want them taped to the wall and some prefer to keep them on their bedside table. Interview on 07/01/25 at 9:00 A.M. with Certified Nursing Assistant (CNA) #231 revealed sometime Resident #16 goes to activities and sometimes she stays in her room. Multiple observations on 06/24/25-06/25/25 and 06/30/25-07/01/25 during the day, revealed Resident #16 was not observed out of her room. Review of the facility policy, Activities and Social Services, no date revealed residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. As much as possible, the facility will provide activities, social events and schedules that are compatible with the residents' interests, physical and mental assessment and over plan of care.

2. Review of the medical record for Resident #110 revealed an admission date of 06/13/25. Diagnoses included chronic pain, hemiplegia and hemiparesis, cerebral infarction, hypertension, atrial fibrillation, congestive heart failure, and narcissistic personality disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a wound assessment report dated 06/20/25 revealed the resident had bilateral lower extremity venous ulcers. Review of a physician order dated 06/21/25 revealed to cleanse the bilateral lower extremities with wound cleanser, pat dry, apply ammonium lactate lotion to both lower legs topically, apply non-adhering dressing then a dry dressing over wounds, cover with an elastic tubular bandage and then wrap with and outer elastic bandage daily and as needed for venous ulcer wound care. Observation on 06/23/25 at 12:30 P.M. revealed Resident #110 had elastic bandages covering his bilateral lower extremities from below the knees to the top of the feet. Further observation revealed the wound dressings were not dated. Interview on 06/23/25 at 12:30 P.M., Resident #110 revealed his wound dressings had not been changed since 06/20/25 when the wound nurse assessed and changed the dressings. Resident #110 stated the staff never dated his wound dressings. Observation on 06/24/25 at 1:32 P.M., Licensed Practical Nurse (LPN) #259 verified Resident #100's wound dressings to the bilateral lower extremities were not dated. Further observation of wound care revealed LPN #259 removed the elastic cover bandage covering the wounds revealing the inner tubular elastic bandage, abdominal pad, and non-adherent were saturated with dried drainage on each lower extremity. LPN #259 applied new wound care dressings per physician orders. LPN #259 had not dated the wound dressings. Interview on 06/25/25 at 2:12 P.M., LPN #259 revealed the wound dressing appeared to not have been changed recently due to the amount of saturation of the dressings. LPN #259 verified she had not dated the residents wound care dressings to the bilateral lower extremities. Interview on 06/25/25 at 9:34 A.M., LPN #275 verified also not dating wound dressings for Resident #110. Further interview with LPN #275 revealed completing the resident's wound care dressing changes on 06/21/25. Review of the Treatment Administration Record (TAR) dated 06/21/25 through 06/24/25 revealed no documentation the resident's wound dressing to the bilateral lower extremities had been completed on 06/23/25. Interview on 06/26/25 at 11:47 A.M., the Director of Nursing (DON) verified Resident #110's wound treatment was not completed on 06/23/25. Review of the undated facility policy Wound Care revealed staff would administer wound care treatments per physician orders and date, time, and initial wound care dressings when completed. 3. Review of the medical record for Resident #27 revealed an admission date of 01/17/25. Diagnoses included chronic obstructive pulmonary disease, malignant neoplasm of colon, type two diabetes mellitus, peripheral vascular disease, acquired absence of right leg above knee, cerebral infarction, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the care plan dated 04/22/25 revealed the resident had a left heel wound. Interventions included a weekly skin assessment for and provide treatment per physician order. Review of a skin/wound progress note dated 05/19/25 at 11:46 A.M. revealed a nursing assistant reported resident sock sticking to foot. Nurse assessed and found a new open area to the left heel measuring approximately three centimeters (cm) by two centimeters with light bleeding and serous drainage. The physician was notified, and a treatment was applied. Review of weekly skin/wound assessments revealed the wound was assessed on 05/27/25. Review of a progress note dated 05/30/25 at 12:47 P.M. revealed the wound nurse practitioner noted the resident had a diabetic foot ulcer to the left lateral foot measuring 2.4 cm in length by three cm in width by 0.1 cm in depth with moderate serous drainage. New wound care orders included to cleanse with wound cleanser, apply calcium alginate with silver to base of wound and secure with bordered foam daily and as needed. Also to float heels while in bed with the use of heel boots. Review of a weekly skin/wound assessment dated [DATE] revealed no assessment of the resident's left heel was completed. Further review of the weekly skin/wound assessments revealed no further weekly wound assessments had been completed since 05/30/25. The resident had appointments at an outside wound care provider on 06/05/25 and 06/19/25 with no wound measurements provided. Observation on 06/24/25 at 2:21 P.M., of wound care for Resident #27 with Licensed Practical Nurse (LPN) #259 revealed a wound on the left posterior heel with discoloration approximately 2.5 centimeters in length and 1.5 cm in width with no depth as the skin was intact. There was no drainage or signs of infection. Interview on 06/30/25 at 1:51 P.M., the Director of Nursing (DON) confirmed there was no documentation of weekly wound assessments completed for Resident #27 since 05/30/25. The DON revealed nursing staff should be completing weekly wound evaluations to monitor, measure, and assess the wound. Review of the undated facility policy Wound Care, revealed no guidelines for the frequency of wound assessments. Further review of the policy revealed to document wound assessment data (wound bed color, size, drainage) obtained when inspecting the wound. Based on observation, interview, record review, and review of the facility policy, the facility/ Hospice Registered Nurse (RN) failed to assure Resident #160 received pain medications when she expressed she was having pain throughout the procedure of an indwelling catheter reinsertion and peri care and the facility failed to address a change in condition timely for Resident #160 when her peri area, buttocks, and under her bilateral breast were observed by facility staff and Hospice RN to be deep red. Additionally the facility failed to ensure wound care was provided and timely complete wound assessments were completed for two (#110, #27) of three residents reviewed for wound care. The facility identified seven residents with non-pressure wounds. The facility census was 57. Findings include: 1. Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, obesity, Diabetes Mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Review of the care plan dated 06/23/25 revealed Resident #160 was at risk for infection and/or trauma related to use of foley catheter, neurogenic bladder. Interventions included to check for patency and urinary output every shift; Monitor for signs and symptoms of urinary tract infection (UTI): burning on urination, flank pain, hematuria, decreased urinary output, change in mental status, change in behavior, fever, change in color, clarity and/or odor of urine. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 to keep foley diagnosis is oliguria. An additional order revised 05/30/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is oliguria. A revised order dated 06/19/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is neurogenic bladder. Review of the physician orders revealed orders dated 05/30/25 for Morphine Sulfate (opioid) oral solution 20 mg/ml give 10 mg by mouth every six hours for pain and 10 mg by mouth every one hour as needed for pain or shortness of breath. Review of the physician orders for Resident #160 revealed an order dated 05/30/25 revealed an order for Enhanced Barrier Precautions (EBP) due to foley catheter every day and night shift. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was scratching at her peri area aggressively. The brief Resident #160 was wearing had been saturated with a red substance. Resident #160 was not responding to questions and continued scratching. Resident #160's husband placed Resident #160's call light on. Observation on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. CNA #280 confirmed Resident #160 had blood inside her brief saturating the center peri area of the brief. CNA #280 turned Resident #160 to her side. A moderate amount of blood was observed on the pad under Resident #160. The indwelling catheter was lying on the mattress next to Resident #160 with a fully inflated balloon. The catheter had blood on the tubing and balloon. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. Multiple old and new scratches were observed on Resident #160's thighs. CNA #226 revealed some of the scratches were older and some were new. There was blood with blood clots inside Resident #160's brief that CNA #226 and #280 removed. At 10:26 A.M. Registered Nurse (RN) #299 entered the doorway of the room. RN #299 did not observe or assess Resident #160, RN #299 stood in the doorway and revealed she will come in and replace the indwelling catheter when her medication pass was completed. RN #299 then exited the room. Observation after peri care was completed revealed Resident #160's vaginal area was deep red, under bilateral breasts were deep red and the buttocks/peri area was deep red. Interview on 06/23/25 at 10:45 A.M. with RN #299 revealed when asked if she was going to replace Resident #160's indwelling catheter, She is hospice so, I am going on break right now. Interview on 06/23/25 at 1:09 P.M. with Hospice #320's Hospice RN #321 revealed Resident #160 had an indwelling catheter due to urinary retention. Hospice RN #321 revealed Resident #160 never removed her indwelling catheter prior to today. Observation revealed Hospice RN #321 placed a pair of clean disposable gloves on. Hospice RN #321 did not wash her hands prior to placing the clean gloves on. Hospice RN then place a pair of sterile gloves over the clean gloves. Hospice RN #321 then attempted to insert the indwelling catheter into Resident #160's urethra with no assistants. Resident #160 was morbidly obese and was not following direction. Hospice RN #321 then attempted several times inserting the catheter into the urethra which was not visible due to positioning. Resident #160 repeatedly yelled out., ow, ow ,ow during the entire procedure of attempting to place the indwelling catheter into the urethra. Hospice RN #321 then inserted the catheter in the area, pushed 30 milliliters (ml) of fluid in the catheter balloon while Resident #160 continued yelling out, ow, ow, ow. Hospice RN #321 confirmed Resident #160's was very red inside her vaginal area and under her breast. Hospice RN #321 also confirmed Resident #160 was having pain during the procedure and confirmed she never offered any as needed pain medication before or during the procedure. Per Hospice RN #321, Resident #160 had as need pain medication available for use if needed. Hospice RN #321 revealed Resident #160 was incontinent of urine on her brief. Hospice RN #321 turned Resident #160 to her right side. Resident #160's buttocks was deep red, Hospice RN #321 pulled Resident #160's brief from under her ripping the brief into several pieces as she kept pulling on it grabbing different areas of the brief. Surveyor suggested waiting for assistants to continue with the care. At 1:28 P.M. Licensed Practical Nurse (LPN) #261 entered the room to assist. Observation revealed the indwelling catheter came out. Hospice RN #321 revealed it fell out because it was not in the right area. Observation revealed during peri care provided by Hospice RN and LPN #261, Resident #160 continued to yell out, ow, ow, ow every time her vaginal area was touched. Hospice RN #321 never offered pain medication. Hospice RN #321 confirmed she never offered Resident #160 any pain medication although Resident #160 repeatedly yelled out in pain throughout the procedure, and confirmed Resident #160 had as needed pain medication available. Interview on 06/24/25 at 1:35 P.M. with RN #299 revealed the Hospice nurse never told her about the red areas in the vaginal area, buttocks or under the breast and confirmed Resident #160 never received orders to treat the areas. RN #299 revealed she will call hospice for new orders. RN #299 confirmed she never attempted to replace Resident #160's indwelling catheter on this day either, she was waiting for Hospice. Review of the physician order for Resident #160 revealed an order dated 06/24/25 for Diflucon 200 mg by mouth for yeast for five days until finished.

