Every finding on record at Kingston of Ashland

Based on medical record review, resident representative interview, staff interview, and policy review, the facility failed to notify the physician of a resident fall. This affected one resident (#91) of three residents reviewed for falls. The facility census was 90.Findings Include: Review of the medical record for Resident #91 revealed an admission date of 10/06/25 and a discharge date of 10/11/25. Diagnoses included metabolic encephalopathy, osteomyelitis of the left radius and ulna, endocarditis, type two diabetes mellitus, chronic pulmonary edema, pneumonia, hypertensive heart disease with heart failure, cardiomegaly, cellulitis of the left upper limb, iron deficiency anemia, congestive heart failure, benign prostatic hyperplasia, urinary retention, anxiety, depression, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #91 dated 10/11/25 revealed the resident had moderately impaired cognition. Interview on 10/28/25 at 8:52 A.M. with Registered Nurse (RN) #147 revealed Resident #91 fell on [DATE], but she was not aware of it until 10/13/25. Interview on 10/28/25 at 10:38 A.M. with the Director of Nursing (DON) revealed Resident #91 fell on [DATE] with his son present in the room and he witnessed the fall. The DON stated the fall occurred at approximately 5:57 P.M. on 10/09/25. Interview on 10/28/25 at 11:49 A.M. with Resident #91's son revealed he observed Resident #91's fall on 10/09/25 and stated Resident #91 was walking between his bed and his wheelchair to transfer himself to the wheelchair when he fell. Review of Resident #91's medical record revealed no documentation of notification to the physician of the resident's fall on 10/09/25. Interview on 10/28/25 at 12:46 P.M. with the DON, the Administrator, and the Regional Quality Assurance Registered Nurse (RQA RN) #302, revealed they talked to the facility Physician as well as Nurse Practitioner (NP) and neither could recall being notified of Resident #91's fall on 10/09/25.Interview on 10/29/25 at 12:40 P.M. with NP #305 revealed she did not receive any notification when Resident #91 fell on [DATE] and was not aware of his fall until 10/13/25. Interview on 10/29/25 at 12:57 P.M. with Medical Doctor (MD) #306 revealed he did not receiving notification when Resident #91 fell on [DATE] and cannot recall when he was notified of Resident #91's fall that occurred on 10/09/25.Review of the facility policy titled, Change in a Resident's Condition or Status, dated September 2024, revealed the nurse supervisor/charge nurse will notify the resident's attending physician, on-call physician, or nurse practitioner when there has been an accident or injury involving the resident. This deficiency represents non-compliance investigated under Complaint Number 2644890.

Based on medical record review, resident representative interview, and staff interview, the facility failed to ensure a complete and accurate medical record for residents regarding documentation of fall incidents. This affected one (#91) of three residents reviewed for falls. The facility census was 90. Findings Include: Review of the medical record for Resident #91 revealed an admission date of 10/06/25 and a discharge date of 10/11/25. Diagnoses included metabolic encephalopathy, osteomyelitis of the left radius and ulna, endocarditis, type two diabetes mellitus, chronic pulmonary edema, pneumonia, hypertensive heart disease with heart failure, cardiomegaly, cellulitis of the left upper limb, iron deficiency anemia, congestive heart failure, benign prostatic hyperplasia, urinary retention, anxiety, depression, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #91 dated 10/11/25 revealed the resident was assessed with moderately impaired cognition.Interview on 10/28/25 at 8:52 A.M. with Registered Nurse (RN) #147 revealed Resident #91 fell on [DATE], but she was not aware of it until 10/13/25. Interview on 10/28/25 at 10:38 A.M. with the Director of Nursing (DON) revealed Resident #91 fell on [DATE] with his son present in the room and witnessed the fall. The DON stated the fall occurred at approximately 5:57 P.M. on 10/09/25. Interview on 10/28/25 at 11:49 A.M. with Resident #91's son revealed he observed Resident #91's fall on 10/09/25 and confirmed Resident #91 was walking between his bed and his wheelchair to transfer himself into the wheelchair when he fell. Review of the Resident #91's medical record revealed no documentation regarding Resident #91's fall on 10/09/25 at approximately 5:57 P.M. Interview on 10/28/25 at 10:38 A.M. with the DON and the Administrator verified no documentation was present in Resident #91's medical record regarding the fall on 10/09/25 at approximately 5:57 P.M. Interview on 10/28/25 at 12:46 P.M. with the Regional Quality Assurance Registered Nurse (RQA RN) #302 verified no documentation was present in Resident #91's medical record regarding the fall on 10/09/25 at approximately 5:57 P.M.This deficiency represents an incidental finding discovered during the investigation of Complaint Number 2644890.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure indwelling urinary catheter drainage bags were maintained in a manner to prevent infections. This affected two (#23 and #69) of three residents reviewed for urinary catheters. The facility census was 90. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/01/21 with diagnoses including chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type two diabetes mellitus, hypertensive heart disease with heart failure, congestive heart failure, nonrheumatic aortic valve stenosis, atrial fibrillation, hyperlipidemia, obstructive sleep apnea, morbid obesity, anxiety, obstructive and reflux uropathy, COVID-19, depression, insomnia, and transient ischemic attack. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was assessed with moderately impaired cognition. Observation on 10/28/25 at 7:45 A.M. revealed Resident #23 in her room with the urinary drainage bag for her indwelling urinary catheter laying directly on the floor. Interview on 10/28/25 at 8:04 A.M. with Licensed Practical Nurse (LPN) #407 verified the urinary drainage bag for Resident #23's indwelling urinary catheter was laying directly on the floor of the resident's room. 2. Review of the medical record for Resident #69 revealed an admission date of 06/14/23 with diagnoses including aphasia following a cerebral infarction, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, neuromuscular dysfunction of the bladder, pneumonia, vitamin D deficiency, depression, bilateral hearing loss, malignant neoplasm of the prostate, cardiomegaly, occlusion and stenosis of the left coronary artery, and hyperlipidemia. Review of the most recent MDS assessment dated [DATE] revealed Resident #69 was assessed with intact cognition. Observation on 10/29/25 at 1:19 P.M. revealed Resident #69's in his room with the urinary drainage bag for his indwelling urinary catheter laying directly on the floor in the room. Interview on 10/29/25 at 1:20 P.M. with Certified Nurse Aide (CNA) #210 verified the urinary drainage bag for Resident #69's indwelling urinary catheter was laying directly on the floor of the resident's room. Review of the facility policy titled, Urinary Catheter Care, dated November 2023, revealed guidelines for facility staff to be sure the catheter tubing and drainage bag are kept off the floor. This deficiency represents an incidental finding discovered during the investigation of Complaint Number 2644890.

