Every finding on record at Lake Pointe Health Care

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure timely provider notification of critical laboratory (lab) values. This affected three (#53, #68, and #86) of four residents reviewed for laboratory services. The facility census was 85. Findings include: 1. Review of the medical record for Resident #86 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebral infraction (stroke), malnutrition, anxiety and depression. Review of the Minimum Data Set (MDS) assessment, dated 03/17/25, revealed Resident #86 had intact cognition. The assessment indicated the resident was incontinent of bladder. Review of the care plan, dated 03/17/25, revealed Resident #86 was receiving antibiotic therapy. Interventions included administering antibiotic and observing for side effects and signs and symptoms of infection. Review of the lab service final report dated 03/21/25 at 5:49 P.M. revealed the urine culture resulted positive for Enterococcus faecalis, an organism that causes urinary tract infections (UTI). Review of the physician orders revealed on 03/25/25, an order for penicillin v potassium 500 milligram (mg), administered every eight hours to treat UTI (four days after lab results were receiving indicating the resident had a UTI). Review of the Medication Administration Record (MAR) for March 2025 confirmed penicillin v potassium 500 mg was administered from 03/25/25 through 04/02/25 at ordered. 2. Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included Alzheimer, depression, anxiety, and gout. Review of the MDS assessment, dated 02/23/25, revealed Resident #86 had impaired cognition and was dependent on staff for toileting. The assessment indicated the resident was incontinent of bladder. Review of the care plan, dated 02/23/25, revealed Resident #86 had an infection related to a UTI. Interventions included administering an antibiotic and observing for side effects and signs and symptoms of infection. Review of the lab service final report, dated 03/14/25, revealed the urine culture resulted positive for Escherichia coli (E coli), an organism that causes UTIs. Review of the physicians orders revealed on 03/18/25, an order for sulfamethoxazole-trimethoprim (antibiotic) 800 mg-500 mg, administered every eight hours to treat a UTI (ordered four days after the lab results indicated the resident had a UTI). Review of the MAR for March 2025 confirmed sulfamethoxazole-trimethoprim 800 mg-100 mg was administered from 03/18/25 through 03/25/25 as ordered. 3. Review of the medical record for Resident #68 revealed an admitted [DATE]. Diagnoses included acute kidney failure, paraplegia, Cushing's syndrome, cerebral infarction, stroke, and retention of urine. Review of the MDS assessment, dated 02/10/25, revealed Resident #68 had intact cognition and was dependent on staff for toileting. The assessment indicated the resident was incontinent of bladder. Review of the after-visit emergency room (ER) summary, dated 03/11/25, revealed Resident #68 had labs completed, which included urinalysis with reflex to culture (confirms the presence of a UTI). Review of the physicians orders revealed on 03/18/25, an order to administer sulfamethoxazole-trimethoprim 800 mg-100 mg every 12 hours for a UTI for seven days. Review of the MAR for March 2025 confirmed sulfamethoxazole-trimethoprim 800 mg-100 mg was administered from 03/18/25 through 03/24/25 (ordered seven days after labs indicated the resident had a UTI). Interview on 04/09/25 at 11:00 A.M. with the Director of Nursing (DON) verified there was a lapse in time from when the urine cultures were resulted to when the physician ordered antibiotics to treat UTIs for Resident #86, Resident #53, and Resident #68. The DON confirmed Resident #86 and Resident #53's urinalysis results were received on a Friday and were not addressed until the next week. The DON stated the facility had physicians on-call during the weekend to address lab results. The DON stated Resident #68's labs were completed when she went out to the ER and confirmed the facility did not follow-up until the concern was brought to their attention, at which time the Nurse Practitioner (NP) looked up the lab report and ordered the antibiotic to treat Resident #68's UTI. Review of the facility policy titled, Laboratory and Radiological Services Result Reporting, undated, revealed that there are clinical and physiological risk when laboratory, radiology, or other diagnostic services are not performed in a timely manner or the results of these services are not reported and acted upon quickly. Delays may adversely affect a resident's diagnosis, treatment assessment and intervention. Nurses will have a sense of urgency for reporting critical labs and radiological findings to the ordering prescriber and document reporting of such items in the progress notes. This deficiency represents non-compliance investigated under Complaint Number OH0016377.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed the smoking policy and ensured safe resident smoking practices. This affected one (Resident #22) of one resident reviewed for smoking. The facility census was 91 residents. Findings include: Review of the medical record for Resident #22 revealed a readmitted [DATE] with diagnoses including chronic respiratory failure, aphasia, type 2 diabetes mellitus (DM), multiple subsegmental thrombotic pulmonary emboli, heart failure, and history of transient ischemic attack (TIA). Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 07/15/24 revealed the resident had intact cognition. Review of the care plan for Resident #22 dated 07/15/24 revealed the resident had a history of utilizing nicotine. Interventions included if resident utilized nicotine products to complete smoking evaluation, provide safe smoking devices if required, and educate resident and resident representative to designated smoking areas and long-term side effects of extended nicotine use Review of the smoking assessment for Resident #22 dated 10/02/24 completed by the Director of Nursing (DON) revealed the resident used a nicotine patch. Review of the physician's orders for Resident #22 dated January 2025 revealed there were no orders for smoking. Review of the smoking assessment for Resident #22 dated 01/23/25 timed at 9:56 A.M. per the DON revealed the resident required supervision for smoking and was unable to light his own cigarette. Observation on 01/23/25 at 9:47 A.M. of Resident #22's room revealed there was a pack of cigarettes and a lighter on the resident's overbed tray. Interview on 01/23/25 at 9:48 A.M. with Registered Nurse (RN) #231 confirmed there was a pack of cigarettes and a lighter on Resident #22's overbed tray. RN #231 confirmed residents were not permitted to keep smoking supplies in their room. RN #231 reported all smoking supplies were to be kept in a locked and secured place. Interview on 01/23/25 at 9:53 A.M. with the DON confirmed residents were not permitted to have smoking supplies, to include cigarettes and lighter in their rooms. The DON verified smoking supplies were to be kept in secured locked units per the facility smoking policy. Review of facility policy titled Resident Smoking Guidelines undated, revealed the facility would promote resident centered care by providing a safe smoking area for residents. Residents would be assessed by an interdisciplinary team (IDT). Staff would store smoking materials in a secured area when not in use by the residents for both independent and supervised smokers.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain acceptable infection control practices during medication administration to prevent the spread of infection. This affected one resident (Resident #46) of three residents reviewed for medications. The facility census was 91 residents. Findings include: Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including peripheral vascular disease and malignant neoplasm of stomach. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #46 dated 12/28/24 revealed the resident had intact cognition. Review of the physician's orders for Resident #46 dated January 2025 revealed an order for Gabapentin 100 milligram (mg) capsule by mouth. Observation of medication administration for Resident #46 on 01/23/25 at 8:55 A.M. per Licensed Practical Nurse (LPN) revealed the nurse removed the resident's Gabapentin capsule from the packaging and dropped the capsule on the medication cart. LPN #254 picked the capsule up off the medication cart and placed it in a medicine cup. LPN #254 opened the capsule and poured the contents in the same medicine cup and mixed with applesauce. LPN #254 took the medication into Resident #46's room and administered the medications to the resident. Interview on 01/23/24 at 9:11 A.M. with LPN #254 confirmed she administered Resident #46's medication after dropping on the medication cart. Interview on 01/23/25 at 9:12 A.M. with the Director of Nursing (DON) confirmed if a nurse dropped medication onto the medication cart, they were to dispose of it and get a new pill. Review of the facility policy titled Medication Administration undated revealed dropped medications would be discarded. This deficiency represents noncompliance investigated under Complaint OH00161498.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were implemented per physician order. This affected one (#18) of three residents reviewed for falls. The facility census was 87. Findings include: Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses included dementia, history of falling, weakness, hypertension, need for assistance with personal care, muscle weakness, and unsteadiness on the feet. Review of Resident #18's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #18's plan of care dated 03/19/24 revealed the resident was at risk for falls related to impaired mobility and cognition, ataxia, and incontinence. Interventions included the bed in the lowest position, engage bed locks, and providing assistive devices as needed. Review of the nursing progress notes dated 03/25/24 and timed 1:11 P.M. revealed Resident #18 sustained a fall when attempting to transfer from bed and therapy was to evaluate the resident for mobility bars. Review of Resident #18 active physician orders revealed an order dated 03/25/24 for bilateral bed rails for mobility. Review of the fall risk assessment dated [DATE] revealed Resident #18 was at risk for falls. Observation on 11/26/24 at 9:07 A.M. and on 11/26/24 at 3:50 P.M. revealed Resident #18 was lying in bed and there were no bed rails/mobility bars attached to the bed. An interview on 11/26/24 at 11:48 A.M. with Housekeeper #478 verified Resident #18 did not have bed rails on the bed. An interview on 11/26/24 at 12:14 P.M. with Certified Nurse Aide #595 also verified Resident #18 did not have bed rails on their bed and should have had them. Review of the undated facility policy titled, Fall Prevention and Management, revealed the facility would attempt to put an intervention in place that could prevent further falls. This deficiency represents non-compliance investigated under Complaint Number OH00159672.