Based on observation, interview, and record review revealed the facility failed to ensure an indwelling catheter for one resident, Resident #160 was addressed timely to include a physical assessment and reinsertion when Resident #160 removed the catheter. The facility also failed to notify the primary care physician of the catheter and failed to notify the primary care physician and Hospice provider of the results of a urinalysis timely that resulted in bacterial growth requiring treatment of an antibiotic. This affected one resident, Resident #160 and had the potential to affect an additional seven residents, Resident #5, #26, #35, #36, #40, #43, and #50 identified by the facility as having indwelling catheters. The facility census was 57. Findings include: Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, Absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Review of the care plan dated 06/23/25 revealed Resident #160 was at risk for infection and/or trauma related to use of foley catheter, neurogenic bladder. Interventions included to check for patency and urinary output every shift; Monitor for signs and symptoms of urinary tract infection (UTI): burning on urination, flank pain, hematuria, decreased urinary output, change in mental status, change in behavior, fever, change in color, clarity and/or odor of urine. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 to keep foley diagnosis is oliguria. An additional order revised 05/30/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is oliguria. A revised order dated 06/19/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is neurogenic bladder. Review of the Nursing Progress Note for Resident #160 dated 06/15/25 at 2:08 A.M. included Resident #160 complained of urgency stating she felt like she had to pee. Increased agitation and confusion. Urine in catheter bag was cloudy and had a strong odor. The note included would speak with hospice for a urine analysis culture and sensitivity (UA C&S) laboratory test Review of the Nursing Progress Note for Resident #160 dated 06/16/25 at 11:59 A.M. revealed Certified Nursing Assistant (CNA) reported urine had a foul odor. Resident educated to consume more water due to strong urine. Review of the Nursing Progress Note for Resident #160 dated 06/18/25 at 9:24 A.M. revealed a call was placed to hospice to obtain a urine sample to send to lab for a UA C&S due to cloudy urine and a strong urine smell and increased confusion. Review of the physician orders for Resident #160 revealed an order dated 06/18/25 revealed an order to collect urine for a urinalysis, culture and sensitivity to be sent to laboratory and notify hospice of results. Review of the Nursing Progress Note for Resident #160 dated 06/19/25 at 6:09 A.M. revealed urine collected from resident this A.M. and sent to lab for a UA C&S. Review of the Nursing Progress Notes for Resident #160 from 06/19/25 through 06/24/25 at 2:00 P.M. revealed no further documentation, results or orders from UA or C&S obtained 06/19/25. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was scratching at her peri area aggressively. The brief Resident #160 was wearing had been saturated with a red substance. Resident #160 was not responding to questions and continued scratching. Resident #160's husband placed Resident #160's call light on. Observation on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. CNA #280 confirmed Resident #160 had blood inside her brief saturating the center peri area of the brief. CNA #280 turned Resident #160 to her side. A moderate amount of blood was observed on the pad under Resident #160. The indwelling catheter was lying on the mattress next to Resident #160 with a fully inflated balloon. The catheter had blood on the tubing and balloon. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. CNA #226 revealed Resident #160 was last changed at 6:00 A.M.; There was blood with blood clots inside Resident #160's brief that CNA #226 and #280 removed. At 10:26 A.M. Registered Nurse (RN) #299 entered the doorway of the room. RN #299 did not observe or assess Resident #160, RN #299 stood in the doorway and revealed she will come in and replace the indwelling catheter when her medication pass was completed. RN #299 then exited the room. Interview on 06/23/25 at 10:45 A.M. with RN #299 revealed when asked if she was going to replace Resident #160's indwelling catheter, She is hospice so, I am going on break right now. Interview on 06/23/25 at 12:14 P.M. with RN #299 revealed the hospice nurse never came yet and she would let the surveyor know when the hospice nurse comes to replace Resident #160's indwelling catheter. Interview on 06/23/25 at 1:09 P.M. with Hospice #320's, Hospice RN #321 revealed Resident #160 had an indwelling catheter due to urinary retention. Hospice RN #321 revealed Resident #160 never removed her indwelling catheter prior to today. Observation revealed Hospice RN #321 placed a pair of clean disposable gloves on. Hospice RN #321 did not wash her hands prior to placing the clean gloves on. Hospice RN then place a pair of sterile gloves over the clean gloves. Hospice RN #321 never placed an isolation gown on. Hospice RN #321 then attempted to insert the indwelling catheter into Resident #160's urethra with no assistance. Resident #160 was morbidly obese and was not following direction. Observation revealed Hospice RN was attempting to hold the catheter in one hand, spread Resident #160's legs with her arms while trying to separate the labia with the second hand to visualize the urethra. Hospice RN #321 then attempted several times inserting the catheter into the urethra which was not visible due to positioning. Hospice RN #321 then inserted the catheter in the area with no urine return observed, pushed 30 milliliters (ml) of fluid in the catheter . Hospice RN #321 confirmed there was no urine return. At 1:28 PM Licensed Practical Nurse (LPN) #261 entered the room to assist. LPN #261 never placed an isolation gown on. Observation revealed the indwelling catheter came out. Hospice RN #321 revealed it fell out because it was not in the right area. LPN #261 revealed she would look to see if the facility had another indwelling catheter for Resident #160. Interview on 06/23/25 at 2:04 P.M. with RN #299 confirmed she did not place Resident #160's indwelling catheter in stating, I did not change the catheter myself because I was busy, there are only two nurses., use to be three, now two nurses for all residents, there's not enough time. Observation on 06/24/25 at 1:35 P.M. revealed Resident #160 was lying in bed. Resident #160 did not have an indwelling catheter. Interview with RN #299 revealed Resident #160 had the catheter replaced on 06/23/24 by the hospice nurse then Resident #160 pulled it out again last night. RN #299 revealed Hospice was called this A.M., they said they will notify Resident #160's case worker and will call back. RN #299 revealed Hospice never called back yet and confirmed Resident #160's primary physician was never notified of the catheter coming out. RN #299 revealed, Most hospice companies take care of everything so we just notify hospice. RN #299 revealed she will call hospice for new orders. RN #299 confirmed she never attempted to replace Resident #160's indwelling catheter on this day either, she was waiting for Hospice. Interview 06/24/25 1:47 P.M. with Director of Nursing (DON) revealed an acceptable amount of time to wait to assess a resident when a resident has a change in condition such as an indwelling catheter coming out would be immediate. The nurse should stop what they are doing and assess the resident including any trauma to the area from the catheter being pulled out. The facility nurse should address the concern, replace the catheter then update hospice and the primary physician. Record review for Resident #160 revealed the UA C&S results for the urine obtained 06/19/25 were not available in the medical records and there was no further documentation after the urine was obtained regarding the urinalysis results. Interview with DON on 06/24/25 at 3:30 P.M. confirmed Resident #160 did not have the UA obtained on 06/19/25 or C&S results in the medical record and no follow up on the results were documented. Interview on 06/24/25 at 4:45 P.M. with DON revealed she called the lab and obtained the results of the UA C&S for Resident #160. Review of the lab results revealed the results were faxed to the facility on [DATE] at 4:20 P.M.; Resident #160 had greater than 100,000 growths of both Escherichia coli and pseudomonas aeruginosa. DON revealed the lab said they just got the results and never sent a preliminary. Interview on 06/24/25 at 4:57 P.M. with Resident #160's husband revealed he noticed a huge change in his wife about two weeks ago and revealed she was sluggish, more confused, not herself. Review of the physician order for Resident #160 revealed an order was written on 06/24/25 for Cipro (antibiotic) 250 mg give one tablet orally two times a day for urinary tract infection (UTI) for seven days. Telephone interview on 06/25/25 at 10:04 A.M. with Laboratory Director #324 revealed Resident #160's urinalysis was obtained from the facility on 06/19/25 at 2:00 A.M.; The urinalysis result were reported faxed to the facility on [DATE] at 7:33 A.M. The C&S was completed on 06/21/25 at 8:55 A.M. but not faxed until 06/24/25. Lab Director #324 revealed when a urinalysis is completed that required a C&S, the urinalysis is sent to a different location for the C&S. The staff that completed the urinalysis at the first lab for Resident #160 did not put the fax request in so that the second lab who completed the C&S was aware to fax the results to the facility. Some facilities have electronic access to obtain results immediately and some prefer to be faxed. The lab does not know unless it is written on the request that they need to fax it. Lab Director #324 confirmed the C&S result would not have been sent to the facility if they did not call to request it on 06/24/25. Review of the lab confirmation sent via e-mail from Laboratory Director #324 confirmed the abnormal urinalysis report for Resident #160 was successfully sent via fax to the facility on [DATE] at 11:20 A.M.; The C&S was sent via fax to the facility on [DATE] successfully at 4:33 P.M. Interview on 06/25/25 at 3:20 P.M. with DON confirmed the facility should have followed up on the lab results for the urinalysis and the C&S for Resident #160 and the nurses should have notified the hospice and physician when they received the results. This deficiency represents non-compliance investigated under Complaint Number OH00166248.

Based on interview, record review, and review of the facility policy, the facility failed to ensure a resident with significant weight loss received timely follow up and the physician was notified. This affected one, (#30) of two residents reviewed for weight loss. The facility census was 57. Findings include: Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), unspecified protein calorie malnutrition, hypothyroidism, and Type Two Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had a weight loss of five percent (%) or more in the last month or loss of 10 % or more in the last six months. Review of the care plan for Resident #30 dated 05/07/25 revealed Resident #30 had a nutritional problem or potential nutritional problems related to ESRD, dialysis, low serum albumin levels, overweight, diabetes, chronic obstructive pulmonary disease (COPD) and diagnosis protein-calorie malnutrition. Interventions included Registered Dietitian (RD) to evaluate and make diet change recommendations as needed (PRN). Review of the physician orders for Resident #30 revealed an order for renal diet regular texture thin consistency, low cholesterol, low saturated fats, low sodium, low potassium, for diet initiated 03/11/25 and medpass (nutritional supplement) 2.0 four ounces with each administration two times a day initiated 04/30/25. Review of the Medication Administration Record (MAR) for Resident #30 for June 2025 revealed Resident #30 drank 0% of the medpass 2.0 (38 of the 54 times) the med pass was offered. Review of the weight record for Resident #30 revealed on 05/05/25 Resident #30 weighed 200.2 pounds (lb). On 06/25/25 Resident #30 weighed 169.2 (15.48%) weight loss. Review of the progress note for Resident #30 dated 05/21/25 at 12:55 P.M. completed by Dietitian #325 revealed current weight 174.2 pounds (LB) was discussed at risk management meeting, down 26 lbs since 05/06, request reweigh. No change in (Resident #30's) medical status noted. Record review of the weight record for Resident #30 revealed the next weight was completed 05/28/25 and the weight was 171.6 lbs. Record review of Resident #30's medical record revealed no further documentation was completed by the Dietitian after 05/21/25 until 06/11/25. Review of the progress note for Resident #30 dated 06/11/25 at 2:46 P.M. completed by Dietitian #325 revealed the June monthly weight was reviewed. Noted 31# weight loss on 30 days. Meal intakes remain 75-100%. Current weight 173#. Requesting a reweigh. Record review of the weight record for Resident #30 revealed the next weight was completed 06/12/25 and the weight was 169.5 lbs. Record review of Resident #30's medical record revealed no further documentation was completed by the Dietitian after 06/11/25. Interview on 06/30/25 10:23 A.M. with Dietitian #325 revealed she tried to review residents' weights monthly and as needed. Dietitian #325 confirmed she did not follow up on Resident #30's significant weight loss after the reweigh in May 2025 or June 2025. Dietitian #325 revealed she forgot to follow up and review the reweighs and confirmed there was no follow up on Resident #30's weight loss. Dietitian #325 revealed the supplement from 05/13/25 was not working for Resident #30. Dietitian #325 stated, I am so sorry, I forgot to follow up on her. Interview on 06/30/25 at 10:31 A.M. with the Director of Nursing (DON) revealed the Dietitian should have been notified of the reweighs and the she should have reevaluated Resident #30 for the significant weight loss and the physician should have also been notified. Interview on 06/30/25 at 10:47 A.M. with Resident #30 revealed she was not sure why she was having weight loss, it was just happening. Resident #30 revealed she did not like the medpass and stated, I am trying to get the dietitian in to get me some boost, I would like that. Review of the facility policy titled, Dietitian undated revealed our facility's dietitian is responsible for, but not necessarily limited to assessing nutritional needs of residents.

2. Record review for Resident #160 revealed an admission date of 05/28/25. Diagnosis included heart failure, obesity, and diabetes mellitus with diabetic polyneuropathy. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Review of the care plan for Resident #160 dated 06/23/25 revealed Resident #160 utilized oxygen therapy related to congestive heart failure, shortness of breath and asthma. Interventions included oxygen settings two to five liters as needed or SP02 less than 90%. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 for oxygen two to five liters as needed for shortness of breath or SPO2 less than 90 %. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was not responding to questions. The nasal cannula and tubing connected to the oxygen concentrator was lying on the floor next to the concentrator. The concentrator was not running. Resident #160's husband placed Resident #160's call light on. Observation on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. At 10:26 A.M. Registered Nurse (RN) #299 entered the doorway of the room. RN #299 did not observe or assess Resident #160, RN #299 stood in the doorway and revealed she will come in and replace Resident #160's indwelling catheter when her medication pass was completed. RN #299 then exited the room. CNA #280 picked Resident #160's nasal cannula off the floor, placed it back in Resident #160's nares and turned on the oxygen concentrator. The concentrator was set at 1.5 liters per minute. No assessment was completed to determine Resident #160's oxygen saturation level and no shortness of breath was observed. Upon exit of the room, CNA #280 confirmed she picked up the oxygen tubing off the floor and placed it in Resident #160's nares then turned the concentrator on. Interview on 06/30/25 at 8:22 A.M. with Registered Nurse (RN) #300 revealed CNA's were not permitted to turn on or off oxygen concentrators. Interview on 06/30/25 at 8:40 A.M. with the Director of Nursing (DON) revealed CNA's were not permitted to apply oxygen or turn on or off oxygen use. Review of the facility policy titled, Oxygen Administration undated revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. The nasal cannula is a tube that is placed approximately one/half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for signs and symptoms of cyanosis, hypoxia, oxygen toxicity, vital signs, lung sounds, and oxygen saturation. Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure physician orders for oxygen contained Liters Per Minute (LPM). This affected two residents (#42 and #160) of two residents reviewed for respiratory care. The facility identified 14 residents receiving oxygen therapy. The facility census was 57. Findings include: Review of Resident #42's medical record revealed an admission date of 02/02/24. Diagnoses include chronic obstructive pulmonary disease, anxiety, atrial fibrillation, and atherosclerotic heart disease. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. Review of Resident #42's physician orders revealed an order to apply oxygen via nasal cannula to keep oxygen saturation (SpO2) level at 93 percent (%) and above. Observation on 06/23/25 at 10:22 A.M. revealed Resident #42 was wearing oxygen via nasal cannula set at five liters per minute (LPM). Concurrent interview with Resident #42 revealed she always wore oxygen. Interview on 06/25/24 at 9:40 A.M. with Licensed Practical Nurse (LPN) #275 verified Resident #42's oxygen was set to five LPM. Interview on 06/25/24 at 9:43 A.M. with LPN #275 verified the physician order for Resident # 42's oxygen had not stated the oxygen LPM. Interview on 06/26/25 at 11:01 A.M., the Director of Nursing (DON) verified a physician order should specify liters per minute for oxygen administration. Review of the undated policy titled Oxygen Administration revealed oxygen should be administered per the physicians orders. Further review of the policy revealed unless otherwise ordered, start the flow of oxygen at the rate of two to three liters per minute.