Based on medical record review, interviews with staff, and facility policy review, the facility failed to ensure a comprehensive post-surgical pain management program was maintained to achieve adequate pain control for Resident 93. This resulted in Actual Harm on [DATE] at 1:38 A.M. when Resident #93, who had a surgical amputation of the left leg (below the knee) on [DATE] and had an order for Oxycodone 10 milligrams (mg) immediate release every four hours for moderate pain, complained of severe post-operative pain rated at a 10 out of 10 (on a ,d+[DATE] pain scale with 0 representing no pain and 10 representing the worst pain the resident had ever experienced); however, the resident's Oxycodone had not been reordered timely, resulting in no narcotic pain medication available for administration and the resident had to be transferred to the emergency room to receive pain medication. This affected one (Resident #93) of two residents reviewed for pain management. The facility census was 92. Findings Include: Review of the medical record for Resident #93 revealed an admitted on [DATE] and a discharge date on [DATE] with the diagnoses including but not limited to surgical amputation of the left lower leg below the knee, chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), and high blood pressure. Review of the physician orders for Resident #93 revealed an order dated [DATE] for narcotic pain medication Oxycodone 10 mg immediate release tablet, take one tablet by mouth (PO) every four hours as needed (PRN) for moderate pain, and an order dated [DATE] for acetaminophen (Tylenol) oral tablet 325 mg, give three tablets by mouth every eight hours for moderate pain. Review of the admission assessment dated [DATE] revealed Resident #93 reported a pain level of six out of 10 on admission. Further review of Resident #93's admission baseline care plan dated [DATE] revealed Resident #93 was at risk for pain related to surgical procedure of left leg below the knee amputation with interventions including medications as ordered, repositioning and elevation as needed. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had intact cognition. Resident #93 required moderate assistance from staff for transfers, mobility, and personal hygiene care. Resident #93 received scheduled and as needed pain medication and Resident #93 had experienced pain five days out of the seven days during the review period. Review of the medication administration record (MAR) dated [DATE] to [DATE] revealed Resident #93 had received the as needed narcotic pain medication Oxycodone 10 mg for a total of 17 doses for pain levels ranging from 7 to 10 with the follow up assessment being marked as effective for pain management of Resident #93. Resident #93 was also receiving scheduled acetaminophen (Tylenol) oral tablet 325 mg, give three tablets by mouth every eight hours for moderate pain. Review of Resident #93's progress note authored by Registered Nurse (RN) #337 dated [DATE] at 1:38 A.M. revealed Resident #93 was yelling and moaning complaining of severe pain. Resident #93 requested narcotic pain medication. RN #337 received in report Resident #93's narcotic pain medication Oxycodone prescription had not been renewed with the pharmacy. RN #337 notified on-call Nurse Practitioner (NP) #339 to request the prescription be renewed. NP #339 denied the request to renew the prescription and instead gave an order for extra strength Tylenol stating will not be giving narcotic orders at 2:00 A.M. RN #337 informed NP #339 Resident #93 would be transferred to the hospital for pain control if requested. Review of Resident #93's progress note authored by RN #337 dated [DATE] at 1:41 A.M. revealed Resident #93 was offered the extra strength Tylenol for pain control, Resident #93 denied the medication and requested to be transferred to the hospital. RN #337 called emergency medical services (EMS) for transport of Resident #93 to the hospital. Resident #93 left the facility at 1:50 A.M. with EMS. Review of the hospital discharge paperwork for Resident #93 dated [DATE] at 2:55 A.M. revealed hospital diagnoses for Resident #93 was postoperative pain with new orders including Oxycodone - Acetaminophen (Percocet) ,d+[DATE] mg per tablet, give one tablet by mouth every six hours as needed for pain and an order for Gabapentin (Neurontin) 400 mg give one capsule by mouth three times daily. Review of the MAR dated [DATE] to [DATE] for Resident #93 revealed Resident #93 received Percocet ,d+[DATE]mg for a total of three doses with pain level ranging from five to seven out of 10 on the pain scale. The follow up documentation revealed the medication was effective in controlling Resident #93's pain. Interview on [DATE] at 10:15 A.M. with RN #337 revealed because Resident #93's prescription for Oxycodone 10 mg had not been renewed, the pharmacy would not give the authorization for RN #337 to remove the narcotic pain medication from the facility's emergency medication machine for administration. Interview on [DATE] at 1:00 P.M. with the Director of Nursing (DON) confirmed Resident #93's narcotic pain medication prescription for Oxycodone 10 mg had not been renewed with the pharmacy and was unavailable when Resident #93 was experiencing a severe pain level of 10 on [DATE] resulting in Resident #93's transfer to the hospital for pain management. The DON stated the original prescription for Resident #93 had been written for a total of 18 doses and expired on [DATE] with the facility not attempting to renew the prescription for Resident #93. Multiple attempts were made on [DATE] during the onsite survey to contact NP #339; however, there was no return contact made with the surveyor. Review of the facility's policy titled Pain Assessment and Management undated revealed pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. This deficiency represents non-compliance investigated under Complaint Number OH00163865.

Based on review of medical records, interviews with staff and residents, facility policy review, and medication manufacturer guidelines review, the facility failed to ensure residents were free of significant medication errors. This resulted in actual harm for one resident on 02/16/25 at 7:23 P.M. when Resident #111, who received long-acting insulin and blood glucose monitoring for the management of Type II diabetes, was administered insulin despite a physician order to hold the insulin when the blood glucose level was below 200 milligrams per deciliter (mg/dL) of blood. The resident's blood glucose level was 109 mg/dL (normal range is 70-100 mg/dL). The resident experienced hypoglycemia (low blood glucose level) with a blood glucose level of 44 mg/dL at 1:30 A.M. and was unresponsive. Resident #111 required the administration of glucagon (injection medication to treat hypoglycemia) and emergency medical transport observation until the resident was stable and hourly blood glucose checks per glucometer to monitor and prevent reoccurrence. Additionally, two other residents (#302 and #404) were placed at risk for the potential for more than minimal harm when their physician ordered medications were not administered as prescribed. This affected three (#111, #302 and #404) of five residents reviewed for medication errors. Findings Include: 1. Review of the medical record for Resident #111 revealed an admitted on 04/29/23 with diagnoses including but not limited to Type II diabetes, high blood pressure, asthma, depression, and anxiety. Review of Resident #111's at risk care plan dated 09/03/24 revealed Resident #111 was at risk for fluctuating blood glucose levels related to diagnosis of Type II diabetes with interventions including regularly monitoring blood glucose levels and administering medications as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had mild cognitive impairment with a Brief Interview of Mental Status score of 12 out of possible 15. Resident #111 had impairment to one side and required limited assistance from staff for personal care, transfers, and medication administration. Resident #111 received insulin injections for seven days during the review period. Review of physician orders for Resident #111 revealed an order dated 02/05/25 for insulin Lantus Solution pen-injector 100 unit/milliliter (ml) inject 55 units subcutaneous (SQ) at bedtime (HS) for glucose control - hold if below (blood glucose level) 200. Blood glucose monitoring four times a day (breakfast, lunch, dinner and bedtime). Insulin Aspart 100 units per ml, give 30 units with all meals. Review of Resident #111's blood glucose results dated 02/16/25 at 7:23 P.M. revealed the result was recorded as 109 mg/dL (the physician orders indicated the resident's Lantus insulin [long-acting insulin which peaks three to four hours after administration]) was to be held (not administered). Review of the February 2025 Medication Administration Record (MAR) for Resident #111 revealed on 02/16/25 at 8:30 P.M., Registered Nurse (RN) #337 administered 55 units of Lantus Insulin to Resident #111. Review of Resident #111's progress note dated 02/17/25 at 1:30 A.M., revealed the resident was observed to be unresponsive and slouching to the right, with their tongue hanging out of their mouth. The resident's blood glucose result was 44 mg/dL of blood per glucometer. The on-call nurse practitioner (NP) was notified, and an order was received for Glucagon 1 milligram (mg) intermuscular and to send Resident #111 to the hospital if needed. Review of Resident #111's progress note dated 02/17/25 at 1:35 A.M. revealed Glucagon 1 mg was administered via intermuscular injection to the left deltoid. Review of Resident #111's progress note dated 02/17/25 at 1:50 A.M. revealed emergency medical services (EMS) were called for transport of Resident #111 to the hospital. Review of Resident #111's progress note dated 02/17/25 at 1:55 A.M. revealed EMS arrived at the facility. Resident #111 remained unresponsive. Blood glucose obtained with result of 65 mg/dL. EMS attempted to initiate intravenous (IV) access and was not successful. Review of Resident #111's progress note dated 02/17/25 at 2:05 A.M. revealed Resident #111 was awake, alert and eating a peanut butter and jelly sandwich. Re-check of blood glucose level with a result of 85 mg/dL. Review of Resident #111's progress note dated 02/17/25 at 2:10 A.M. revealed a recheck of the blood glucose with a result of 98 mg/dL. EMS stated Resident #111 was stable and left the facility. Resident #111 was not transported to the hospital. Review of Resident #111's progress note dated 02/17/25 at 3:47 A.M. revealed the on-call NP was notified Resident #111 remained in the facility with a new order received to obtain blood glucose every hour. Resident #111 and son were notified of the new order. Review of Resident #111's progress note dated 02/17/25 at 7:00 A.M. revealed Resident #111's vital signs were blood pressure 108/70 mmHg (normal 120/60 mmHg), pulse 57 beats per minute (normal range 60-90 bpm), temperature 97.4 degrees Fahrenheit, respirations 18 breaths per minute (normal 12-20 breaths per minute), blood glucose 196 mg/dL. On call NP notified with new order to hold insulin dosage for breakfast. Review of Resident #111's progress note dated 02/17/25 at 10:36 A.M. revealed the NP was notified of Resident #111's blood glucose reading of 249 mg/dL and ordered to continue to hold the resident's insulin. Resident #111 was more alert and talkative and consumed 95% of the breakfast meal. Hourly blood glucose monitoring was discontinued at 8:00 A.M. Review of the facility's medication error report dated 02/17/25 and completed by RN #337 revealed Resident #111 was administered 55 units of Lantus Insulin on 02/16/25 at bedtime. Resident #111's blood glucose reading was 109 mg/dL. The physician order was for Lantus insulin with parameters to hold the insulin if the blood glucose results were below 200 mg/dL. Further review of the February 2025 MAR revealed the resident's scheduled insulin was resumed on 02/18/25. An interview on 03/24/25 at 3:25 P.M. with Resident #111 revealed Resident #111's blood glucose results fluctuate a lot and usually will be low instead of being high. Resident #111's diabetes is monitored by a specialist. An interview on 03/25/25 at 12:47 P.M. with the Director of Nursing confirmed RN #337 had administered Lantus insulin to Resident #111 when the blood glucose result was 109 mg/dL which was below the parameters set for the administration of the Lantus insulin. This resulted in a significant medication error. The resident's Lantus insulin was ordered to be held for a blood glucose level of less than 200 mg/dL, and it wasn't. The resident developed hypoglycemia which warranted the administration of Glucagon and more frequent blood glucose monitoring due to low blood sugar. Review of the facility's policy titled Administering Medications dated 04/01/24 revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the physician orders, including any required time frame. Review of the manufacturer guidelines for Insulin Glargine (Lantus) revealed the onset of action for Lantus insulin is three to four hours after administration with no pronounced peak effect. 2. Review of the medical record for Resident #302 revealed an admitted [DATE] with diagnoses including right femur fracture, COPD, high blood pressure, atherosclerotic heart disease, and hyperlipidemia. Review of the physician orders for Resident #302 revealed an order dated 09/03/24 for an antiplatelet medication Clopidogrel Bisulfate (Plavix) 75 mg give one tablet by mouth in the morning for atherosclerotic heart disease, and an order dated 09/03/24 for antihypertensive medication Carvedilol (Coreg) 3.125 mg give one tablet by mouth every morning and at bedtime for high blood pressure. Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #302 had cognitive impairment with a BIMS score of 12 out of possible 15 and required assistance from staff for personal hygiene care and medication administration. Review of Resident #302's progress note dated 03/14/25 at 9:20 A.M. revealed Resident #302 had been administered the wrong morning medications during morning medication pass by LPN #330. LPN #330 had administered a lower dose of Coreg and a dose of the anticoagulant medication, Eliquis, to Resident #302 (these medications were not ordered for the resident). Resident #302's vital signs were stable and there was no sign of bleeding. Resident #302's daughter was notified, and the on-call NP was notified. Review of the facility's medication error report dated 03/14/25 completed by LPN #330 revealed Resident #302 had received Resident #300's Eliquis and Coreg medications during the morning medication administration. Resident #302 had a head-to-toe assessment completed by LPN #330 with no negative findings documented. Resident #300's morning medications were removed from the facility's emergency medication machine and administered per physician order. An interview on 03/25/25 at 1:20 P.M. with the DON confirmed on 03/14/25 Resident #302 had been administered Resident #300's morning medications including the anticoagulant Eliquis and high blood pressure medication, Coreg. The DON stated the expectation of the facility nurses was to accurately read the physician orders and check the medications with the resident's MAR and name prior to administration of the medications. Review of the facility's policy titled Administering Medications dated 04/01/24 revealed medications ordered for a particular resident may not be administered to another resident. The individual administering the medications must verify the resident's identity before giving the resident his/her medications. 3. Review of the medical record for Resident #404 revealed an admitted on 01/31/25 with a readmitted from the hospital on 02/20/25. The resident had diagnoses including but not limited to diverticulitis of the large intestine, arterial fibrillation (AFib), heart failure, chronic kidney disease Stage 3, Type II diabetes, and peripheral vascular disease (PVD). Review of Resident #404's Medicare 5 - Day MDS assessment dated [DATE] revealed Resident #404 had impaired cognition with a BIMS score of 11 out of 15. Resident #404 required assistance from staff for personal care, transfers, and medication administration. Resident #404 was receiving diuretic medication and heart failure was marked as a diagnosis. Review of the hospital discharge paperwork and physician orders for Resident #404 dated 02/20/25 revealed an order for Furosemide oral tablet (Lasix) 20mg, give one tablet two times per week. Review of Resident #404's physician orders revealed an order dated 02/24/25 for diuretic medication Furosemide oral tablet (Lasix) 20 mg, give one tablet by mouth in the morning every Monday, Thursday, and Saturday for heart failure. Further review revealed a discontinued order dated 02/20/25 to 02/24/25 for diuretic medication Furosemide oral tablet (Lasix) 20 mg, give one tablet twice a day for heart failure. Review of Resident #404's MAR dated 02/20/25 to 02/24/25 revealed Resident #404 had been administered Furosemide 20mg, two times per day for a total of four days. Review of Resident #404's progress note dated 02/24/25 at 12:10 P.M. authored by LPN #217 revealed the order for Furosemide 20 mg and been clarified and changed to administration two times per week instead of two times daily. Review of the facility's medication error report completed by LPN #217 revealed Resident #404's discharged physician order from the hospital dated 02/20/25 for Furosemide 20 mg had been transcribed incorrectly instead of being administered two times weekly, the order had been transcribed to be administered two times per day with Resident #404 receiving the Furosemide 20 mg two times per day for four days resulting in a significant medication error. An interview on 03/25/25 at 8:50 A.M. with LPN #217 revealed on 02/24/25 LPN #217 was reviewing Resident #404's recent laboratory results with NP #312 which indicated abnormal results with kidney function. LPN #217 reviewed Resident #404's hospital discharge medication orders dated 02/20/25 and saw where the Furosemide 20 mg order had been transcribed incorrectly in Resident #404's medical record. NP #312 clarified Resident #404's Furosemide order and LPN #217 updated the Furosemide order to reflect Furosemide 20mg to be administered two times per week. An interview on 03/25/25 at 1:10 P.M. with the DON confirmed Resident #404's hospital discharge order for Furosemide 20 mg, give one tablet by mouth two times per week had been transcribed incorrectly into Resident #404's medical record for Furosemide 20 mg to be given two times daily resulting in a significant medication error. The DON stated the expectation of the facility nurses is to accurately read the physician orders and check the medications with the resident's MAR and name prior to administration of the medications. Review of the facility's policy titled administering medications dated 04/01/24 revealed medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00163865.