Based on review of facility billing records, emails, invoices and past due notices, review of bank statements, review of the facility assessment, Nursing Home Admission Agreement, facility policy and procedures, and interviews with residents/family, staff, vendors, and company personnel, the facility neglected to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid in a timely manner to prevent the actual and potential interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. This resulted in Immediate Jeopardy on 04/01/24 when the identified lack of financial solvency placed all facility residents at risk for serious harm, injury, hospitalization , displacement due to the actual and potential interruption in utility and/or outside service providers. Financial concerns were identified and included, but were not limited to delinquent balances owed to the water company resulting in a shut off notice issued 04/01/24 with water services to end 04/12/24, delinquent balances owed to the phone leasing company resulting in phone service interruption on 04/01/24, delinquent balances owed to the facility current food vendor which resulted in food delivery being placed on hold on 04/02/24, and delinquent balances owed to the contracted therapy provider resulting in therapy services terminating on 04/05/24. This had the potential to affect all 56 residents residing in the facility. On 04/02/24 at 2:47 P.M., the Administrator, Director of Nursing (DON) and Chief Executive Officer (CEO) #805 were notified Immediate Jeopardy began on 04/01/24 when an onsite investigation determined the facility neglected to meet all financial obligations for the delivery of care and maintenance of the facility by not paying vendors in a timely manner to prevent actual and potential interruption in services and to meet the total care needs of residents. The Immediate Jeopardy remains ongoing as of 04/15/24 as the facility failed to provide evidence of an effective abatement plan. Findings include: On 03/22/24 at 2:50 P.M. confidential information provided to the State agency revealed ongoing financial solvency concerns in the facility and that the facility was not paying their vendors. The concerns included therapy services being on hold for residents due to non-payment, the facility running out of food for residents, having little to no resident care supplies (including incontinence briefs) and that the facility phones were set to be turned off due to non-payment. Additional confidential concerns provided to the State agency included concerns the facility had been in financial trouble for almost a year due to the inability to pay vendors. The source of the concern indicated the facility would change vendors, with a specific example given of the facility food vendor, who after owing upwards of $60,000-$70,000 to the previous company and not being able to pay them, the facility simply switched to a new vendor. The source indicated there were some utilities/vendors who required cash payment as they would no longer take a check or electronic payment from the facility. The source also shared he/she had witnessed vendors come into the facility and sit until they received payment, because the facility was so far behind on payments. Lastly the source indicated the facility was utilizing agency staffing to fill 99% of their shifts and had not had a Director of Nursing or Minimum Data Set (MDS) nurse for some time. On 03/26/24 at 7:38 A.M. an interview with the Administrator revealed she began her employment with the facility on 03/20/23. During the interview she indicated she did not handle any financial aspects of the facility. The Administrator indicated the facility was a non-profit facility with a Board of Directors and Chief Executive Officer (CEO) #805 was responsible for the financial aspect of the facility including paying vendors. On 03/27/24 at 12:38 P.M. interview with CEO #805 revealed the facility had payment issues due to a low census and low funds and were now just catching up on their payments. On 03/27/24 at 1:44 P.M. a telephone interview with Business Office Manager (BOM) #831 revealed during routine audits she noted the facility was unable to process payments for resident care and the facility bills were not paid timely (date(s) not provided). BOM #831 indicating she reported these concerns to CEO #805 (date(s) not provided). On 04/01/24 at 1:41 P.M. an interview with the Medical Director revealed he was not aware of the facility being behind on payments. The Medical Director revealed he was unaware of residents not having enough supplies, food, medications, or not receiving resident care. The Medical Director revealed he attended a quarterly Quality Assurance/Performance Improvement (QAPI) meeting the week prior and the facility did not bring up any issues with the inability to pay vendors. The Medical Director then stated he was not involved in the financial side of the facility. On 04/01/24 at 4:06 P.M. an interview with CEO #805 revealed the facility had a cash flow issue due to changes in management. CEO #805 indicated their Minimum Data Set (MDS) employee, MDS #826 quit recently on 02/25/24 and the previous BOM, BOM #870 quit 12/29/23, and the facility had a difficult time finding replacements. CEO #805 stated resident MDS 3.0 comprehensive assessments were not being completed on time and the facility was not generating payments for resident care due to late MDS assessments. He denied the facility initiated or developed any type of QAPI plan to resolve the identified financial issues, to ensure vendors were paid in a timely manner to prevent potential or actual interruption in services and to meet the total care needs of all residents admitted to and/or retained in the facility. CEO #805 stated the facility had three options, keep going like they were, find new staff to timely complete resident care and billing or shut down the facility. Review of the Deposit Accounts bank statement dated 04/01/24 revealed the skilled nursing facility had a current balance in its general fund operations account of $6,971.18. On 04/02/24 at 2:29 P.M. an interview with the Administrator revealed she was resigning her position as administrator at the facility effective 04/22/24. The Administrator also revealed Rehab Director #824 had recently resigned his position due to the instability of the facility. On 04/03/24 at 11:16 A.M. interview with CEO #805 revealed he realized late on 04/02/24 Business Office Manager (BOM) #831 was not completing her duties as required and had not sent out billing in a timely manner for the months of 01/2024 and 02/2024. CEO #805 then stated this was the reason the facility had cash flow issues. There was no evidence this had been identified by the facility as a potential reason for cash flow issues prior to 04/02/24 during the onsite survey investigation. On 04/03/24 at 11:38 A.M. an interview with the Administrator and the Director of Nursing (DON) revealed CEO #805 talked to all staff on 04/02/24 during the evening shift and told them the State agency had identified monetary concerns. The Administrator and DON revealed they felt the CEO created increased anxiety and panic with the staff because of his communication and even stated to staff that all of the facility bank accounts were frozen. On 04/03/24 at 12:08 P.M. an interview with Board Member #866 revealed the most recent board meeting was held on 03/21/24 which was an executive session due to an employee grievance. The meeting prior to this was held on 03/13/24 which himself, CEO #805, Board Member #867 and Board Member #868 were in attendance for. He stated during this meeting, the financial side of the building was discussed. He stated he was aware several vendors were not getting paid timely but stated he was not aware of any disconnection notices. Board Member #866 revealed it was his understanding CEO #805 worked out payment arrangements with the vendors including the food vendor. He stated he was aware therapy services discontinued their service and was also aware that the phones were not working. Board Member #866 revealed Plan B regarding the phones was arranged to include changing phone providers. No additional information was provided as to why the plan did not include paying the current phone service. He stated he comes to some of the facility QAPI meetings, but not all of them. He stated the boards stance on the facility money issues included trying to get a loan on the property or selling some of the property to an interested buyer. On 04/11/24 at 11:16 A.M. an interview with the Administrator revealed beginning over the previous two months she had increased concerns related to her ability to effectively function as the administrator in the facility due to conflict that was occurring with CEO #805. The Administrator indicated there had been some concerns during the entire time of her employment that had escalated during the recent months and included concerns the CEO was not providing effective leadership or managing the facility finances properly. As of 04/01/24, during an on-site investigation, the facility and/or vendors provided information of outstanding balances included but were not limited to the following: Balances of $2205.00 and $2,632.50 owed to Registered Dietitian (RD) #829, a balance of $2,099.71 for Supply Vendor #853, a balance of $56,348.62 for Staffing Vendor #854, a balance of $23,795.48 for Pharmacy Collections #842, a balance of $7,028.43 for Medical Supply #859, a balance of $10,132.04 for Supply Vendor #860, a balance of $12,722.19 for Food Vendor #858, a balance of $40,259.27 for Food Vendor #852, a balance of $11,091.80 for Information Technologies (IT) #843, a balance of $55,180.95 for Therapy #847, a balance of $3,170.00 for Phone #848, a balance of $33,278.93 for Supply Vendor #857, a balance of $1,175.74 for Monitoring Vendor #861, a balance of approximately $5,200.00 to Oxygen Vendor #862 and a balance of $5,642.97 to Water/Sewer Vendor #863. These balances totaled $271,963.63. a. Review of the master therapy list revealed 20 residents were currently on therapy caseload/services including Resident #3, #4, #6, #7, #8, #12, #13, #14, #19, #20, #23, #26, #30, #37, #44, #51, #55, #106, #107 and #108. Review of an email from Therapy Credit Manager #847 from the facility contracted therapy department dated 03/28/24 at 1:53 P.M. revealed this vendor had not heard from anyone (from the facility) regarding payment or a plan to get current. On 04/01/24 at 1:50 P.M. an interview with Therapy Credit Manager #847 revealed the facility was outside their contracted terms due in part to money owed the therapy vendor. Therapy Credit Manager #847 revealed the facility had made a payment on 03/04/24 for $6,000 and an additional payment on 03/11/24 for $30,000. However, she stated the facility was supposed to make payments every thirty days and the facility was past due in the amount of $20,072.15 for 01/2024 and $35,108.80 for 02/2024 for a total of $55,180.95. On 04/03/24 at 2:25 P.M. interview with Physical Therapy Assistant (PTA) #869 revealed the contracted therapy vendor was terminating therapy services from the building on 04/05/24 due to lack of payment. On 04/04/24 at 11:31 A.M. an interview with Administrator revealed of the 20 residents on therapy, seven residents, Resident #6, #7, #8, #13, #106, #107 and #108 requested to be transferred or sent home due to lack of therapy services. On 04/10/24 at 9:24 A.M. a telephone interview with the Administrator revealed CEO #805 was in negotiations with another therapy company to provide therapy services. No additional information was provided related to the status of the residents affected by the termination of therapy provider and their therapy needs between 04/06/24 and 04/10/24. Interview on 04/11/24 at 9:40 A.M. with Resident #44 indicated she was ordered therapy services and was not getting it. Record review revealed the resident had been on therapy case load for speech therapy services for dysphagia. The resident's last documented therapy session was on 04/05/24. Interview on 04/11/24 at 9:35 A.M. with Resident #51 revealed she was not receiving therapy services and was getting rusty. Record review revealed the resident had been on therapy case load for physical therapy services for gait training. The resident's last documented therapy session was on 04/05/24. On 04/11/24 at 4:30 P.M. the Administrator provided information CEO #805 had met with a new therapy company for possible new merger/contract for services and new therapy director. However, the Administrator indicated the date for implementation was unknown as of this time. In addition, CEO #805 was unavailable to provide any additional information related to therapy services at of this time. On 04/12/24 at 11:30 A.M. the facility provided a list of residents, including Resident #6, #7, #8, #13, #106, #107 and #108 who had actually discharged from the facility between 04/05/24 and 04/09/24 per their request due to the lack of therapy services available in the facility. Resident #12 discharged home on 04/06/24 after completing therapy services on 04/05/24. On 04/15/24 at 10:22 A.M. during an interview with the DON, the DON revealed the facility had not contracted with a therapy company to provide therapy services to residents as of this date. On 04/15/24 at 11:10 A.M. an interview with the Administrator revealed CEO #805 informed her that a meeting with a therapy company was held on 04/12/24 but as of this date, services for therapy/contracted provider was not confirmed. On 04/15/24 at 12:52 P.M. during a follow-up interview with the Administrator, the Administrator indicated CEO #805 had replied to a text message she had sent him regarding therapy. The Administrator revealed CEO #805 indicated they would have a new therapy company within 10 days. The Administrator revealed CEO #805 did not provide the name/phone number of the new therapy service and stated she was not aware if there was an actual contract yet. b. On 04/02/24 at 1:52 P.M. a telephone interview with Water/Sewer Vendor #863 revealed the facility had a current balance of $8,868.78 which included a past due balance of $5,642.97. Water/Sewer Vendor #863 revealed the facility was issued a disconnect notice effective 04/12/24 if payment in the amount of at least $5,642.97 was not made. On 04/03/24 at 1:25 P.M. a follow up telephone interview with Water/Sewer Vendor #863 with CEO #805 and Licensed Practical Nurse (LPN) 701 (the Wellness Director for the Assisted Living) in attendance revealed the facility owed $8,868.78 with a past due balance of $5,642.97 which had to be paid by 04/12/24 or the water would be disconnected. The facility provided evidence of a payment made to the water company dated 04/03/24 (during the onsite survey). On 04/09/24 at 12:55 P.M. an additional follow up interview with Water/Sewer #877 confirmed a payment was made and the disconnection notice was removed from the account (based on the payment). c. Review of an email from Staffing Vendor #854 dated 03/18/24 at 8:54 P.M. indicated the staffing vendor attempted to reach the facility by phone on 03/18/24 without success. The email included the facility account would be pending on 03/20/24 due to non-payment. The email instructed the facility to please provide a payment update on the identified invoice by 03/19/24 to prevent the account from being pended. An amount of $35,551.18 was now past due with $20,797.44 due 03/19/24 for a total past due balance in the amount of $56,348.62. On 03/26/24 at 8:36 A.M. an interview with Scheduler #821 revealed the facility required the use of agency nursing staff to adequately staff all shifts in the facility. However, if this current staffing agency used by the facility would discontinue providing staff as of 04/01/24 they would not have enough nurses to cover all shifts. Scheduler #821 also revealed the facility did not have sufficient staff to cover a shift if one of their regular staff members called off. On 03/26/24 at 9:45 A.M. an interview with CEO #805 verified the facility did not have enough facility employed nurses to cover all open shifts. CEO #805 confirmed the facility had used nurses from a staffing agency to fill these shifts. On 04/01/24 at 9:07 A.M. a telephone interview with Staffing Agency #837 revealed the facility owed a total of $116,924.69 to this staffing agency and no payment arrangements had been made as of this date. Staffing Agency #837 revealed the facility account had been suspended as of 03/27/24 due to non-payment and no agency staff would be provided to the facility moving forward. On 04/01/24 an interview beginning at 10:35 A.M. with Scheduler #821 indicated the facility started using staffing agency in 06/2023 and the facility had previously used five different staffing agencies that were all terminated/discontinued due to nonpayment. Scheduler #821 indicated the current staffing agencies (noted above) would no longer send staff because of a delay in or lack of payments. Scheduler #821 revealed for the April 2024 schedule there were 49 open shifts that did not have nurse scheduled due to the lack of facility employed staff and/or the inability to use agency staffing. On 04/01/24 at 10:35 A.M. review of the facility staffing schedules with Scheduler #821 verified the 49 unfilled nursing shifts from 04/01/24 to 04/30/24 in which there was no nurse scheduled for the shift. This included seven shifts from 04/01/24 to 04/06/24 which the Director of Nursing (DON) indicated the administrative staff would have to fill and they would take the staffing week by week. On 04/03/24 at 11:40 A.M. an interview with the DON revealed her last day in the facility was going to be 04/18/24 as she was an interim DON and had requested another assignment. During the interview the DON revealed as of this date, the facility did not have enough nursing staff to cover 04/06/24 or 04/07/24. The DON indicated she was going to try to call nursing staff to see if she could find coverage for the weekend. On 04/11/24 at 10:21 A.M. interview with the Interim DON revealed staff nurses had picked up the open shifts and/or worked over on 04/06/24 and 04/07/24. Review of the Facility Wide Assessment form dated 05/2018 and last updated 05/23/23 revealed the facility supplied resident support/care needs including activities of daily living, mobility and fall/fall with injury prevention, bowel/bladder, skin integrity, mental health and behavior services, medication administration, pain management, infection control and prevention, management of medical conditions, therapy services and nutrition services. Nurse management included a full-time DON, two full time unit managers, a full time MDS coordinator, a scheduling coordinator, three-day nurses, two-night nurses, seven STNA's for dayshift, seven STNA's for second shift and five STNA's for nightshift. The staffing also included a full-time Administrator, transportation director, registered dietitian, full time maintenance/housekeeping/laundry director, full time activities director, full time social services director, full time admissions/marketing director, full time billing office manager, full time human resources, full time therapy director and contracted medical director. d. Review of Food Vendor #858's (a previous food supplier) billing invoice dated 04/01/24 revealed the facility had a past due balance for a total amount of $12,722.19. The total past due balance included a past due amount of $931.02 for thirty days and $11,791.17 sixty days past due. Review of Food Vendor #852's (the current food supplier) invoice dated 04/01/24 from service of 12/12/23 through 03/29/24 revealed the facility owed a total of $95,098.80 which included $54,839.53 of the bill that was current and an additional $40,259.27 that was past due. On 04/01/24 at 10:53 A.M. telephone interview with Food Supplier #838 (for Food Vendor #852) with Dietary Kitchen Manager #830 in attendance verified a balance to Food Vendor #852 in the amount of $95,098.80 which included a past due amount of $40,259.47. Food Supplier #838 indicated the facility bill of $40,259.47 was greater than 60 days past due and the facility payments included $5,000 the week prior, a promised $10,000.00 on 04/08/24 and an additional promised $10,000.00 on 04/15/24. Food Supplier #838 indicated the vendor had requested the facility initiate a better payment plan to pay off the past due balance. On 04/01/24 at 10:47 A.M. an interview with Dietary Kitchen Manager #830 revealed the facility had difficulty paying vendors. Dietary Kitchen Manager #830 stated vendors had put their account on hold and they could not order general resident care supplies, she could not remember the exact dates but stated it was at some point in 01/2024 or 02/2024. On 04/01/24 at 10:55 A.M. interview with the Credit Management Staff (Food Supplier #851 and Food Supplier #838) associated with Food Vendor #852 with Dietary Kitchen Manager #830 in attendance revealed the last couple payments from the facility included a payment on 03/05/24 for $8,000.00 and a payment on 03/18/24 of $5,000.00. Credit Manager for Food Supplier #851 indicated a plan was requested to bring the payments current and the plan had not been addressed yet even though she tried to discuss the plan to bring the overdue invoices current with CEO #805. Credit Manager for Food Supplier #851 confirmed the facility began using them as a vendor for the second time around 09/2023. On 04/01/24 at 11:44 A.M. an interview with Kitchen Dietary Manager #830 revealed Credit Manager for Food Supplier #851 text her at this time and stated the vendor was considering holding