Based on medical record review, interview and facility policy review the facility failed to maintain accurate medical records by not transcribing physician orders correctly. This deficient practice affected one resident (Resident #348) out of five residents reviewed for medication errors. The facility census was 92. Findings Include: Review of the medical record for Resident #348 revealed admitted on 02/22/25 with diagnoses including but not limited to high blood pressure, type two diabetes, Congestive Heart Failure (CHF), and osteoporosis. Review of the hospital discharge orders dated 02/22/25 for Resident #348 revealed an order for Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning every Monday for supplemental use. Review of the physician orders for Resident #348 revealed an order dated 02/22/25 for a vitamin D2 supplement Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning for supplemental use (daily). Review of the Medication Administration Record (MAR) dated 02/22/25 to 02/28/25 revealed the order for Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning (daily) for supplemental use was marked as being administered on 02/23/24 in the morning. Further review of the MAR revealed on 02/24/25 the order was marked as not administrated by Licensed Practical Nurse (LPN) #217. An interview on 03/25/25 at 8:05 A.M. with LPN #217 revealed on 02/24/25 during the morning medication administration for Resident #348 LPN #217 recognized the order for Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) had been transcribed incorrectly during Resident #348's admission process on 02/22/25. LPN #217 notified the physician for clarification and entered the correct order for Ergocalciferol oral capsule 1.25 milligrams (mg) (50,000 units) give one capsule orally in the morning every Monday for supplemental use. An interview on 03/25/25 at 1:18 P.M. with the Director of Nursing (DON) confirmed Resident #348's order for vitamin D2 supplement Ergocalciferol had been incorrectly transcribed during Resident #348's admission process on 02/22/25. A review of the facility's policy titled Administering Medications dated 02/01/23 revealed medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00163865

Based on interviews and record review, the facility failed to complete the medical record and accurately document the clinical status for one resident (Resident #105) of four resident's sampled. The census was 101. Findings Include: Review of the medical record for Resident #105 revealed an admitted [DATE] with diagnoses including anemia, type two diabetes, paroxysmal atrial fibrillation, congestive heart failure, protein calorie malnutrition, macular degeneration, spinal stenosis, presence of cardiac pacemaker, chronic kidney disease stage three, and cardiomyopathy. Resident #105 expired on [DATE]. Review of the vital sign record on [DATE] revealed Resident #105's vital signs were documented as blood pressure ,d+[DATE]; temperature was 97.4; pulse was 66; respirations 18; oxygen saturation 95% on room air. No vital signs were documented on [DATE]. Review of physician orders revealed an order to monitor residents confusion and altered mental status, if it progresses, daughter would like resident sent to the Emergency Department (ED) for evaluation, two times a day for monitor for confusion for four administrations, dated [DATE] at 5:29 P.M. Review of the medical record on [DATE] revealed no documented clinical assessments for Resident #105. Interview on [DATE] at 4:35 P.M., Registered Nurse (RN) #150 stated Resident #105's vital signs had been completed and communicated to the facility Nurse Practitioner by way of telephone. RN #150 confirmed medical documentation for vital signs or assessments were not recorded in the electronic medical record on [DATE]. Interview on [DATE] at 5:05 P.M. with the Administrator and Director of Nursing (DON), both confirmed no vital sign documentation was recorded for Resident #105 on [DATE]. Review of the facility policy titled Change in a Resident's Condition or Status dated [DATE], revealed the nurse supervisor/charge nurse will record the residents medical record information relative to changes in the residents medical/mental condition or status.

Based on record review and interview the facility failed to ensure daily weights and laboratory tests were obtained and/or reported as ordered for Resident #110. This affected one resident (#110) of four residents reviewed for quality of care. The facility census was 91. Finding included: 1. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE]. Diagnoses included surgery to the digestive system, colostomy, malignant neoplasm of the sigmoid colon, congestive heart failure, chronic kidney disease, insomnia, dilated cardiomyopathy, and pacemaker. She was discharged to the hospital on 06/27/24. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had intact cognition and had a surgical wound and ostomy. She needed set up assistance for eating and weighed 134 pounds (lbs). Review of the physician's orders revealed Resident#110 was order daily weights and to notify the provider of a weight gain of three pounds (lbs) in one day or five pounds in one week dated 06/05/24. Review of the daily weights for Resident #110 revealed no documentation of daily weights on 06/08/24, 06/10/24, 06/13/24, 06/14/24, 06/18/24, 06/19/24, 06/20/24 and 06/21/24. Review of the weights for Resident #110 revealed she weighed 133.6 lbs on 06/04/24, 133.8 lbs on 06/05/24 and 06/06/24, 139.0 lbs on 06/07/24, 140.2 lbs on 06/09/24, 127.0 lbs on 06/11/24, 123.0 lbs on 06/12/24, 123.7 lbs on 06/15/24, 123.7 lbs on 06/16/24, 123.6 lbs on 06/17/24, 124.6 lbs on 06/22/24, 128.0 lbs on 06/23/24, and 127.8 lbs on 06/24/24. On 09/12/24 at 10:33 A.M. an interview with the Director of Nursing (DON) confirmed the physician was not notified on 06/07/24 for Resident #110 having a 5.2-pound weight gain from 06/06/24 to 06/07/24 or on 06/24/24 for her 3.2-pound weight gain from 06/22/24 to 06/24/24. 2. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE]. Diagnoses included surgery to the digestive system, colostomy, malignant neoplasm of the sigmoid colon, congestive heart failure, chronic kidney disease, insomnia, dilated cardiomyopathy, and pacemaker. She was discharged to the hospital on 06/27/24. Review of the admission MDS assessment dated [DATE] revealed Resident #110 had intact cognition and had a surgical wound and ostomy. Review of the physician's orders revealed Resident #110 had an order for a wound culture per the daughters request due to a change in drainage color dated 06/12/24. Review of the physician's orders revealed Resident #110 had an order for levofloxacin 500 milligrams once daily for seven dated for infection dated 06/19/24. Review of the wound culture of the lower abdomen wound with a collection dated of 06/12/24, received date of 06/14/24 and reported date of 06/18/24 revealed the culture was positive for the organism pseudomonas aeruginosa. Review of the Infection Control log revealed Resident #110 had a wound infection on 06/19/24 and was prescribed levofloxacin 500 milligrams. On 09/10/24 at 12:14 P.M. an interview with the DON revealed she was not with the company when the lab test was done for Resident #110 so she does not know why it was drawn on 06/12/24 but not sent to the lab until 06/14/24. She verified that was what the documentation stated. She stated the lab was short staffed just like everyone else and they try to get them to pick up every day but somedays they do not show up. This deficiency represents non-compliance investigated under Complaint Number OH00157221.