the food order for the order date of 04/02/24 due to lack of payment. On 04/02/24 at 10:27 A.M. interview with Food Supplier #838 for Food Vendor #852 revealed she was physically in the facility to pick up a $10,000.00 check the facility was going to provide. She stated the food vendor decided to hold all future food orders until another $30,000.00 (total $40,000.00) was paid. She stated this would put the facility about sixty days past due and they would still owe another $65,000.00 to the vendor. She stated Dietary Kitchen Manager #830 reported the facility had approximately three weeks of food supplies available. On 04/02/24 at 11:14 A.M. interview with Dietary Kitchen Manager #830 revealed the facility would be able to follow the approved menu from the dietitian from 04/01/24 to 04/13/24 with the food they had on hand and without the food vendor delivering food. After that, she stated she would have to piece meal the meals by the available food supply. She indicated she was provided a facility credit card on this date to purchase fresh items including milk, eggs, and bread. During the interview, she shared she had resigned her position in the facility effective 05/01/24 but did not provide a reason why. On 04/03/24 at 1:41 P.M. a telephone interview with Food Supplier #838 and Credit Manager for Food Supplier #851 with CEO #805 in attendance revealed the facility agreed upon amount of payment of $10,000.00. Credit Manager for Food Supplier #851 stated they needed a plan to go forward of when the account would be made current and could not release a shipment of food until a concrete plan was put in place. Credit Manager for Food Supplier #851 stated their company could not allow the account to be over the 60-day term. On 04/09/24 at 10:03 A.M. an interview with Dietary Kitchen Manager #830 indicated she conducted an audit of food supplies on 04/02/24 and determined the facility actually had enough food to provide meals to residents per the menus or appropriate substitutions until 04/20/24. She stated after that time, she would have to piece meal the dinners with minimal food to pick from. Dietary Kitchen Manager #830 indicated she was provided a credit card to be able to go and buy fresh food supplies when needed (between this time and 04/20/24) with a $2500.00 limit. On 04/09/24 at 10:42 A.M. an interview with the Administrator indicated the facility was no longer going to use Food Vendor #852 and were reviewing options including Food Vendor #878 and Food Vendor #879 pending reviews on pricing, menu selection and delivery. On 04/10/24 at 4:23 P.M. information provided from the Administrator revealed the facility had decided to stay with Food Vendor #852 based upon a mutual agreement for delivery and payment (cash on delivery). The Administrator indicated delivery would resume next week. On 04/11/24 a tour of the facility kitchen revealed the facility had food available to serve meals as planned from 04/11/24 to 04/14/24. During the tour, Dietary Kitchen Manager #830 provided receipts for food purchases made, using the credit card she was issued on 04/05/24 and 04/09/24. On 04/05/24 $757.31 was spent and on 04/09/24 $1055.97 was spent for a total of $1813.28. On 04/11/24 at 7:59 A.M. interview with representatives from Food Vendor #852 with the Administrator present revealed they had spoken with CEO #805 on 04/10/24 to provide an offer on how to continue with their services as a food vendor. The CEO was informed the facility would need to pay by credit card, check or ACH with any order being cash on delivery (COD), plus a payment of $2500.00 per week to pay the outstanding back balance owed. The representative indicated the CEO stated he was still looking at other vendors and they (Food Vendor #852) would get paid at some point and he would let them know. The representative indicated CEO #805 then hung up on them. The representatives revealed there was no current order or delivery scheduled for the facility as of this date/time. On 04/11/24 at 10:07 A.M. and 11:16 A.M. interview with the Administrator revealed she was not part of the conversation between Food Vendor #852 and CEO #805 on 04/10/24 and was only reporting (on 04/10/24) to the State agency what she had been told (by CEO #805). The Administrator verified the facility did not have a current food vendor and indicated she had no authority to make decisions about this as it was being handled by CEO #805. The Administrator then shared that CEO #805 had since gone out of state, she was having trouble reaching him and did not know when he would return other than hearing rumor of him being back on 04/16/24. On 04/12/24 at 10:40 A.M. interview with the Administrator revealed the facility was in the process of resuming services with Food Vendor #858 (one of their previous food vendors who had terminated due to non-payment). However, as of this date there was no evidence a first payment had been made to the vendor (per the vendors request) or evidence of confirmation of an actual food delivery being scheduled. The Administrator revealed the facility was in the beginning phases of the process with securing Food Vendor #858. Dietary Kitchen Manager #830 revealed she had approximately $300.00 left on the credit card available to purchase food supplies as of this date/time. On 04/15/24 at 9:04 A.M. interview with Dietary Kitchen Manager #830 revealed she had been told by the Administrator that Food Vendor #858 was going to be the facility food vendor. Dietary Kitchen Manager #830 revealed she had been attempting to reach their food representative from this vendor since Friday with no success. She indicated CEO #805 was supposed to make payment and supposed to get an order, but stated she was unaware of what the status of this was as of this date/time. During the interview, Dietary Kitchen Manager #830 revealed the credit card she had been given to purchase food items with was no longer usable as it had been maxed out. On 04/15/24 at 9:11 A.M. a follow-up interview with Dietary Kitchen Manager #830 revealed she had spent $78.00 to purchase milk this morning (previous milk supply from 04/12/24). She was unable to use the credit card to purchase anything else as of this time. During this interview, Dietary Manager #830 revealed a dietary cook had submitted a resignation, effective 04/24/24. Dietary Manager #830 confirmed her last date of employment would be 05/01/24. On 04/15/24 at 10:08 A.M. observation of the freezer and dry storage area with Dietary Kitchen Manager #830 revealed for the lunch meal on 04/15/24, which was scheduled to be spaghetti and meatballs, the facility was substituting meatballs and cream sauce. On 04/15/24 at 12:32 P.M. an interview with Resident #29's son with Dietary Kitchen Manager #830 in attendance revealed he comes in daily to visit his mother and the mother had not been receiving her ice cream every meal since 04/11/24. He stated his mother practically lives off of ice cream and coffee and he was upset that she was private pay and he had to stop at the store to get ice cream for his mother. Interview on 04/15/24 at 12:36 P.M. with Dietary Kitchen Manager #830 indicated she was aware they were out of ice cream since 04/10/24 and Resident #29 did not receive ice cream as ordered. She stated she went this morning, and the credit card she had been given to purchase food (in the absence of a food vendor) would not work to buy ice cream because the credit card had reached it max limit. In addition, review of RD #829's billing statement dated 01/31/24 with a due date of 02/22/24 revealed 49 hours were billed for consultant dietitian services for 01/2024 in the amount of $2,205.00. The bill was unpaid as of 04/01/24. Review of RD #829's billing statement dated 02/26/24 with a due date of 03/22/24 revealed the facility owed 58.5 hours of consultant dietitian services for 02/24 in the amount of $2,632.50. The bill was unpaid as of 04/01/24. On 04/01/24 at 11:09 A.M. interview with RD #829 with Kitchen Dietary Manager #830 in attendance indicated she had not been paid by the facility for 01/2024 and 02/2024 for a total amount due of $4,630.00 which was due on 03/21/24. She indicated she provides the facility a 21-day grace period and sometimes it takes 45 days or 60 days for a payment, but she stated she does eventually receive payment. She stated she never knew when she would get paid. e. On 04/01/24 at 9:30 A.M. an attempt to contact the facility by telephone was unsuccessful. The call could not be completed as dialed. Interviews with staff during the investigation verified the facility phone system was not currently working and they could not receive incoming calls or make outgoing calls using the facility phone system. The staff interviewed revealed they had to use their own personal cell phones to make calls, including calls to physicians. On 04/01/24 at 2:18 P.M. telephone interview with Phone Representative #848 revealed telephone service in the building had been initiated in May 2022 and was not working on this date due to a technical issue. Phone Representative #848 revealed the facility had an outstanding current balance owed of $3,170.00 for the rental of telephone equipment and this balance would have to be paid before the company would come out to service the phones. Phone Representative #848 revealed the facility broke their 5-year contract (end date 04/01/27) due to non-payment and now the full amount due must be paid in the amount of $31,700.00 to resume services. On 04/01/24 from 2:43 P.M. to 3:00 P.M. interviews with Resident #15, #23, #24, and #52 revealed they used the facility phone to contact their family members. Review of the Telephone Rental bill dated 04/02/24 revealed the facility owed $3,170.00 due on 03/01/24 and total amount owed as of 04/01/24 was $31,700.00. On 04/02/24 at 12:20 P.M., an interview with the Administrator and the DON revealed the facility had begun receiving emails from family, vendors and dialysis centers regarding residents because the facility phones were not working. The Administrator indicated she

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, interviews with staff and family, review of a closed medical record, the elopement investigation, and review of the facility document titled Resident Elopement, the facility failed to prevent the elopement of one resident (Resident #75) who had impaired cognition and was assessed as an elopement risk. This resulted in Immediate Jeopardy on 07/30/19 at approximately 7:30 P.M. when Resident #75 left the facility unsupervised, without staff knowledge, through a security exit door that did alarm when exiting but was not responded to appropriately by staff. The likelihood of Actual Harm that is Immediate Jeopardy occurred when Resident #75 was found approximately a half mile from the facility. The facility did not know Resident #75 was missing for approximately three hours until the resident's wife called the facility to let them know he was at her house. This affected one of three residents reviewed for elopement. The facility identified 14 residents at risk for elopement. The facility census was 71 residents. On 08/05/19 at 3:10 P.M. the Administrator, Director of Nursing (DON), the Chief Executive Officer and the Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 07/30/19 at 7:30 P.M. when Resident #75 left the facility unsupervised and without staff knowledge through a facility secure exit door that alarmed and the resident was not known to be missing for approximately three hours. The Immediate Jeopardy was removed and the deficient practice corrected on 07/31/19 when the facility implemented the following corrective actions: · On 07/30/19 at 10:05 P.M. a head count of all residents was immediately conducted by LPN #306 to assure all other residents in the facility were safe and accounted for upon notification of the elopement of Resident #75. All residents were accounted for. · On 07/30/19 at 11:30 P.M. upon notification of Resident #75's elopement ADON #301 immediately removed Licensed Practical Nurse (LPN) #310 from the floor and placed LPN #310 on suspension pending investigation. ADON #301 replaced LPN #310 on the floor. The Chief Executive Officer (CEO) was also present at the time ADON #301 replaced LPN #310. · On 07/31/19 from 8:00 A.M. to 8:30 A.M. the Maintenance Director conducted an audit on all alarmed doors and found them to be in working order. · On 07/31/19 from 8:45 A.M. to 9:30 P.M., 94 of 98 facility staff members (12 management, 1 activity, 19 dietary, 6 laundry/housekeeping, 51 nursing and 5 therapy) participated in a mandatory all staff in-service on the facility elopement policy conducted by the Administrator. Four nursing staff have not received the in-service training, but the training will be provided in person prior to the staff reporting to their next working shift. · On 07/31/19 at 12:38 P.M., 3:20 P.M. and 10:05 P.M., 51 facility staff members (8 management, 2 activities, 8 dietary, 7 laundry/housekeeping, 23 nursing and 3 therapy) participated in elopement drills, conducted by Administrator or Maintenance Director #321. · On 07/31/19 at 12:40 P.M. after completing a thorough investigation, the Administrator terminated the employment of LPN #310. · Beginning 07/31/19 the facility began conducting weekly elopement drills for three weeks on all three shifts, then monthly for three months, then incorporated into QAPI to determine the ongoing need. Elopement drills will be conducted no less than semi-annually. · As of 08/01/19 the facility activated a new and additional mandatory in-service for all employees in their electronic education system to educate all staff on elopement, wandering, and identifying resident behaviors that placed them at risk. This in-service will be completed by 08/31/19. As of 08/06/19, 82 of 107 staff still need to complete mandatory in-service by 08/31/19. · The facility implemented a new practice on 08/01/19 that all new hires will have the elopement education as part of their mandatory training and due within their first month of employment. This practice will continue to be monitored by the CEO for monthly compliance. All staff will continue to be educated on elopement annually. · On 08/05/19 from 10:07 A.M. to 12:38 P.M., 08/06/19 from 9:00 A.M. until 10:31 A.M., and on 08/07/19 from 10:13 A.M. until 10:25 A.M. 18 employee interviews were completed with STNA #300, LPN #302, LPN #303, LPN #304, STNA #315, LPN #311, STNA #309, STNA #307, STNA #312, LPN #306, STNA #308, STNA #315, Receptionist #322, Environmental Coordinator #323, Kitchen Manager #324, Maintenance Director #325, Activity Staff #326, and Housekeeper #327. All staff were aware of the elopement policy and procedures, the exit door security codes, and where to locate the resident elopement books. · The facility has scheduled an additional mandatory in-service for all employees of the facility on 08/09/19 to reiterate and reinforce the step by step outline in the 'Resident Elopement' policy that was originally presented to employees on 07/31/19. The facility will also continue training on the elopement policy and having new hired employees sign off on the education of the above steps as it currently does during orientation. Findings Include: Review of Resident #75's closed medical record revealed he was originally admitted to the facility on [DATE], readmitted on [DATE] for respite care, and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care initiated on 06/12/19 revealed the resident wandered up and down the halls throughout the day. Interventions included redirect the resident from an exit when he is observed about to enter an unsafe area and a wander guard bracelet (a device that alarms when exiting the door to the outside) to alert staff to his exiting unsafe areas. Staff were to respond immediately to the alarm and take him back to a safe area. Review of July, 2019 physician orders [REDACTED]. Review of the elopement risk assessment dated [DATE] indicated Resident #75 was at risk for elopement. Resident #75 had a history of [REDACTED]. Review of the elopement investigation dated 07/31/19 revealed written statements provided by LPN #310 and State tested Nurse Aide (STNA) #309 who responded to the security exit door alarming when Resident #75 eloped from the facility. The statement written by LPN #310 dated 07/30/19 revealed she heard the exit door alarm on the(NAME)Hall and responded to the alarm sounding with STNA #309. LPN #310 indicated both STNA #309 and herself went out the door to look around and the only person that could be seen was standing at the corner. The staff could only see their head and shoulders. LPN #310 indicated STNA #309 and herself went back into the facility, closed the door and reset the security alarm. Per LPN #310, about 30 seconds later the alarm sounded again. This happened several times. LPN #310 called security to assist with the reset of the door alarm. Review of the written statement provided by STNA #309 dated 07/30/19 revealed she responded to the exit door alarm on(NAME)Hall and assisted LPN #310 with seeing if someone went out the door. There was a person standing at the corner, but STNA #309 did not see anyone close to the door, so they went back in. LPN #310 reset the exit door alarm but 30 seconds later the alarm sounded again. This happened two to three times (the alarm re-sounding). STNA #309 indicated she suggested a headcount to LPN #310. Review of the written statement provided by LPN #306 dated 07/30/19 revealed Resident #75's wife called in to the facility (no time specified). LPN #306 indicated she went to Resident #75's room and he was not there, and other staff began searching for the resident. Resident #75's wife called back stating Resident #75 was at the house with her. Resident #75's wife indicated her neighbor observed the resident walking and gave him a ride home. LPN #306 asked the resident's wife if Resident #75 was wearing his wander guard and if she was bringing him back to the facility. Resident #75's wife stated he was resting, and she would not be bringing him back to the facility. LPN #306's statement indicated after hanging up with Resident #75's wife the STNA reported to her that previously in the shift an alarm on Station one had gone off and LPN #310 turned the alarm off. Review of the written statement provided by STNA #308 revealed she was unaware of the situation (elopement) until Resident #75's wife called the facility to notify them that he had made it home safely. Review of the written statement provided by the Administrator on 07/30/19 revealed he was notified around 10:00 P.M. that Resident #75's wife called in and stated Resident #75 was at home. The Administrator indicated he confirmed the whereabouts, his safety, overall general health and well-being of Resident #75 with the resident's wife. Resident #75's wife stated he was okay and in good spirits. The Administrator then began education with all staff about elopement instruction. Review of the written statement from an interview conducted by the Administrator with Resident #26 dated 07/31/19 at 11:45 A.M. revealed Resident #26 stated on 07/30/19 around 7:30 P.M. to 8:00 P.M. the alarm went off and she told LPN #310 that someone had gone out the door. Resident #26 stated she did not see if staff went out the door to look, but LPN #310 did acknowledge her statement. Review of the written statement provided by Admissions and Marketing Director #320 dated 07/31/19 at approximately 11:45 A.M. revealed she had met with Resident #75's wife and daughter to discuss the events that occurred with her husband on the evening of 07/30/19. Resident #75's wife informed her that she was awakened in her home at approximately 10:00 P.M. by her neighbor. Apparently two young girls had found Resident #75 at the intersection of two busy streets, asleep underneath a tree and had stopped to see if he needed assistance. At that time, Resident #75 was unable to tell them who he was but offered a piece of paper from his wallet. He informed them this is a very important piece of paper. The paper had his name and address on the front. The girls took Resident #75 to that address but were unable to awaken Resident #75's spouse. At that point, the girls went next door to the neighbor, and he had a key to the house. After again knocking and no answer, the neighbor entered the home with Resident #75. Resident #75's wife was informed of Resident #75 being found by the two girls. Interview on 08/05/19 at 10:00 A.M. with ADON #301 revealed on 07/30/19 around 10:00 P.M. she was notified of the elopement of Resident #75 and that he had made it to his home safely. ADON #301 stated she came in to the facility to escort LPN #310 off the floor and immediately suspended her pending completion of the investigation. ADON #301 stated she replaced LPN #310 on the floor at that time. ADON #301 stated a head count of all residents had been completed and statements were being taken. Interview on 08/05/19 at 10:20 A.M. with the Administrator revealed that Resident #75 walked out of the building unsupervised, setting off the exit door alarm and walked to his house. The Administrator stated LPN #310 and STNA #309 responded to the alarm and did not think any resident had left the facility. LPN #310 turned off the alarm and did not notify anyone else and did not complete a resident head count. The Administrator stated he was notified at 10:02 P.M. that Resident #75's wife called in and stated Resident #75 was at home and safe. The Administrator stated he came in immediately and LPN #310 was suspended pending investigation and was terminated on 07/31/19. The Administrator verified