Based on review of the medical record and interview with staff the facility failed to complete a thorough and timely post-fall assessment and notify the family of a fall for Resident #109. This affected one resident ( Resident #109) of three reviewed for falls. The facility census was 91. Findings included: Review of the closed medical record revealed Resident #109 was admitted to the facility on [DATE]. Diagnoses included hemiplegia of the right side following a cerebral infarction, intracerebral hemorrhage, encephalopathy, pulmonary fibrosis, dysphagia, respiratory disorders, begin prostatic hyperplasia, kidney failure, hypertension, and atherosclerotic heart disease. He was discharged to the hospital on [DATE] where he later expired. Review of the physician's orders dated [DATE] revealed Resident #109 had orders for fall mats to both sides of the bed at bedtime and a low bed. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #109 had severely impaired cognition and was incontinent of bladder and bowel. He required partial/moderate assist with eating and was dependent for toileting and bathing. Review of the fall risk assessment dated [DATE] revealed Resident #109 was a high risk for falls. Review of the fall investigation report dated [DATE] revealed Resident #109 was found on [DATE] at 2:30 A.M. lying on the ground next to his bed with his head towards the head of the bed. A blanket was covering him and the call light was pinned to him. The resident was alert with no injuries noted at the time. Resident stated he rolled out of bed. The State tested Nursing Assistant (STNA) statement reports the resident stated his head hurt then denied anything hurting. Review of the undated, signed, handwritten witness statement from STNA #255 revealed on [DATE] (this was actually [DATE]) at around 2:00 A.M. she was assisting a resident to the bathroom when the nurse came into the room and stated Resident #109 was on the floor. When she walked into the room Resident #109 was on the floor parallel with the bed next to the heating unit, his head was under the red chair in the room and the nurse was standing beside him. Resident #109 was wrapped up in his blanket with his call light still attached to his shirt and his bed was in the low position. She went to get the Hoyer lift so they could get him up off the floor. They got him back into the bed and the nurse felt the back of his head for a goose egg and said there was not one. Resident #109 stated his head hurt then said nothing hurt. When she came back to work on [DATE] she thought Resident #109 did not seem to be doing well so she approached the nurse working that night and asked her what was going on with him because the other night he was talking to her. She asked her if there was any documentation of a fall and the nurse stated no. She told her what had happened on [DATE] ( the date was actually [DATE]) and the nurse told her to report it. She stated there was no assessment or neurological assessment was done. Review of the progress/nursing/skilled notes from [DATE] to [DATE] revealed no documentation of a neurological assessment being completed for Resident #109. Review of the physician's telehealth note dated [DATE] at 3:00 A.M. revealed Resident #109 was being seen due to complaints of pain. He had a diagnosis of chronic pain however he was unable to clearly state where and was not endorsing an exam however the nurse stated he did appear to be in pain. Review of the nursing note dated [DATE] at 12:19 P.M. revealed the family of Resident #109 was notified of a fall on [DATE]. The family was requesting the resident be sent to the hospital for a head scan. Review of the hospital records dated [DATE] revealed Resident #109 had a head scan during the hospitalization which confirmed a brain bleed that was aged/unchanged from prior imaging done in [DATE]. Resident #109 was placed on comfort care with hospice services and expired at the hospital. On [DATE] at 9:18 A.M. in interview with Family Member #400 revealed Resident #109 was admitted to the facility due to the brain bleed and she was concerned about him falling at the facility but he facility stated they would lower his bed and place mats on the floor which they did do. She stated they would be there all the time and it would take forever to get anyone to answer the call light, most times it was up to an hour. She stated on [DATE] her father was not acting right; he was very fidgety and kept holding his head saying oh my over and over. She stated she spent the night with her father on Friday, Saturday, and Sunday ([DATE], [DATE], and [DATE]). She stated on [DATE] her father was complaining of stomach pain and she explained to the nurse (patty) that this was how he was acting prior to the first brain bleed but she would not listen to her. She stated during the night she asked the nurse if her father could have something for a headache and the nurse stated to her is it his head or stomach and I told her to just give him some Tylenol. She stated they had a meeting on [DATE] with the Director of Nursing (DON) and another person because their father was declining so fast and wanted to know what to do and they were told that he had fallen on Thursday night ([DATE]) and it was not reported. They told them they wanted him sent to the hospital. She stated by then he was completely unresponsive. She stated the hospital did a cat scan which was negative but the physician at the emergency room (ER) stated they should have done a Magnetic Resonance Imaging (MRI) because that was the only way to really tell. She stated he was severely dehydrated and had a urinary tract infection. She stated her father passed away at the hospital. On [DATE] at 1:37 P.M. an interview with the DON revealed she was not employed at the facility with Resident #109 had fallen but she verified the documentation revealed he had fallen on [DATE] and it was not reported and there was no documentation of an assessment, vital signs or neurological assessment had been completed. She stated the nurse had been terminated due to the incident. On [DATE] at 2:25 P.M. an interview with Registered Nurse # 401 revealed on the morning of [DATE] right before shift change at 6:00 A.M. she was at the desk charting and the call light for Resident #109 was on and the nursing assistant was in a room helping another resident so she went to answer it. She stated when she went into the room Resident #109 was hanging halfway out of the bed between the bed and the wall. She stated his bed was in the lowest position, the mats were on the floor, he was wrapped up in his blankets and the call light was clipped to the blanket by his head. She stated he said she had to go to the bathroom. She stated she went and got the nursing assistant and they got the Hoyer and put him back into bed. She stated she checked him over and did not see anything wrong him and she asked him if he was in pain and he stated no. She stated they changed his brief because he had been incontinent. She verified she had not charted on the incident or called the family because she did not believe it was a fall. On [DATE] at 2:46 P.M. an interview with STNA #255 revealed she worked 10:00 P.M. to 6:00 A.M. on [DATE] into [DATE]. She stated she walked passed Resident #109 room around 2:00 A.M. and he was lying on the floor mat on the side of the bed between the bed and the wall. She stated he had his blankets wrapped around him with his call light still attached to his blanket. She stated his call light was not on. She stated the nurse was sitting at the nurse's station so she asked her to come to the room because he was on the floor. She stated they got him up off the floor with the Hoyer, the nurse checked him out and there were no other issues with him the rest of the night. She stated she came back to work on [DATE] and she asked the nurse who was working that night if it was documented he had a fall and the nurse stated no and told her to write a statement and turn it so she did. This deficiency represents non-compliance investigated under Complaint Number OH00157236 and OH00157221.

Based on record review and interview the facility failed to ensure medication was obtained timely from the pharmacy for Resident #20. This affected one resident (#20) of four residents reviewed for pharmacy services. The facility census was 91. Finding included: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, pulmonary fibrosis, chronic duodenal ulcer, hypertensive heart, kidney disease, atrial fibrillation, major depressive disorder, anxiety, chronic pain syndrome, glaucoma, and macular degeneration. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition. Review of the Medication Administration Record (MAR) revealed Resident #20 had not received her Entresto (heart failure medication) ,d+[DATE] milligram tablet twice a day from admission on [DATE] to [DATE]. Review of the progress notes on [DATE] at 11:08 A.M. revealed Resident #20 to have two plus non-pitting edema in both her legs. Review of the pharmacy delivery slip revealed six Entresto ,d+[DATE] milligram tablets were delivered on [DATE]. Review of the progress notes from [DATE] to [DATE] revealed no documentation the physician or nurse practitioner were notified the facility was unable to get Entresto for Resident #20. Review of the physician progress notes dated [DATE] and [DATE] revealed no documentation of Entresto not being available for Resident #20. On [DATE] at 10:45 A.M. an interview with Licensed Practical Nurse (LPN) #351 revealed she had called the pharmacy several times about the Entresto for Resident #20 and they kept telling her it would be delivered but it would never come in. She stated the last time she called they stated it was a billing issue. She stated they finally got it in a few days ago. She stated it was always something with the pharmacy. She verified Resident #20 had developed some edema in both her legs during that time. On [DATE] at 11:30 A.M. an interview with LPN #351 verified she never notified the physician the medication was not available from the pharmacy. On [DATE] at 2:35 P.M. an interview with the Director of Nursing (DON) revealed the Entresto for Resident #20 was expensive and the pharmacy would not send it for Resident #20 because she did not have insurance at that time. She stated Medicare had her as deceased in the system. She stated they were attempting to get to straightened out. She stated she had the medication now. This deficiency represents noncompliance investigated under Complaint Number OH00157222.

Based on observation, record review and interview, the facility failed to provide timely toileting assistance to Resident #1 who required staff assistance for activities of daily living (ADL). This affected one resident (#1) of three residents reviewed for assistance with ADLs. The facility census was 91. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included hemiplegia following a cerebral infarction, intracerebral hemorrhage in the brain stem, respiratory failure, dysarthria, obstructive hydrocephalus, depression, hepatitis, osteoarthritis, and history of transient ischemic attack. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and was occasionally incontinent of bladder and always continent of bowel. Resident #1 required staff assistance for toileting and dressing. Review of Resident Council Minutes dated 08/14/24 revealed the residents at the meeting voiced concerns it took a while for the call lights to be answered. Observation on 09/09/24 at 10:30 A.M. revealed the call light monitor at the nurses' station indicated the call light for Resident #1's room had been on for 44 minutes. On 09/09/24 at 10:30 A.M. an interview with Licensed Practical Nurse (LPN) #296 verified the call light for Resident #1's room had been on for 44 minutes. On 09/09/24 at 10:45 A.M. an interview with Resident #1 revealed she had her call light on because she needed to go to the bathroom and wanted to get up and dressed for therapy. She stated she was supposed to have speech therapy at 9:00 A.M. so she turned her call light on at around 8:00 A.M. She stated the nursing assistant (did not know her name) came in and told her she would be right back but she never came back. She stated at 9:50 A.M. she put her call light on again and it had been on ever since. She stated she should just mess the bed but she does not want to do that. She stated sometime it takes two to three hours to get her call light answered in the morning. On 09/09/24 at 10:50 A.M. an interview with LPN #296 revealed the staff had not been into Resident #1 room yet but they were going into her room after they finished up in the room they were in at that time. On 09/09/24 at 10:58 A.M. the nursing assistant went into take care of Resident #1. On 09/10/24 at 8:30 A.M. an interview with Resident # 92 revealed it could take hours to get a call light answered when she needs help. She stated she has had to sit in her own stool for hours while waiting for assistance and sometimes the staff come in and tell her they will come back to help but they do not. On 09/10/24 at 3:45 P.M. an interview with Resident #106 revealed the call lights have gotten better since she said something in the Resident Council meeting but the problem was that the staff come into your room and tell you they would be back and they never come back then you have to turn the call light on again. On 09/10/24 at 2:55 P.M. an interview with the Director of Nursing (DON) revealed Resident #1 had complained to the staff about her call light being on for so long yesterday and the staff was educated and she requested to be moved to a more visible room and that move was done today. Review of the facility policy titled,Answering the Call Light, dated 02/23 revealed the purpose was to respond to the resident's requests and needs. This deficiency represents noncompliance investigated under Complaint Number OH00157222 and OH00157221.

Based on review of the resident council meeting minutes, resident and staff interviews, the facility failed to provide the group with responses, action regarding their concerns of call light response times. This affected seven (#22, #24, #30, #47, #48, #52 and #70) of seven residents who regularly attend council meetings. The facility census was 97. Findings include: Review of the resident council meeting minutes was completed with the Activities Director (AD) #1 on 03/06/24 at 2:11 P.M. AD #1 identified she takes the notes for the resident council meetings and documents the concerns resident have. AD #1 identified she started at the facility in October 2023 and is new to the position. The interview confirmed the council did not conduct a meeting in December 2023 due to a COVID outbreak. The minutes identified concerns for call light response times in January and February 2024. The interview identified she has no evidence the resident concerns were shared with anyone and follow up completed. The interview confirmed she also has no evidence the Council President or Administrator signed the minutes following the January or February meeting, as that section on the minutes is blank. Interview with Resident Council President #22 was completed on 03/06/24 at 3:10 P.M. The president confirmed she has not been provided with the completed resident council minutes to review and sign since the new Activities Director started. The interview confirmed there has been no follow up regarding the residents' concerns for call light response times. The interview confirmed that all seven residents had complaints regarding the call light response times during the past two meetings. This deficiency represents non-compliance investigated under Complaint Number OH00151270.

Based on policy review, staff interview, and record review the facility facility failed to transcribe and implement physician ordered laboratory testing for Resident #90. This affected one (Resident #90) of three residents reviewed for laboratory services. The facility census was 88. Findings include: Closed medical record review for Resident #90 revealed an admitted [DATE]. Diagnoses included osteomyelitis (bone infection) of the right foot and ankle status post surgical debridement and malnutrition. Resident #90 was transferred to the hospital on 09/18/23. Review of Resident #90's physician orders, dated 09/08/23, revealed an order for Vancomycin (antibiotic) one gram daily intravenously and Zosyn (antibiotic) 3.375 grams three times daily intravenously to treat osteomyelitis. Review of Resident #90's hand-written physician's orders, dated 09/11/23, revealed laboratory testing to include a complete blood count (CBC), a basic metabolic panel (BMP), a C-Reactive Protein (CRP) level, and a Vancomycin trough (a level for monitoring therapeutic level of the medication in the bloodstream) was to be drawn on 09/13/23. Review of Resident #90's medical record revealed no evidence of the facility nursing staff having transcribed or implemented the physician-ordered laboratory testing during Resident #90's stay at the facility. Interview on 10/04/23 at 11:33 A.M. with the Director of Nursing (DON) verified there was no evidence of Resident #90's physician-ordered laboratory testing having been completed while a resident of the facility. The DON stated the orders must have been missed as they were never put into the electronic medical record, which was integrated with the laboratory provider's system. Review of the policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated 12/27/22, revealed the facility must provide laboratory services or have a contractual agreement with an outside company who can meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. The provider will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests, the laboratory, diagnostic or radiology provider or other testing source will report test results to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00146986. This is an example of continued non-compliance from the survey dated 09/26/23.

Based on observations, medical record review, resident interview, family interview and staff interviews, the facility failed to ensure a resident was provided with assistance of removing facial hair. This affected one (#64) of three residents reviewed for assistance with activities of daily living. The facility census was 93. Findings include: Review of Resident #64's medical record revealed an admission on 01/25/21, with medical diagnoses including: chronic lymphedema, Alzheimer's disease, history of Covid-19 virus and benign prostatic hypertrophy (BPH) with indwelling urinary catheter. The most recent facility quarterly minimum data set assessment (MDS) dated [DATE] identified the resident had moderately impaired cognition. The assessment identified Resident #64 required one-person physical assistance with Activities of Daily Living (ADL's). Review of a physician order dated 09/09/23 revealed an order for Resident not to shave himself. Observation on 09/25/23 at 8:02 A.M., revealed Resident #64 was in bed and was observed with a large amount of facial hair, that appeared to be growing a beard and mustache. Interview with Resident #64, at this time, revealed he does not want to be growing a beard or mustache and stated, it's way too long. Observation on 09/25/23 at 10:02 A.M., with State tested Nurse Assistant (STNA) #104 identified Resident #64 can shave himself using an electric razor. STNA #104 verified the resident has not been shaved in a very long time. Interview on 09/25/23 at 12:23 P.M., with Resident #64's son revealed Resident #64 likes to be clean shaven every day. Resident #64's son stated he does not feel the resident is able to safely shave himself any longer and identified staff need to shave him. Observation and interview on 09/25/23 at 12:50 P.M., with the Director of Nursing (DON) verified Resident #64 has a large amount of facial hair at this time and needs shaved. The DON stated it does appear he has not been shaved in a long period of time and the staff should be shaving the resident and not himself. This deficiency represents non-compliance investigated under Complaint Number OH00146181.