that LPN #310 should have made sure the person at the corner was not a resident. The Administrator verified that LPN #310 did not follow the proper procedures for resident elopement. Interview on 08/05/19 at 11:15 A.M. with Resident #26 revealed that last week the door alarm by her room went off and she saw a resident leave the facility. Resident #26 stated she told LPN #310 and STNA #309 that she saw a male resident go out the door at the time the alarm was going off. Interview on 08/05/19 at 12:13 P.M. with Resident #75's wife revealed she was home sleeping on 07/30/19 and it was around 9:00 P.M. to 9:30 P.M. at night when she was awakened by noise in her house. The noise was from her neighbor and husband. She was told about the two girls finding him and assisting him home. She stated she called the facility after she got her husband in bed and resting, around 10:00 P.M. to let them know he was home and safe. Interview on 08/05/19 at 12:38 P.M. with LPN #310 revealed she was the nurse for Station One and was working on 07/30/19 from 6:00 P.M. to 6:00 A.M. LPN #310 stated around 7:30 P.M. she heard the exit door alarm going off on(NAME)Hall and STNA #309 went to check the door alarm too. Both staff went outside to see if they could see any one outside. LPN #310 indicated there was no one by the building but there was someone standing down at the corner. LPN #310 was unable to make out if it was a man or women. LPN #310 stated she did not think it was a resident, she thought it was maybe a family member, so she went back into the facility and reset the security exit door. She was unable to reset the door alarm, so she called the security guard to reset the alarm. LPN #310 stated after Resident #75's wife called in, an STNA told her Resident #26 had stated she saw a resident go out the exit door when it alarmed. LPN #310 stated Resident #26 did call her into her room when the door alarm was going off but the alarm kept going off, and she was focused on getting the alarm to reset and did not go back in to Resident #26's room to see what she wanted. LPN #310 stated the security guard said he only heard the alarm once, so she thought it was when she opened the exit door. LPN #310 stated Resident #75 was not in the elopement book that night and she was not his nurse and did not know him. LPN #310 verified that she should have done a head count when the security door alarmed. Interview on 08/06/19 at 9:00 A.M. with STNA #309 revealed she worked 07/30/19 from 6:00 P.M. until 6:00 A.M. on Station One. STNA #309 stated she responded to the door alarm on(NAME)Hall at approximately 7:30 P.M. STNA #309 stated she went outside to look for a resident and there was no one close around the building. There was someone standing at the corner but she was unable to determine if it was a man or woman. STNA #309 stated she went back in and LPN #310 reset the code for the exit door. STNA #309 stated Resident #26 told her right after the alarm went off that she saw someone go out the door. STNA #309 stated she suggested a headcount for all residents but LPN #310 said we didn't see anyone so, no we didn't need to do a head count. STNA #309 stated she went back to her assignment. STNA #309 stated she did not know Resident #75 was missing until around 9:30 P.M. to 10 P.M. when Resident #75's wife notified the facility that he was at home. Interview on 08/06/19 at 9:26 A.M. with STNA #307 revealed she had worked at the facility on 07/30/19 from 2:00 P.M. to 10:00 P.M. STNA #307 stated she knew Resident #75 and had last seen him after dinner wandering in the hall by Station Two, with another resident about 5:30 P.M. STNA #307 stated she did not see him exit seeking throughout the shift. STNA #307 stated he was not one of her residents, so she did not check on him every two hours. STNA #307 stated Resident #75's wife called around 9:45 P.M. and the nurse answered the phone and got disconnected. Resident #75's wife called back and STNA #307 answered the phone and the resident's wife stated, I just wanted to let the nurse for room [ROOM NUMBER] know that he was at home. STNA #307 then gave the phone to LPN#306. Interview on 08/06/19 at 10:28 A.M. with STNA # 312 revealed she worked at the facility on 07/30/19 from 6:00 A.M. to 6:00 P.M. and was not Resident #75's aide. STNA #312 stated Resident #75 wandered throughout the facility in the halls but she did not see him exit seeking at any time. STNA #312 stated she last saw Resident #75 at 6:00 P.M. wandering around nurses' Station Two and Resident #75 was not agitated or exit seeking at that time. Interview on 08/06/19 at 11:07 A.M. with LPN #306 revealed she worked at the facility on 07/30/19 from 6:00 P.M. to 6:00 A.M. LPN #306 stated she was Resident #75's nurse and she last saw Resident #75 around 7:00 P.M. when she gave him his night time medications. LPN #306 stated Resident #75's wife called between 9:00 P.M. and 10:00 P.M. and she answered the phone. LPN #306 stated she was unsure why Resident #75's wife was calling, she thought his wife asked to speak to Resident #75, so LPN #306 put the wife on hold and went to Resident #75's room, he was not there so she was checking other resident rooms and common areas. At that time Resident #75's wife hung up. LPN #306 stated she had STNA #307 call over to nurse's Station One to start looking for him. That is when Resident #75's wife called back and said she wanted to let the nurse for room [ROOM NUMBER] know that he was home and safe. LPN #306 stated from the first call to second call was about 5 to 10 minutes. After she hung up from the second call STNA #307 told her the Station One aide (STNA #309) told her the alarm went off earlier and the nurse turned the alarm off because there was no one by the building when she checked. Interview on 08/06/19 at 11:31 A.M. with STNA #308 revealed she worked at the facility on 7/30/19 from 2:00 P.M. to 10:00 P.M. and was Resident #75's aide. STNA #308 stated she last saw Resident #75 between 7:00 P.M. and 7:30 P.M. in the hall way by his room. STNA #308 stated Resident #75 was asking about his wife and she told him his wife brought him there for a few days and he had a room and he was okay with that. STNA #308 stated Resident #75 did not appear agitated and had not been exit seeking. STNA #308 never saw the resident go anywhere except on Unit Two. STNA #308 stated she did not know he had eloped until his wife called in before end of shift and she answered the phone. STNA #308 stated Resident #75's wife wanted to talk to the nurse for room [ROOM NUMBER] and this is when STNA #308 said they found out that Resident #75 eloped and was at home with his wife. Review of facility policy titled Resident Elopement, dated 08/14/17, revealed when a door alarm sounds, staff will immediately check the outside of the building to determine if a resident has exited the building and notify all staff by overhead paging code E. If resident is not found within ten minutes the Administrator and DON are to be notified. This deficiency substantiates Complaint Number OH 063.

Based on review of a closed medical record, staff interview, policy review, review of the Ohio Revised Code (ORC), review of the Ohio Administrative Code (OAC), review of the job descriptions for Registered Nurses (RN) and Licensed Practical Nurses (LPN) and staffing schedules, and review of the Self-Reported Incident (SRI), the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) for one resident (Resident #101) who was identified as a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #101 did not receive CPR or EMS services and expired at the facility. This resulted in Immediate Jeopardy for one resident (Resident #101) out of 12 residents reviewed for death from [DATE] through [DATE]. The facility identified 34 residents residing in the facility designated with Full Code status. The facility census was 62. The Chief Executive Officer (CEO), Administrator, and the Director of Nursing (DON) were notified on [DATE] at 10:00 A.M. that Immediate Jeopardy began on [DATE] at 5:20 A.M. when Resident #101 was found without vital signs and LPN #24 and RN #13 failed to initiate CPR or contact EMS. Resident #101 expired at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at approximately 5:35 A.M., LPN #24 notified Medical Doctor (MD #50) that Resident #101 was found without vital signs. MD #50 was also notified the resident's hands and feet were cold and blue, the pupils were fixed, and her mouth was wide open. MD #50 gave a verbal order to release the body to the funeral home based on the information LPN #24 provided to the physician. · On [DATE] the facility suspended LPN #24 and RN #13 pending the outcome of the investigation. Upon completion of the facility's investigation and individual counseling regarding advanced directives, LPN #24 and RN #13 were allowed to return to work. · On [DATE] at approximately 12:30 P.M. the DON (or designee) started in-service education on the CPR policy for all licensed nurses. Education was completed either in-person, by phone, by e-mail, or by text message. As of [DATE], 18 of 21 nurses had been in-serviced regarding code status responses. As of [DATE] all 21 nurses were in-serviced. · On [DATE] by 3:39 P.M. the medical records clerk (MR #60) completed medical record audits to ensure the correct code status was appropriately identified for all 61 residents residing in the facility. · On [DATE] the Quality Assurance Performance Improvement committee met to review the lack of CPR for Resident #101. The facility's new employee orientation was updated to include more information on advance directives and CPR. · On [DATE] at 9:36 P.M. the DON completed advanced directive in-servicing for all nurses employed by the facility. Five nurses who worked on an as needed basis (PRN) were not in-serviced due to not working during the time frame. Those five nurses were notified they could not return to work until they completed the mandatory in-service. As of [DATE], 20 of 22 licensed nurses had been in-serviced on code status. · On [DATE] the DON began random mock code audits at least three times a week for one month. After one month the audits were to be completed once a week for one month. Upon completion of the second month the audits were to be completed bi-weekly for four months. The audit included where advance directives can be located, two scenarios for the nurses to complete, and questions regarding overhead paging of a life-threatening event. The facility had been completing mock code audits since [DATE]. The audits were bi-monthly in January and monthly starting February through June. The audits were completed as a Plan of Correction (P(NAME)) to the annual 2016 survey. The audits were completed by medical records and reviewed by the DON and LNHA. · On [DATE] through [DATE] interviews with RN #13 confirmed she had received training regarding the facility's CPR policy. RN #13 correctly verbalized an understanding of the CPR policy, her responsibility regarding a resident's code status, and confirmed cardiac resuscitation should have been started. LPN #24 was interviewed on [DATE] at 12:17 P.M. confirmed she had not started CPR on Resident #101 as she felt it was inappropriate. LPN #21 confirmed she had been re-educated on code status response and would start CPR on a full code even if she felt it was wrong. · On [DATE] the facility identified a total of 12 residents who expired between [DATE] and [DATE], including Resident #101. The medical records of those 11 additional residents (Resident #100, Resident #102, Resident #103, Resident #104, Resident #105, Resident #106, Resident #107, Resident #108, Resident #109, Resident #110, and Resident #111) were reviewed for code status. There were no concerns noted and the facility completed the appropriate actions at the time of death. · On [DATE] the medical records for all 65 current residents were reviewed for Code status by the medical records clerk and reviewed by the CEO, DON, LNHA and the unit managers. The appropriate Code status was noted on the 65 records reviewed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the closed medical record for Resident #101 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of Resident #101's comprehensive care plan revealed the resident's code status was not addressed; however, review of Resident #101's most current physician orders [REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and needed extensive assistance of one person for all personal care except for eating and traveling about the facility in her wheelchair. Review of the progress notes for Resident #101 revealed the resident was given [MEDICATION NAME] (an anti-anxiety medication) at 7:03 P.M. on [DATE] for a complaint of increased anxiety. The next entry in the progress notes was [DATE] at 5:28 A.M. by LPN #24 stating Resident #101 had expired at 5:20 A.M. At 6:28 A.M. LPN #24 documented a summary of what had occurred when Resident #101 was found unresponsive. LPN #24 wrote 0515 upon entering resident's room, resident was found cold, with blue fingertips and toes, with mouth gaping open, with saliva on the right side of her face, rigor mortis was set in at this time. No radial pulse or blood pressure was present, no apical pulse or pedal pulses present. 0520 Death was confirmed with other nurse. 0530 MD #51 was notified via phone of death of resident, MD #51 gave verbal order to release body to funeral home. Review of the progress notes revealed no documentation indicating CPR had been attempted. A self-reported incident (SRI) was reported to the state agency on [DATE] for possible neglect. The summary of the incident revealed the facility was investigating the possibility of a nurse or nurses not providing care to Resident #101 in a timely fashion. The summary of the incident contained no information regarding Resident #102 going into [MEDICAL CONDITION] or if resuscitative measures were attempted. The facility's investigation found no evidence of abuse, neglect, or misappropriation. The facility did implement a corrective action for the nurses involved for not following facility policy. An interview was conducted with the Administrator and DON on [DATE] at 2:20 P.M. regarding the code status of Resident #101. Both confirmed Resident #101 was a full code and said LPN #24 did not call a code as she felt it would be an abuse of the corpse. The DON said both LPN #24 and RN #13 were immediately suspended pending an investigation. The DON, the Administrator, and supervisory staff immediately began in-servicing the nurses on the code status of residents as well as beginning an audit of all charts for code status. The DON said they updated their code policy to include scenarios of what should be done when a resident was found unresponsive. The DON notified the Administrator on [DATE] at 9:36 P.M. All nurses, except for five nurses who only worked when needed, had been in-serviced regarding code status. No nurses were allowed to return to work until the in-service was completed. The DON posted a list of employees who could not work until the in-service had been completed at both nurses' stations and on the staff telephone book. As each nurse completed the required in-service their name would be crossed off the list and the initials of who provided the in-service were placed next to the nurse's name. Interview with the DON [DATE] at 5:30 P.M. revealed on [DATE] the CEO, the Administrator, LPN #26 (unit manager for Resident #101's hall), and herself met [DATE] to review the incident and decided to not substantiate the allegation of abuse, neglect, or misappropriation as LPN #24 and RN #13 had no willful intent to harm the resident. The DON indicated that conclusion was due to the potential neglect not being willful. Interviews were conducted with State tested Nurse Aides (STNA) #34, STNA #35, and STNA #36 on [DATE] regarding working the 10:00 P.M. to 6:00 A.M. shift on [DATE]. The STNAs stated d they did not provide care for Resident #101 on the night of [DATE]. They were familiar with her, as they pick up extra shifts, but did not see or provide any type of care for her that shift. The STNAs said the only way they can determine the code status of a resident was to access the information on the resident's chart in the computer. Interview with RN #13 on [DATE] at 10:51 A.M. revealed she had only worked for the facility since [DATE]. Her assignment was not on the unit where Resident #101 resided. RN #13 said she was working on medication administration at approximately 5:20 A.M. when STNA #35 came over and told her LPN #24 needed her on the other unit. RN #13 said she entered the resident's room and observed Resident #101 lying in bed. The resident's back was arched, her hands were purple, her pupils were fixed, and no heart beat was heard. RN #13 said the STNAs put her to bed around midnight and then they did not check on her again. RN #13 said as she left the resident's room she heard someone say Resident #101 was a full code but was not sure who said it. RN #13 told LPN #24 to call the physician as he would not make them begin CPR. RN#13 did not realize that pronouncement of death was out of her scope of practice. RN#13 said since then she has been re-educated and realizes now CPR should have been started. Interview with LPN #24 on [DATE] at 12:17 P.M. revealed she had been the nurse assigned to provide care for Resident #101 the night of [DATE] into [DATE]. LPN #24 said she started her shift at 10:00 P.M. She received report from off-going nurse LPN #25 who told her Resident #101 had been fine on her shift. LPN #24 said the resident was sleeping when she started her shift. LPN #24 went into Resident #101's room to administer medications at approximately 5:15 A.M. LPN # 24 did not assess her until 5:15 A.M. because there was no indication to assess her. LPN #24 said the resident was very stiff and had no vital signs when she entered her room. She then sent an STNA to the other station to get RN#13 to verify the resident had expired. Resident #101's code status was verified in the medical record after the STNA was sent to get RN#13. LPN #24 verified Resident #101 was a Full Code at that time. LPN #24 informed RN #13 of this when she arrived on the unit. RN #13 verified with LPN #24 Resident #101 had no pulse. LPN #24 said she did not start CPR as she did not feel it was appropriate since the resident was dead. LPN #24 was re-educated by the DON on what to do when a resident who was a full code was found without a pulse but also said she does not agree with providing resuscitative measures on someone who was clearly dead. LPN #24 said she had not worked in the facility since the morning of [DATE]. Interview with MD #51 on [DATE] at 5:00 P.M. revealed he was the physician for Resident #101. On the morning of her death his partner, MD #50, was covering his residents. MD #51 confirmed Resident #101 had been a full code per her choice and the nurses should have started CPR when they found her without a pulse. MD #51 confirmed a nurse could not pronounce death as it would be outside of their scope of practice. Review of the ORC Section 4723.36 titled Determination of death by certified nurse practitioner or clinical nurse specialist revealed a registered nurse (RN) may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory function are not being artificially sustained and, at the time of the determination and pronouncement of death is made, the RN is providing or supervising the individual's care through a licensed hospice care program or any other entity that provides palliative care. Review of the OAC [DATE] titled Pronouncement of Death revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. According to the OAC [DATE] an LPN is not permitted to pronounce an individual's death. Review of the personnel files for LPN #24 and RN #13 revealed both nurses were new to the facility. LPN #24's date of hire was [DATE] and RN #13's date of hire was [DATE]. Both had signed statements in their files indicating they had read and understood the facility's code status policy while in orientation. Both nurses received disciplinary action for failing to abide by professional standards when they chose to not begin CPR on a resident with a full code status. Review of the medical records for Resident #100, Resident #102, Resident #103, Resident #104, Resident #105, Resident #106, Resident #107, Resident #108, Resident #109, Resident #110, and Resident #111, who died in the facility from [DATE] through [DATE], revealed the facility responded appropriately to the code status each resident had chosen. Code status was reviewed for all residents in the facility and each resident had a code status in their orders. Review of the facility's Advance Directives policy, revised [DATE], and the Cardio-Pulmonary Resuscitation (CPR) for Adults policy, revised [DATE], revealed if the resident had requested to be a full code then when finding the resident without a pulse CPR should be initiated immediately. CPR should continue until a physician issues an order to stop CPR or emergency medical technicians arrive and take over care of the resident. Review of the job descriptions for an RN and an LPN nurses stated the nurse was responsible to initiate any emergency interventions as necessary, including CPR. Review of the staffing schedule as worked the night of [DATE] into [DATE] revealed the facility had two nurses working (one for each station), and a total of five aides providing care to 65 residents. The DON confirmed this was the usual staffing for the night shift. This deficiency substantiates Master Complaint Number OH 300 and Complaint Number OH 287.