Based on medical record reviews, urinary drainage bag instructions, policy review, resident interview, family interview and staff interviews, the facility failed to obtain a urine specimen from urinary catheter and failed to ensure staff was knowledgeable of the procedure. This affected one (#55) of three residents reviewed with urinary catheters. The facility identified nine current residents utilizing urinary catheters. The facility census was 93. Findings include: 1. Review of Resident #55's medical record identified admission to the facility occurred on 10/07/22, with diagnoses including: stroke, diabetes, and congestive heart failure. Resident #55 was noted in the medical record to have an indwelling urinary catheter. The progress notes identified on 09/22/23 a urine sample was obtained to check for infection. According to the records identified on 09/24/23, the laboratory identified the sample was contaminated and a new sample needed to be recollected. Review of a physician order dated 09/24/23, revealed to recollect Urine for Urinalysis, culture and sensitivity (UA C&S). Interview on 09/25/23 at 8:23 A.M., with Resident #55 and two of Resident #55's family members revealed a few days ago the facility obtained a urine sample, and they were told they had to do it again because it was contaminated. Resident #55 confirmed she is waiting on the new sample results to come back and has lots of pressure in her bladder area. Interview on 09/25/23 at 10:02 A.M., with Licensed Practical Nurse (LPN #101) revealed when asked the process for obtaining a urine sample, from a resident with an indwelling urinary catheter. LPN #101 identified she drains the urine from the catheter into the drainage bag, places a new bag and obtains the urine sample, by draining urine from the bottom of the new bag. Interview on 09/25/23 at 10:11 A.M., with LPN #102 revealed when asked to walk through the process of obtaining a urine sample from a resident with an indwelling urinary catheter. LPN #102 identified she would take the catheter apart from the drainage bag and obtain the urine through the catheter. Interview on 09/25/23 at 10:14 A.M., with LPN #105 revealed when was asked to walk through the process of obtaining a urine sample from a resident with an indwelling urinary catheter. LPN #105 identified she would disconnect the tubing from the catheter, clean with alcohol and get the sample from the catheter tip. Review of the policy titled Cultures, Specimen Collection, dated July 2023, revealed the section for urine culture from indwelling catheter revealed to: a. Validate the physician order for the culture. b. Approximately 30 minutes prior to collection of the specimen, clamp the collection tube to allow urine to accumulate. c. Put on gloves. d. Wipe the sampling port with alcohol. e. Connect a needle into the sampling port at 90-degree angle. f. Insert a needle into the sampling port. g. Aspirate the specimen into the syringe h. Transfer the specimen to a sterile container. I. Unclamp the drainage tube. Observation of the facility package of Urinary Drainage Bags revealed there is a Needless sampling Port. There is additionally a non-return valve, which prevents urine from returning into the tubing. The directions for the use of the Needless sampling are listed directly on the bag. 1. Wash hands 2. Kink Tube 3-4 inches below sample point and wait for urine to collect 3. Clean port with Alcohol Insert syringe with or without needle in to center of port, 4 Aspirate sample 5 Restore urine flow. 6 Clean port Interview on 09/25/23 at 12:50 P.M., with the Director of Nursing (DON) identified she had contacted the facility laboratory to obtain information on how many urine samples in the past three months have been contaminated. The interview identified she was not able to produce this information. The interview confirmed the facility was going to start immediate education of the nursing staff to ensure correct obtaining of urine samples was being completed. This deficiency represents non-compliance investigated under Complaint Number OH00146181.

Based on observations, resident and staff interviews, and facility policy review, the facility failed to ensure residents were able to have visitors at the time of their choosing. This had the potential to affect all 79 residents residing in the facility. The census was 79. Findings include: Observation of the front door of the facility on 05/15/23 at 7:30 A.M. revealed a sign posted that identified visitation hours Monday through Friday were between 8:00 A.M. and 7:00 P.M., and on Saturday and Sunday between 8:00 A.M. and 4:00 P.M. The sign further indicated after hours visits required prior approval. A meeting occurred with the Resident Council on 05/16/23 at 10:30 A.M. and Resident #40 and Resident #65 voiced concerns with the facility's visitation hours. Both residents stated they had visitors come after 4:00 P.M. on the weekends and were not able to visit. Interview with the facility Administrator on 05/16/23 at 2:38 P.M. confirmed the visitation sign posted on the door listed the hours the facility has a receptionist. The Administrator confirmed if visitors come after those posted hours, they have to ring a door bell for staff to let them in. The interview confirmed at this time the sign did not identify that visitation was open and the sign indicated visitors could not visit without prior approval after those hours. Review of the facility's policy for visitation dated 10/10/22 revealed inquires concerning visitation should be directed to the Administrator.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 76 residents who received food from the kitchen. The facility identified three (#17, #21 and #284) residents who received nothing by mouth. The facility census was 79. Findings include: Observation during the initial tour of the kitchen on 05/15/23 from 8:02 A.M. through 8:15 A.M. revealed the ceiling and wall were peeling in the dry storage area, the exhaust fan above the dish machine had grease and dust covered on the louvers on the exhaust fan, and the tabletop mixer had dried food on the top where the attachments are inserted and on the bowl holder. Observation in the walk-in refrigerator revealed precooked French toast outside of its original container and sausage patties with no label or date on it. Observation of the reach-in refrigerator revealed standing water inside the refrigerator and there was dried food on the interior walls. Interview with Dietary Manager #298 verified the findings at time of observation of 05/15/23 between 8:02 A.M. and 8:15 A.M. Review of the facility policy titled, Food Storage, dated May 2018, revealed food is stored, prepared, and transported to prevent contamination and all foods should be labeled and dated.