Based on review of medical records, review of Emergency Medical Service (EMS) reports, review of hospital records, review of monthly medication pharmacy reports, interviews with residents and staff, interviews with Physician #330, Consultant Pharmacist #210 and Certified Nurse Practitioner (CNP) #120, review of the Nursing Drug Handbook, 30th Edition 2017, and the website titled, Medscare.com/drugs/[MEDICATION NAME], the facility failed to ensure two residents (#87 and #90), who were receiving [MEDICATION NAME] (a medication used to treat nerve pain), were not receiving excessive doses of the medication that were up to three and one-half times the daily maximum recommended dosage (maximum daily use is 600 mgs/day in divided doses) and not in excessive duration for a period of over three months. Additionally, the facility failed to adequately monitor the medication which resulted in adverse consequences and side effects without decreasing the medication. The failure to identify and administer the proper recommended dosages resulted in Immediate Jeopardy and actual harm to Resident #87 when the resident required transportation to the local emergency roiagnom on three different occasions with side effects of the medication and other related symptoms including chest tightness, difficulty breathing, dizziness, inappropriate speech, jerky movements/tremors, confusion and abnormal thinking. The resident was admitted to the hospital and expired on [DATE]. Furthermore, the failure to identify and administer the proper recommended dosages of the medication to Resident #90 resulted in Immediate Jeopardy with the potential to result in the likelihood of serious adverse consequences of the medication, harm and/or death when the resident received more than three and one-half times the maximum daily allowable dosages and had side effects including a weight gain of over 30 pounds and facial [MEDICAL CONDITION] since starting on the medication. This affected two (#87 and #90) of four residents who were receiving the medication [MEDICATION NAME] since [DATE]. The facility also failed to ensure two (#69 and #99) residents had adequate indications for the use of their medications that was not Immediate Jeopardy. This affected two of seven residents reviewed for unnecessary medication. The facility census was 68. On [DATE] at 1:39 P.M., the Administrator, Chief Executive Officer (CEO) #300 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:00 P.M. when Resident #87 received [MEDICATION NAME], 300 milligrams (mgs) three times a day for a total of 900 mgs, which was one and one-half times the maximum daily allowable dosage. She continued on this dosage while at the facility until she had a [MEDICAL CONDITION] and expired at the hospital on [DATE]. The Immediate Jeopardy continued for Resident #90 from [DATE] at 2:00 P.M. through [DATE] at 8:00 A.M. when the resident was receiving more than three and one-half times the maximum daily allowable dosage that went unrecognized by facility nursing staff, Consultant Pharmacist #210 and CNP #120 for over three months. The Immediate Jeopardy was removed on [DATE] when CNP #120 ordered to decrease and titrate Resident #90's [MEDICATION NAME] down to safe and recommended dosages and the facility implemented the following corrective actions: · On [DATE] at 9:45 A.M., the DON identified and reviewed two (#99 and #36) current additional resident's records who were on [MEDICATION NAME] and were found to be on acceptable dosages. · On [DATE] at 12:30 P.M., CNP #120 was placed on administrative leave. · On [DATE] at 12:45 P.M., the DON began in-servicing all licensed nurses on what to do when receiving physician orders [REDACTED]. If the medication or treatment is out of the ordinary, the nurse should call the physician or the pharmacy immediately to clarify the order. This was completed on [DATE] at 7:33 P.M. · On [DATE] at 2:00 P.M, the DON contacted their contracted pharmacy to discuss a process for ensuring abnormally high medication doses were not ordered. · On [DATE], CNP #120 was terminated by the facility. · On [DATE], at 9:45 A.M., Resident #90's attending physician evaluated the resident at the facility regarding the titration of the medication and no concerns were noted at that time. · On [DATE] at 3:50 P.M, the consultant pharmacist completed reviews of all resident medications and found no irregularities. This was completed at 6:31 P.M. · On [DATE] at 4:45 P.M., the facility contacted the Board of Nursing and reported CNP #120 regarding the excessive dose of [MEDICATION NAME] ordered for Residents #87 and #90. · On [DATE] at 4:45 P.M., the contracted pharmacy was conducting an investigation of the incident and how to prevent future occurrences and identify excessive dosages of medications. · On [DATE] between 4:05 P.M. and 4:17 P.M., Licensed Practical Nurses (LPN) #13, #18, #19, #100 and Registered Nurse (RN) #25, were interviewed regarding the in-service they received addressing physician orders [REDACTED]. All staff interviewed were able to correctly articulate the information provided during the in-service. Although the Immediate Jeopardy was removed on [DATE], the deficiency 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 to investigate and identify medications ordered are at acceptable dosages to ensure on-going compliance. Findings include: Review of Resident #87's medical record revealed an admitted on [DATE]. [DIAGNOSES REDACTED]. Prior to admission, hospital records dated [DATE], identified [MEDICAL CONDITION] Stage III/IV secondary to diabetic [MEDICAL CONDITION] with a baseline Creatinine (test to determine how kidneys are functioning) of 1.8 milligrams/deciliter (mg/dl) (normal levels range from 0.6 to 1.2 mg/dl). Review of the Nursing Drug Handbook, 30th Edition 2017, revealed the reference identified renal doses of [MEDICATION NAME] would be in correlation with renal function (kidney) and identified a maximum dosage not to exceed 300 mgs per day in divided doses. Review of the hospital discharge medication list dated [DATE] revealed an order for [REDACTED].M. documented Resident #87 received [MEDICATION NAME] 75 mgs, two capsules three times a day for a total daily dose of 450 mg. Review of physician orders [REDACTED].#120 for [MEDICATION NAME] 300 mgs, three times a day (TID). Review of the MAR for [DATE] identified Resident #87 received 900 mgs of [MEDICATION NAME] daily from [DATE] at 2:00 P.M. through [DATE] at 8:00 P.M. Review of the progress notes dated [DATE] at 1:40 P.M. revealed Resident #87 reported chest tightness and difficulty breathing. The notes documented Resident #87 was assessed as resident confused at present which was not normal for the resident. Review of the hospital discharge records dated [DATE] revealed to continue to take [MEDICATION NAME], 75 mgs two capsules, three times a day, for a total of 450 mgs. The hospital records did not identify the incorrect dosage of [MEDICATION NAME] Resident #87 received while in the nursing facility. Review of the MAR for Resident #87 revealed she was receiving [MEDICATION NAME] 300 mgs, three times a day from 2:00 P.M. on [DATE] through 2:00 P.M. on [DATE] at 2: 00 P.M. for a total of 900 mgs a day. Review of the progress notes on [DATE] at 9:30 P.M. revealed Resident #87 was found face down on the floor and was unable to recall the event leading up to the fall. The notes further revealed the resident complained of dizziness, had inappropriate speech/confusion at times as well as jerking body movements involving the head, torso, and legs. The note indicated the inappropriate speech/confusion continues. The facility contacted CNP #120 who ordered Resident #87 to be sent to the emergency room . The progress notes dated [DATE] at 1:00 P.M., revealed the hospital identified Resident #87 was returning back to the facility as multiple testing was completed including a Computerized Axial Tomography (CAT) scan which showed no abnormal results. The notes documented the physicians could not figure out why she acts like she does. Review of the MAR for Resident #87 revealed she was receiving [MEDICATION NAME] 300 mgs, three times a day from [DATE] at 8:00 P.M. through [DATE] at 2:00 P.M. for a total of 900 mgs a day. Review of the progress notes dated [DATE] at 3:37 A.M. revealed Resident #87 had increased confusion as well as some twitching noted and was exhibiting hallucinations. Staff contacted CNP #120 who ordered Resident #87 to be sent to the hospital. The record documented staff were monitoring Resident #87 all shift and symptoms were not decreasing. On [DATE] at 1:59 P.M., Resident #87 returned from the emergency room and remains very confused and agitated at times. The progress notes identified a [MEDICATION NAME] was removed upon return from the emergency room . The resident continued to be confused and anxious with hallucinations. Review of the progress notes dated [DATE] at 3:30 P.M. revealed staff spoke with CNP #120 due to concerns of increased confusion and inappropriate conversations. A new order to decrease [MEDICATION NAME] to 150 mgs TID (400 mg) was given. On [DATE] at 6:02 P.M., the charge nurse reported giving [MEDICATION NAME] to the resident at approximately 5:00 P.M. due to a low blood sugar of 70 mg/dl and the resident was non-responsive. The nurse supervisor was in the room with Resident #87 at 5:10 P.M. and identified the resident was non-responsive to verbal/tactile stimulation. Further review of the notes revealed they were unable to obtain the resident's blood pressure and a weak thready pulse with decreased respirations, one every 15 seconds was noted. EMS was immediately notified and arrived at the facility within one minute. Review of the EMS report dated [DATE] revealed they arrived at the facility at 5:12 P.M. The report indicated upon their arrival in Resident #87's room, staff were observed performing Cardio [MEDICAL CONDITION] Resuscitation on the resident. The staff notified them the resident complained about not feeling well throughout the day. Review of the hospital records on [DATE] at 5:50 P.M. revealed Resident #87 expired at 5:50 P.M. Review of Resident #87's death certificate dated [DATE] revealed the cause of death as cardiopulmonary arrest, [MEDICAL CONDITION] infarction and uncontrolled diabetes. 2. Review of the medical record of Resident #90 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission comprehensive assessment dated [DATE] revealed Resident #90's cognition was intact. Interview on [DATE] at 9:11 A.M. revealed Resident #90 had a weight gain of 30 pounds since starting [MEDICATION NAME]. Resident #90's weight record on [DATE] revealed Resident #90 weighed 231 pounds and on [DATE] weighed 266 pounds. Review of Resident #90's physician orders [REDACTED].#90 was admitted with an order for [REDACTED].M. dose of [MEDICATION NAME] was administered to Resident #90, the order was changed to [MEDICATION NAME] 400 mgs, three times a day, for a total of 1200 mgs. Resident #90 received this dose of [MEDICATION NAME] from [DATE] at 2:00 P.M. through [DATE] at 8:00 A.M. Further review of physician orders [REDACTED]. Resident #90 received this dose from [DATE] at 2:00 P.M. through [DATE] at 2:00 P.M. On [DATE], Resident #90's [MEDICATION NAME] was increased by 100 mgs to be given with the current 600 mgs, three times a day for a total of 2,100 mgs. However, this dose was not available and did not begin until [DATE] at 8:00 P.M. through [DATE] at 8:00 A.M. Review of the monthly pharmacist's Medication Regimen Reviews dated [DATE], [DATE], and [DATE] revealed Resident #90 was reviewed during each of the consultant pharmacist visits. Further review revealed the consultant pharmacist made no recommendations for Resident #90. During a telephone interview with CNP #120 on [DATE] at 10:02 A.M. she was notified by the State Agency surveyor Resident #90 had a current order and was receiving 2,100 mgs of [MEDICATION NAME] daily. CNP #120 responded What's wrong with that, she herself was on 900 mgs a day. CNP #120 was asked if she was referring to [MEDICATION NAME], a drug in the same classification as [MEDICATION NAME] but with different dosages, which she did not respond to. Interview with Pharmacist #210 on [DATE] at 10:32 A.M. verified the maximum daily dosage of [MEDICATION NAME] shall not exceed 600 mgs per day in divided doses. Pharmacist #210 further revealed Resident #90 was receiving 2,100 mgs per day at this time. During a telephone interview with Physician #330 on [DATE] at 10:46 A.M. he was notified by the State Agency surveyor Resident #90 had a current order and was receiving 2,100 mgs of [MEDICATION NAME] daily. Physician #330's response was Oh my and identified he was not aware and would take care of this immediately. The physician identified [MEDICATION NAME] should not exceed 600 mgs daily. Review of the Nursing Drug Handbook, 30th Edition 2017 revealed [MEDICATION NAME] was used for neuropathic pain associated with spinal cord injury/diabetic [MEDICAL CONDITION], partial onset [MEDICAL CONDITION] and [MEDICAL CONDITION] with unlabeled uses as moderate pain and social anxiety disorder. The dosage listed as a maximum for daily use included 600 mgs per day in divided doses. The reference identified renal doses would be in correlation with renal function (kidney) and identified a maximum dosage not to exceed 300 mgs per day in divided doses. The side effects for the medication included mental status changes such as mood, affect, behavioral changes, and weight gain; and to notify the physician. Review of the website titled, Medscape.com/drug/[MEDICATION NAME], revealed adverse effects included heart failure, [MEDICAL CONDITION] (dizziness), incoordination, confusion, abnormal thinking, tremors, facial [MEDICAL CONDITION] and weight gain. 3. Review of Resident #69's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] identified she was alert and oriented. Review of Resident #69's medication regime completed on [DATE] included [MEDICATION NAME], a medication used for [MEDICAL CONDITION]. The medical record had no documented medical reason for Resident #69 to be receiving [MEDICATION NAME]. Interview with Resident #69 and a family member on [DATE] at 3:57 P.M. revealed Resident #69 verified she does not have [MEDICAL CONDITION] or any symptoms. Resident #69 stated she had no idea why she was on the medication, [MEDICATION NAME]. Interview with LPN #13 on [DATE] at 10:22 A.M. verified she was not sure why Resident #69 was receiving [MEDICATION NAME]. 4. Review of Resident #99's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The medical record revealed there was no psychiatric [DIAGNOSES REDACTED]. Resident #99's medication regime was reviewed and included a psychoactive drug, [MEDICATION NAME]. Interview with LPN #13 on [DATE] at 12:15 P.M. verified she could not locate any evidence why Resident #99 was receiving a psychoactive medication ([MEDICATION NAME]) and stated CNP #120 should review medications of residents when they are admitted .