Based on observation, medical records review, resident and staff interview, and facility policy review, the facility failed to ensure residents were not administered antibiotics without an appropriate indication for use or a stop date per facility policy. This affected three (#17, #18 and #31) of seven sampled residents reviewed for antibiotic use. The facility identified 16 residents were currently receiving antibiotics. The facility census was 79. Findings include: 1. Review of Resident #18's medical record revealed an admitted to the facility occurred on 06/15/22 with medical diagnoses including chronic kidney disease, urinary tract infection, anxiety, and chronic respiratory failure. Further review of the medical record revealed Resident #18 was in the hospital from 04/14/23 through 04/19/23 with urosepsis related to an indwelling Foley catheter. The hospital discharge orders included removal of the urinary catheter. Review of the physician orders for Resident #18 revealed an order written by Certified Nurse Practitioner (CNP) #276 dated 04/22/23 for Resident #18 to receive the antibiotic Macrobid 50 milligrams (mg) by mouth daily for recurrent urinary tract infections. The medication order did not have a stop date and continued to be administered daily as of 05/16/23. Interview with CNP #276 on 05/17/23 at 11:04 A.M. confirmed Resident #18's urinary catheter was removed while she was in the hospital on 04/19/23. CNP #276 stated the hospital notes identified the urosepesis was believed to be caused by the catheter. The interview additionally confirmed Resident #18's antibiotic had no current stop date and Resident #18's previous urinary tract infection occurred on 09/17/22 at which time she also had a urinary catheter in place. 2. Review of Resident #31's medical record revealed admission to the facility occurred on 04/01/21 with medical diagnoses including diabetes, congestive heart failure, major depression, and stroke. Review of Resident #31's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and walked with supervision. The assessment identified Resident #31 had no ulcers. Resident #31 received hospice services since her admission. Review of Resident #31's physician orders revealed on 07/22/21 an order for the antibiotic Cephalexin 500 mg by mouth to give daily for prophylaxis for recurrent cellulitis. Review of Resident #31's medication administration records revealed as of 05/17/23 Resident #31 continued to receive the antibiotic daily. The medication administration records revealed no evidence of any attempt to reduce the dose or stop the antibiotic. Interview on 05/16/23 at 12:50 P.M. with Resident #31 stated she had no idea why she received a daily antibiotic. Review of Resident #31's pharmacist medication reviews and recommendations completed on 06/28/22 and 03/27/23 revealed a pharmacist requested a stop date for Resident #31's antibiotic. Further review of the pharmacist medication reviews revealed CNP #276 disagreed with the recommendation with rationale that Resident #31 was a hospice resident and received end of life care. Interview with CNP #276 on 05/17/23 at 11:22 A.M. confirmed there were no attempts to stop Resident #31's antibiotic since it started on 07/22/21. 44454 3. Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses included urinary tract infection, type II diabetes mellitus, heart failure, depression, retention of urine, and dehydration. Review of Resident #17's plan of care, dated 04/28/23, revealed the resident had recurring urinary tract infections. Interventions included administering antibiotics per physician order and reporting signs or symptoms of urinary tract infections. Review of Resident #17's physician orders revealed a current order dated 04/27/23 for the antibiotic Bactrim oral tablet 400-80 mg, 0.5 tablets via percutaneous endoscopic gastrostomy (PEG) tube. The medication order did not have a stop date and was continuing to be administered daily as of 05/16/23. Interview on 05/16/23 at 1:07 P.M. with Infection Preventionist #274 revealed Resident #17 had been on several prophylactic antibiotics due to a previous history of recurring urinary tract infections. Infection Preventionist #274 reported Resident #17's last urinary tract infection was in 2021. Infection Preventionist #274 verified Resident #17's antibiotic ordered by the physician had no stop date. Review of the facility policy titled, Antibiotic Stewardship Program, dated 10/13/21, revealed prescribing clinicians would be encouraged to utilize the antibiotic time out as a component of the organization's Antimicrobial stewardship program. The policy further revealed a specific end date for the antibiotic should be included in the medication order.

Based on review of resident personal needs accounts (PNA), staff interview, and review of a facility policy, the facility failed to notify residents or resident representatives when resident accounts reached $200 less than the Social Security Income (SSI) resource limit. This affected two (#2 and #12) of five resident PNAs reviewed. The facility census was 79. Findings include: 1. Review of Resident #2's PNA account identified the current balance as of 05/17/23 was $3,911.31. The PNA account included monies from the CARES Act of $2,245.09 that was received on 04/09/21. The PNA account records identified no notifications of the need to spend down following 12 months from the receipt of the CARES Act stimulus check. 2. Review of Resident #12's PNA account identified the current balance as of 05/17/23 was $2,792.41. The PNA account included monies from the CARES Act of $1,617.24 that was received on 04/09/21. The PNA account records identified no notifications of the need to spend down following 12 months from the receipt of the cares act stimulus check. Interview with the Activities Director (AD) #271, stated she also managed the resident's PNAs and confirmed there were no notifications to spend down resident PNAs sent to any resident or resident representatives in the past year. AD #271 stated she believed this should be completed at a cooperate level. Review of facility policy related to resident trust accounts, dated December 2019, revealed a section titled, Allowable Balances, which indicated the policy identified resident trust accounts will be audited monthly to determine if any Medicaid resident has a balance nearing the resource limit. The resident or resident representative will be notified if and when the total amount of funds in the account, plus other nonexempt resource of which the facility had knowledge, reach $200 less than the SSI limit for one person or the maximum amount permitted by a receipt of Medicaid under state law. The resident or resident representative will be advised that if the amount in their account, in additional to the value of other nonexempt resources, reaches the SSI resource limit for one person, eligibility for Medicaid or SSI may be lost. Documentation of the notification will be maintained in the respective folder.

Based on medical record review and staff interview, the facility failed to ensure the appropriate documentation was contained in the medical record for residents who were discharged . This affected one (#281) of five residents reviewed for hospitalization . The facility census was 79. Findings include: Review of Resident #281's medical record revealed an admitted [DATE]. The resident was discharged from the facility while in the hospital on 04/27/23. Diagnoses included acute pyelonephritis, type II diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, and heart failure Review of Resident #281's five-day Medicare Minimum Data Set (MDS) 3.0 assessment, dated 04/27/23, revealed the resident was cognitively intact and required extensive assistance of one staff for a majority of the activities of daily living. The resident received oxygen, dialysis, and intravenous medications. Review of Resident #281's respiratory progress notes dated 04/27/23 and timed 8:25 A.M. revealed the resident was seen by respiratory therapy and was not responding. Resident #281 was sent out to the hospital. Review of Resident #281's nursing progress notes dated 04/27/23 and timed 3:21 P.M. revealed Resident #281's husband called and reported Resident #281 was being admitted to the hospital for a urinary tract infection, was non-responsive, and was concerned the resident had tested positive for the narcotic pain medication Fentanyl. The unidentified nurse who received the telephone call assured Resident #281's husband the resident had not received Fentanyl, as Resident #281 had a prescription for Fentanyl upon admission but Resident #281 and her husband reported Resident #281 had a negative experience with Fentanyl, and was subsequently never entered into her orders. Review of Resident #281's nursing progress notes dated 04/27/23 and timed 6:30 P.M. revealed Resident #281 was admitted to the hospital for acute delirium and urinary tract infection. The nurse at the hospital reported the drug screen only indicated a positive versus negative as opposed to giving an actual blood level of Fentanyl. Emergency department physicians indicated they had no explanation for Fentanyl being in the resident's system. Review of Resident #281's nursing progress notes dated 04/28/23 and timed 2:58 P.M. revealed the nurse practitioner spoke with the hospital social worker to discuss positive Fentanyl results. Resident #281 did not receive Fentanyl while in the facility and positive results indicated use within one day. Review of Resident #281's social service progress notes dated 05/01/23 and timed 9:41 A.M. revealed the resident discharged to the hospital on 04/27/23. Review of Resident #281's social service progress notes dated 05/04/23 and timed 10:19 A.M. revealed social services contacted Resident #281's spouse per his request. Resident #281's spouse inquired about why the facility did not accept the resident back after her hospital stay. Rationale regarding declination of readmission was discussed. Resident #281's husband had further nursing questions and would follow up with the nurse practitioner. Resident #281's spouse requested the resident's medical records at this time. Review of Resident #281's paper and electronic medical records revealed no documentation from a physician regarding the resident's discharge. Interview on 05/17/23 at 2:05 P.M. with Social Worker #563 revealed Resident #281 was ultimately discharged due to a controlled substance being found in her system upon admission to the hospital. Interview on 05/17/23 at approximately 4:00 P.M. with the Director of Nursing (DON) verified Resident #281 was discharged from the facility and not accepted back due to Fentanyl being found in her system. The facility had suspicion the resident's husband brought Fentanyl in for the resident and felt the resident was a danger to herself and others. The DON verified there was no physician documentation in the medical record pertaining to this. Review of the facility policy titled, Bed Hold, Transfer, and Discharge Notice, dated September 2018, revealed the facility would provide notice to residents who were transferred or discharged from the facility per applicable federal and state regulations. The policy also stated when a resident was involuntarily discharged , the medical record would contain the basis for transfer or discharge and documentation by a physician when transfer or discharge was necessary for safety reasons.