Based on review of medical records, review of monthly medication pharmacy reports, review of the facility's policies and procedures related to pharmacy services, interviews with residents and staff, interviews with Physician #330, Consultant Pharmacist #210, and Certified Nurse Practitioner (CNP) #120, review of the Nursing Drug Handbook, 30th Edition 2017, and the website titled, Medscare.com/drugs/lyrica, the facility failed to ensure Consultant Pharmacist #210 reported drug irregularities to the attending physician, the Medical Director and the Director of Nursing (DON) for one (#90) resident who was receiving Lyrica (a medication used to treat nerve pain), when the resident was receiving excessive doses of the medication that were up to three and one-half times the daily maximum recommended dosage (maximum daily use is 600 milligrams (mgs)/day in divided doses) and in excessive duration for a period of over three months. Additionally, the facility failed to ensure their pharmacy polices addressed steps/guidelines the pharmacy should take when an irregularity was identified that required urgent action to protect the residents. The failure of the pharmacy to identify the proper recommended dosages and any irregularities resulted in Immediate Jeopardy with the potential to result in the likelihood of serious adverse consequences of the medication, harm and/or death to Resident #90 when the resident received more than three and one-half times the maximum daily allowable dosages for over three months with side effects including a weight gain of over 30 pounds and facial edema since 01/26/17, when the medication was started. This affected one (#90) of four residents who were receiving Lyrica since January 2017. The facility census was 68. On 05/03/17 at 1:39 P.M., the Administrator, Chief Executive Officer (CEO) #300 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 01/26/17 at 2:00 P.M. when Resident #90 received Lyrica, 400 mgs three times a day for a total of 1,200 mgs and was increased two more times until on 03/02/17 at 8:00 P.M. at which time the resident received 700 mg three times a day for a total of 2,100 mgs. The Immediate Jeopardy continued for Resident #90 from 01/26/17 at 2:00 P.M. through 05/03/17 at 8:00 A.M. when the resident was receiving more than three and one-half times the maximum daily allowable dosage and went unrecognized by facility nursing staff, Consultant Pharmacist #210 and CNP #120 for over three months. The Immediate Jeopardy was removed on 05/04/17, when CNP #120 ordered to decrease and titrate Resident #90's Lyrica down to safe and recommended dosages and when the facility implemented the following corrective actions: · On 05/03/17 at 9:45 A.M., the DON identified and reviewed two (#36 and #99) current additional resident records who were on Lyrica and were found to be on acceptable doses during the monthly drug regimen review. · On 05/03/17 at 12:30 P.M., CNP #120 was on placed on administrative leave. · On 05/03/17 at 12:45 P.M., the DON began in-servicing all licensed nurses on what to do when receiving physician orders for medications. The nurses were instructed to look at each order and identify if the medication or treatment appeared to be out of the ordinary. If the medication or treatment is out of the ordinary, the nurse should call the physician or the pharmacy immediately to clarify the order. This was completed on 05/03/17 at 7:33 P.M. · On 05/03/17 at 2:00 P.M, the DON contacted their contracted pharmacy to discuss a process for ensuring abnormally high medication doses were not ordered. · On 05/04/17, CNP #120 was terminated from the facility. · On 05/04/17 at 3:50 P.M, the consultant pharmacist completed reviews of all resident medications and found no irregularities. This was completed at 6:31 P.M. · On 05/04/17 at 4:45 P.M., the contracted pharmacy was conducting an investigation of the incident and how to prevent future occurrences and identify excessive doses of medications. · On 05/04/17 between 4:05 P.M. and 4:17 P.M., Licensed Practical Nurses (LPN) #13, #18, #19, #100 and Registered Nurse (RN) #25 were interviewed regarding the in-service they received addressing physician orders for medications and if the medication was out of the ordinary, the need to immediately clarify the medication order and contact the physician or pharmacy. All staff interviewed were able to correctly articulate the information provided during the in-service. Although the Immediate Jeopardy was removed on 05/04/17, the deficiency 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 to ensure the pharmacy investigates and identifies medications that are ordered at unacceptable doses and to ensure the facility policy and procedures address a plan regarding what to do when a drug irregularity is identified to ensure on-going compliance. Findings include: Review of the medical record for Resident #90 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission comprehensive assessment dated [DATE], revealed Resident #90's cognition was intact. Interview on 05/04/17 at 9:11 A.M. revealed Resident #90 had a weight gain of 30 pounds since starting Lyrica. Resident #90's weight record on 01/25/17 revealed Resident #90 weighed 231 pounds and on 05/03/17 weighed 266 pounds. Review of Resident #90's hospital discharge medication dated 01/25/17, revealed an order for [REDACTED]. Review of the physician orders and Medication Administration Records (MARs) on 01/27/17, after the 8:00 A.M. dose of Neurontin was administered to Resident #90, revealed the order was changed by CNP #120 to Lyrica 400 mgs, three times a day, for a total of 1200 mgs. Resident #90 received this dose of Lyrica from 01/26/17 at 2:00 P.M. through 02/13/17 at 8:00 A.M. Further review of physician orders written by CNP #120 revealed on 02/13/17, Lyrica was changed to 600 mgs, three times a day, for a total of 1800 mgs. Resident #90 received this dose from 02/13/17 at 2:00 P.M. through 03/02/17 at 2:00 P.M. On 03/01/17, CNP #120 ordered Resident #90's Lyrica increased to 100 mgs to be given with the current 600 mgs, three times a day for a total of 2,100 mgs. However, this dose was not available and did not begin until 03/02/17 at 8:00 P.M. through 05/03/17 at 8:00 A.M. Review of the monthly pharmacist's Medication Regimen Reviews dated 02/14/17, 03/10/17, and 04/19/17, revealed Resident #90 was reviewed during each of the consultant pharmacist visits. Further review revealed Consultant Pharmacist #220 did not make any recommendations for Resident #90 during any of the three monthly visits. During a telephone interview with CNP #120 on 05/03/17 at 10:02 A.M. she was notified by the State Agency surveyor Resident #90 had a current order and was receiving 2,100 mgs of Lyrica daily. CNP #120 responded What's wrong with that, she herself was on 900 mgs a day. CNP #120 was asked if she was referring to Neurontin, a drug in the same classification as Lyrica but with different dosages which she did not respond to. Interview with Pharmacist #210 on 05/03/17 at 10:32 A.M. verified the maximum daily dosage of Lyrica shall not exceed 600 mgs per day in divided doses. Pharmacist #210 further revealed Resident #90 was receiving 2,100 mgs per day at this time. During a telephone interview with Physician #330 on 05/03/17 at 10:46 A.M. he was notified by the State Agency surveyor Resident #90 had a current order and was receiving 2,100 mgs of Lyrica daily. Physician #330's response was Oh my and stated he was not aware and would take care of this immediately. The physician confirmed the dosage of Lyrica should not exceed 600 mgs daily. Review of the Nursing Drug Handbook, 30th Edition 2017 revealed Lyrica was used for neuropathic pain associated with spinal cord injury/diabetic peripheral neuropathy, partial onset seizures and fibromyalgia with unlabeled uses as moderate pain and social anxiety disorder. The dosage listed as a maximum for daily use included 600 mgs/day in divided doses. The reference identified renal doses would be in correlation with renal function (kidney) and identified a maximum dosage not to exceed 300 mgs/day in divided doses. The side effects for the medication included mental status changes such as mood, affect, behavioral changes, and weight gain; and to notify the physician. Review of the website titled, Medscape.com/drug/lyrica, revealed adverse effects included heart failure, vertigo (dizziness), uncoordination, confusion, abnormal thinking, tremors, facial edema and weight gain. Review of the facility policy titled, Consultant Pharmacist Services Provider-Requirements, dated 03/01/17, revealed the pharmacist was responsible to review each residents' medications monthly. The pharmacist was to facilitate the identification of medications and information on contraindications, side effects and/or adverse effects, dosage levels and other pertinent information. In addition, there was no facility policy that addressed steps/guidelines the pharmacy should take when an irregularity was identified that required urgent action to protect the residents. Interview with the DON on 04/04/17 at 3:30 P.M., verified the above information and that the facility was not able to provide any additional policies related to pharmacy services.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, policy review, in-service documentation review, employee file review, self-reported incident report review, Board of Nursing Pronouncement of Death Publication review, nurse practitioner and staff interviews, the facility failed to provide necessary care and services when staff did not initiate Cardiopulmonary Resuscitation (CPR) for one resident (#98) found unresponsive, without vital signs and who was a full code status. This resulted in Immediate Jeopardy for one resident of three residents reviewed who required CPR in the event of a cardiopulmonary arrest. The facility identified a total of 45 residents who were a Full Code status. The facility census was 64. On [DATE] at 2:19 P.M., the Administrator, Chief Executive Officer (CEO) and Director of Nursing (DON) were notified the Immediate Jeopardy began on [DATE] at 4:30 A.M. when Resident #98 was found unresponsive without vital signs, and Licensed Practical Nurse (LPN) #200 failed to initiate CPR or call 911. The Immediate Jeopardy was removed and the deficient practice was corrected on [DATE], when the facility implemented the following corrective actions: · On [DATE] at 1:00 P.M., LPN #200 was suspended and will not be permitted to work pending investigation. · On [DATE] at 7:47 P.M., the State Agency was notified due to the potential for neglect of Resident #98. · On [DATE] at 1:00 P.M., LPN #200 was notified of her termination from the facility. · On [DATE] at 11:00 A.M., the DON completed in-service education on the CPR policy for all licensed nurses. If staff were unavailable (for example part time staff) they were contacted via phone and were informed of the in-service content and informed that shift they could not work until they received in-service materials. · On [DATE] by 11:00 A.M., the DON completed audits of all resident charts for correct code status information and readily available in the correct location. · On [DATE], the DON (or designee) began daily audits including mock code drills and CPR quizzes on random shifts for one month. Twice weekly audits will commence after the first month for duration of one month. After the first two months have concluded weekly audits will continue for the duration of four months. · On [DATE] by 6:00 P.M. an audit was completed to ensure current CPR certification for all licensed nurses. · On [DATE] at 1:00 P.M., the quality assurance (QA) committee met to review the internal plan of action and the findings from all of the audits. The QA committee determined the initial audits were effective. Periodically, per established QA procedures audits will be reviewed to determine effectiveness. The QA was also held on [DATE] and [DATE]. · On [DATE] at 5:51 P.M., the facility reported LPN #200 to the Ohio Board of Nursing. · On [DATE], interviews starting at 1:25 P.M., with LPN #201, #202 and Registered Nurse (RN) #301 revealed staff were knowledgeable about initiating CPR and where to locate resident's code status. All staff interviewed were able to correctly articulate the information provided in the in-service. · On [DATE], an additional interview with LPN #203 at 9:19 A.M., revealed proper knowledge about where to check for a resident's code status and the procedure to follow to initiate CPR. Findings include: Review of Resident #98's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #98's advance directive orders dated [DATE] revealed Resident #98 elected code status was full code and required full resuscitative measures. Review of Resident #98's monthly physician orders dated [DATE] revealed a physician order for [REDACTED].>Review of Resident #98's nursing progress notes dated [DATE], documented Resident #98 expired on [DATE] at 4:30 A.M., and a message was left for the nurse practitioner on the communication board (a clip board in the facility with handwritten notes). The medical record contained no documentation of the physician being notified of the absence of vital signs or Resident #98's condition when found. Medical record review also revealed no documentation of staff performance of cardiopulmonary resuscitation or calls made to 911. Further review of the nursing progress notes dated [DATE] at 4:45 P.M., revealed Resident #98's family was notified and a message was left for the nurse practitioner via the communication board. Review of Resident #98's death assessment form dated [DATE], revealed the Nurse Practitioner was notified of Resident #98's death at 6:22 A.M. Review of self-reported incident (SRI) investigation notes revealed a written statement by LPN #200 dated [DATE] (no time). LPN #200 stated Resident #98 was without respirations and pulse. LPN #200 documented On Sunday [DATE] at 4:30 A.M., STNA #400 came to this nurse and stated Resident #98 had either just passed away or was about to pass away. STNA #400 stated Resident #98 had made a strange sound and his bowels and bladder had let go. Also when he opened the eye lids the eyes were fixed and glazed. This nurse took a stethoscope, a blood pressure cuff, and a thermometer and a pulse oximetry to Resident #98's room. He had ceased to breathe despite being on two liters of oxygen via nasal cannula. There were no respirations, heartbeat or bowel sounds. This nurse went to station #1 to ask Registered Nurse (RN) #300 to verify that Resident #98 had ceased to breathe. This nurse was unaware of Resident #98's code status at that time. This nurse did not start CPR because of being unaware he was a full code until this nurse went into the computer to write the nursing note. Review of the SRI investigation statement written by RN #300, dated [DATE] (no time), revealed LPN #200 asked her to verify Resident #98 did not have vital signs. RN #300 did not document the time LPN #200 asked for assistance. RN #300 revealed on the way to Resident #98's room she had asked LPN #200 if Resident #98 was on Hospice. LPN #200 told her Resident #98 was not on Hospice and had been declining for a few days. RN #300 indicated Resident #98 had no chest rise or fall, no respirations and no apical pulse. Resident #98 was lying in bed with head of bed slightly elevated with eyes closed and mouth open and covered with a sheet and blanket. Review of SRI statement provided by STNA #400, dated [DATE] (no time), revealed Resident #98 appeared to not be breathing after his bed bath. STNA #400 indicated he notified LPN #200 that Resident #98 appeared not to be breathing. STNA #400 further revealed LPN #200 looked at Resident #98 and left to get RN #300 from the other nurse's station. STNA#400 stated RN #300 indicated Resident #98 was no longer with us. Interview on [DATE] at 1:02 P.M., with the Director of Nursing revealed LPN #200 did not perform CPR, call 911, notify the physician or document absence of vital signs in the medical record. The DON further revealed there had been no codes in the facility since [DATE]. Interview on [DATE] at 9:07 A.M., with the Nurse Practitioner (NP) #600 revealed she was notified of Resident #98's absence of vital signs on [DATE] at 6:22 A.M. and ordered the release of the body to the funeral home. The NP #600 revealed she was not aware of Resident #98's full code status. Interview on [DATE] at 12:59 P.M., with the Director of Nursing revealed the facility in-service covered existing policies and procedures on initiating a code and CPR policy. The DON further revealed all nurses brought in their CPR certification cards to photocopy. All nurses were given a copy of the CPR policy and a copy of the DNR protocol residents receive in their admission packet. Nurses were also given a copy of the Advanced Directive Policy last revised [DATE]. Staff were informed the facility would be conducting daily mock codes and situational code status quizzes. Staff were instructed regarding the location of code status in the resident chart and electronic chart. Staff were instructed they must initiate CPR on residents who are a full code. Additionally, staff was informed if a resident expires they must notify either the physician or nurse practitioner via phone and document. Staff were also told not to put notification of an expired resident on the communication board. Interview on [DATE] at 1:10 P.M., by telephone with RN #300 revealed LPN #200 asked her to verify vitals sometime between 4:00 A.M. and 4:30 A.M. RN #300 asked LPN #200 if it was an emergency and LPN #200 told her no. RN#300 indicated LPN#200 waited for her to finish with her patient and they walked to the other end of the building. RN #300 revealed she asked LPN #200 if Resident #98 was on Hospice and LPN# 200 said no he had been declining for a few days. RN #300 revealed she verified Resident #98 was without vital signs and asked LPN #200 if she needed anything else. LPN #200 said no, so RN #300 went back to the residents at the other end of the building. RN #300 revealed she was not aware of Resident #98's code status until [DATE], when the DON contacted her to ask questions. RN #300 indicated she was out of town on [DATE] and came in to the facility to write her statement around 1:00 P.M. to 1:30 P.M. on [DATE]. Interviews were attempted on [DATE], with STNA #400 and LPN #200 via telephone with no success. Review of the facility personnel files revealed STNA #400 and RN #300 resigned from the facility. Review of LPN #200's personnel file revealed LPN #200 was terminated on [DATE]. Review of the facility policy Notification of Change in Condition last revised [DATE], revealed except in medical emergencies, notifications will be made within 24 hours. Review of the facility policy CPR for Adults last revised [DATE], revealed the staff should begin CPR immediately if a resident has no pulse, no respirations or is unresponsive. Review of the facility's policy DNR Protocols dated ,[DATE] revealed CPR will be initiated if a resident is not coded as a do not resuscitate. The Ohio Board of Nursing Pronouncement of Death Publication, Number OBN - 102, revised on [DATE], indicates the pronouncement of death is a decision which could only be made by an individual holding a current certification to practice medicine or surgery or osteopathic medicine or surgery issued under section 4731 of the Ohio Revised Code. This deficiency substantiates Complaint Number OH 906.

Based on medical record review, staff interview, and facility policy review, the facility failed to monitor weights and provide additional nutritional support for one (#64) of three residents reviewed for nutrition. This resulted in actual harm when Resident #64 experienced significant weight loss and altered laboratory values which required hospitalization . The facility identified four residents with unplanned weight loss. The facility census was 73. Findings include: Resident #64 was admitted to the facility 02/22/12, with a recent hospitalization on [DATE], and subsequent re-entry to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was alert, oriented, and extremely hard of hearing. He was independent with eating, and required supervision for all other activities of daily living. His weight was 170 pounds. The resident was not receiving a mechanically altered or therapeutic diet. The nutritional and hydration care area assessments (CAA) did not trigger based on the MDS assessment. Review of the admission physician orders revealed the resident was on a regular diet with thin liquids. The orders did not include any monitoring of intakes and/or outputs. Review of the "Nutritional Risk Assessment" dated 02/28/12, identified the resident was at nutritional risk due to advanced age, limited mobility, and confused mental status. The nutritional goal was to prevent rapid weight changes, dehydration, and maintain current skin status. Nutritional interventions included a regular diet, monitor weights, monitor laboratory results, medication changes, and meal intakes. There was no mention of fluid intakes or requirements. The dietary plan of care dated 02/29/12, stated the resident has [MEDICAL CONDITION]. The goal was for the resident to be free of signs and symptoms of [MEDICAL CONDITION] through the next review date of 5/25/12. There is no mention of weight maintenance or maintaining adequate hydration. A physician's order written on 04/14/12, instructed the resident to receive a diuretic medication, [MEDICATION NAME] 40 milligrams, daily for mild congestive [MEDICAL CONDITION] as noted on a chest x-ray and in recent laboratory results. Review of the resident's weight record revealed the following: 02/22/2012 170 pounds (#) 02/29/2012 171 # 03/14/2012 173 # 03/20/2012 170 # 04/24/2012 175 # 05/28/2012 143 # 06/12/2012 145 # According to the social service assessment dated [DATE], the resident's length of stay was unknown and he would be appropriate for assisted living following therapy. Review of the social service progress note dated 02/23/12, revealed the resident planned to go to assisted living following the completion of his therapy. However, the social service progress note dated 03/19/12, stated the social worker spoke with the resident at the request of therapy for general sadness. When asked how the resident was feeling, he immediately broke down crying. His major concern was not getting to assisted living and ending up as a permanent resident in the facility. The resident also expressed some sadness about the loss of his wife. Review of the social service progress note dated 05/10/12, revealed the social service representative again spoke with the resident about his increasing frustration with the status of moving to assisted living. The resident stated he was "thrown in the corner" (residents bed is next to the window) and "just left, no one visits". The resident stated he was giving up on going to assisted living as he has "been here for two months and is getting nowhere". The social service intervention was to speak to the resident's responsible party for resident to see psychiatry services related to increasing agitation and confusion. Review of the hospital "History and Physical" dated 05/24/12, revealed the resident was seen in the emergency room after he passed out at the nursing home. The initial evaluation at the emergency department found the resident to be dehydrated with elevated potassium levels. The plan was to continue intravenous hydration, repeat laboratory tests and resume diet. Review of the medical record revealed that the resident returned to the facility on [DATE]. The residents weight at this time was 143 pounds. The quarterly MDS dated [DATE], recorded Resident #64's weight as being 175 pounds. There was no weight loss identified. Review of the "Nutritional Risk Assessment" dated 05/31/12, revealed the resident's most recent weight on 04/24/12 was 175 pounds. The resident's goal weight was 166 to 180 pounds. The resident remained at nutritional risk due to advanced age, [DIAGNOSES REDACTED]. The nutritional goal was to maintain good intakes, good skin status, and have no signs or symptoms of dehydration. Interventions included a regular diet, monitor residents weights, laboratory results, medications, and meal intakes. A multiple vitamin was ordered daily and a plan to monitor dietary texture, tolerance, and the need for a renal restricted diet. The assessment stated the resident's needs were 1988 milliliters of fluid and 2200-2400 calories per day to maintain current his weight. The assessment further identified the resident's current diet and intakes met the needs of the resident and will maintain his current weight. Review of the current June 2012, physician orders revealed the resident continues to receive a regular diet with thin liquids. There were no orders to monitor the resident's fluid intake and output. Review of the medical record from 04/24/12 through the current date of 06/14/12, revealed no dietary or nursing entries concerning the resident's hydration status. There were no notes found reflecting the notification of the dietician or the physician of the resident's hydration status. Review of the Certified Nurse Practitioner's (CNP) progress notes dated 05/09/12, 05/14/12, 06/08/12, and 06/11/12 make no mention of the resident's nutrition or hydration status. During an interview with Licensed Practical Nurse (LPN) #42 on 06/14/12 at 7:35 A.M., she stated monthly weights are being done by nursing assistants and given to the director of nursing (DON). She stated the charge nurse does not know the monthly weights. The DON tells the charge nurse if there is weight loss and if an order for [REDACTED]. On 6/14/12 at 11:24 A.M., during an interview with the DON, she stated State tested Nursing Assistant (STNA) #4 does weekly and monthly weights and gives the weights to her. She identified STNA #4 has reference to the resident's previous months weights, but she, the DON, is the one who inputs the weights and makes the decision if there needs to be a re-weigh or if the dietician or physician should be notified of the resident's weight loss to make dietary changes. She further verified she did not enter the resident's 05/28/12 weight in the computer, and the dietician used the weight from 4/24/12 on the 5/31/12 quarterly MDS. She stated the dietician was in the building on 06/12/12, when June weights were taken, and this is when the weight loss was discovered. She verified Resident #64 is not receiving a dietary supplement or fortified foods, and she does not review the weights with the dietician for weight loss. On 06/15 /12 at 10:30 A.M., during an interview with CNP #2, she verified she was not aware of the resident's weight loss prior to 06/12/12, when the May and June 2012 weights were requested by the surveyor. Review of the facility policy entitled "Weight" revised January 2010, identified residents who are considered at risk for unintentional weight loss will be weighed weekly and will be referred to risk management. All risk residents include residents with significant weight loss. Additionally, monthly weights will be completed by the 15th of the month. The director of nursing and dietary will review the log of weights and determine if residents have had a significant weight loss.

Based on medical record review and staff interview, the facility failed to ensure one (#64) resident received adequate hydration. This resulted in actual harm when Resident #64 experienced an altered level of consciousness and was subsequently hospitalized for [REDACTED]. The facility verified that there were no other residents with dehydration issues. The facility census was 73. Findings include: Resident #64 was admitted to the facility 02/22/12, with a recent hospitalization on [DATE], and subsequent re-entry to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was alert, oriented, and extremely hard of hearing. He was independent with eating and required supervision for all other activities of daily living. His weight was 170 pounds. The resident was not receiving a mechanically altered or therapeutic diet. The nutritional and hydration care area assessments (CAA) did not trigger based on the MDS assessment. Review of the admission physician orders [REDACTED]. The orders did not include any monitoring of intakes and/or outputs. Review of the "Nutritional Risk Assessment" dated 02/28/12, identified the resident was at nutritional risk due to advanced age, limited mobility, and confused mental status. The nutritional goal was to prevent rapid weight changes, dehydration, and maintain current skin status. Nutritional interventions included a regular diet, monitor weights, monitor laboratory results, medication changes, and meal intakes. There was no mention of fluid intakes or requirements. The dietary plan of care dated 02/29/12, stated the resident has [MEDICAL CONDITION]. The goal was for the resident to be free of signs and symptoms of [MEDICAL CONDITION] through the next review date of 05/25/12. There is no mention of weight maintenance or maintaining adequate hydration. A physician's orders [REDACTED]. Review of the resident's weight record revealed the following: 02/22/2012 170 pounds (#) 02/29/2012 171 # 03/14/2012 173 # 03/20/2012 170 # 04/24/2012 175 # 05/28/2012 143 # 06/12/2012 145 # According to the social service assessment dated [DATE], the resident's length of stay was unknown and he would be appropriate for assisted living following therapy. Review of the social service progress note dated 02/23/12, revealed the resident planned to go to assisted living following the completion of his therapy. However, the social service progress note dated 03/19/12, stated the social worker spoke with the resident at the request of therapy for general sadness. When asked how the resident was feeling, he immediately broke down crying. His major concern was not getting to assisted living and ending up as a permanent resident in the facility. The resident also expressed some sadness about the loss of his wife. Review of the social service progress note dated 05/10/12, revealed the social service representative again spoke with the resident about his increasing frustration with the status of moving to assisted living. The resident stated he was "thrown in the corner" (residents bed is next to the window) and "just left, no one visits". The resident stated he was giving up on going to assisted living as he has "been here for two months and is getting nowhere". The social service intervention was to speak to the resident's responsible party for resident to see psychiatry services related to increasing agitation and confusion. Review of the hospital "History and Physical" dated 05/24/12, stated the resident was seen in the emergency room after he passed out at the nursing home. The initial evaluation at the emergency department found the resident to be dehydrated with elevated potassium levels. The plan was to continue intravenous hydration, repeat laboratory tests, and resume diet. Review of the medical record revealed that the resident returned to the facility on [DATE]. The residents weight at this time was 143 pounds. The quarterly MDS dated [DATE] recorded Resident #64's weight as being 175 pounds. There was no weight loss identified. Review of the "Nutritional Risk Assessment" dated 05/31/12, revealed the resident's most recent weight on 04/24/12 was 175 pounds. The resident's goal weight was 166 to 180 pounds. The resident remained at nutritional risk due to advanced age, [DIAGNOSES REDACTED]. The nutritional goal was to maintain good intakes, good skin status, and have no signs or symptoms of dehydration. Interventions included a regular diet, monitor residents weights, laboratory results, medications, and meal intakes. A multiple vitamin was ordered daily and a plan to monitor dietary texture, tolerance, and the need for a renal restricted diet. The assessment stated the resident's needs were 1988 milliliters of fluid and 2200-2400 calories per day to maintain current his weight. The assessment further identified the resident's current diet and intakes met the needs of the resident and will maintain his current weight. Review of the current June 2012, physician orders [REDACTED]. There were no orders to monitor the resident's fluid intake and output. Review of the medical record from 04/24/12 through the current date of 06/14/12, revealed no dietary or nursing entries concerning the resident's hydration status. There were no notes found reflecting the notification of the dietician or the physician of the resident's hydration status. Review of the Certified Nurse Practitioner's (CNP) progress notes dated 05/09/12, 05/14/12, 06/08/12, and 06/11/12, made no mention of the residents hydration status. Review of April and May meal intake records revealed the resident was eating 50-100% for meals and on some days meal intake was not recorded. During an interview with Registered nurse (RN) #6 on 06/14/12 at 4:00 P.M., she stated she is not sure the resident was eating 100% of his meals as recorded on the meal intake records, due to his severe depression. She feels he was not eating and drinking due to severe depression over life circumstances. She verified the resident's fluid intake and output was not monitored at any time since admission to the facility.