Based on medical record review, review of an activity calendar, observation, and staff interview, the facility failed to ensure residents were provided with assistive devices per physician orders and the plan of care. This affected one (#18) of three residents reviewed for assistance with eating and drinking. The facility census was 87. Findings include: Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses included dementia, history of falling, weakness, hypertension, need for assistance with personal care, muscle weakness, and unsteadiness on the feet. Review of Resident #18's plan of care dated 03/28/24 revealed the resident had potential for altered nutrition status and/or related problems. Interventions included providing assistance with meals, staff to feed the resident, and a two-handled cup with lid. Review of Resident #18's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #18's active physician orders revealed an order dated 11/17/24 for Resident #18 to receive a two-handled cup with a lid for all liquids. Review of the activity calendar for 11/26/24 identified coffee time was scheduled for 10:00 A.M. Observation on 11/26/24 at 10:56 A.M. revealed Resident #18 was seated in the dining area for the activity. Resident #18 was given a disposable cup of coffee with a lid and did not receive a cup with handles. Observation on 11/26/24 at 11:18 A.M. of Resident #18's lunch meal revealed the resident received one beverage in a two-handled cup with a lid. The resident also received another beverage which was not in a cup with handles or had a lid. An interview on 11/26/24 at 11:25 A.M. with Housekeeper #478 verified Resident #18 received coffee and juice in cups which did not have handles. An interview on 11/27/24 at 8:26 A.M. with Dietitian #834 revealed Resident #18 was to receive a two-handled cup for beverages to facilitate Resident #18's independence with drinking. Review of the activity calendar for 11/27/24 identified coffee social was scheduled for 10:00 A.M. Observation on 11/27/24 at 10:04 A.M. revealed Resident #18 was seated in the dining area for the activity. Resident #18 was given a disposable cup of coffee with a lid and did not receive a cup with handles. An interview on 11/27/24 at 11:34 A.M. with Activities Leader #833 verified Resident #18 received coffee in a disposable cup and did not receive a cup with handles on 11/26/24 or 11/27/24. This deficiency represents non-compliance investigated under Complaint Number OH00159672.

Based on interview, record review, and facility policy review, the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #33. This affected one resident of one (Resident #33) reviewed for dialysis. The facility census was 82. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included but were not limited to encephalopathy, stage five hypertensive chronic kidney disease, dependent on renal dialysis, Alzheimer's dementia, type II diabetes mellitus, legal blindness and unspecified protein-calorie malnutrition. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #33 revealed she was on dialysis treatments. Review of the care plan for Resident #33, last reviewed on 09/05/24, revealed she was receiving dialysis and interventions included communication with dialysis center regarding medication, vital signs, weights, any restrictions, diet order, nutritional and fluid needs, lab results, and who to notify with concerns. Evaluation following dialysis treatment and report abnormal findings to the medical provider, nephrologist/dialysis center, resident and resident representative. Review of physician's order dated 09/07/24 for Resident #33 revealed an order to check dialysis site for signs and symptoms of infection and an order dated 09/10/24 for dialysis treatments on Tuesdays, Thursdays, and Saturdays. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for October 2024 for Resident #33 revealed no monitoring of dialysis site. Review of the vitals documentation for Resident #33 revealed last documented occurrence of blood pressure monitoring was on 09/06/24. Review of the nursing progress note dated 10/22/24 timed at 4:26 P.M. for Resident #33 revealed she returned from dialysis with her site bleeding through the gauze and clothing. Nurse spoke with dialysis center, reinforced the dressing obtained vitals and continued to monitor. Review of nursing progress notes from 07/01/24 through 10/22/24 did not reveal any additional documentation on resident status prior to or post dialysis treatments. Review of the pre and post dialysis assessments for Resident #33 in the electronic medical record revealed a pre/post dialysis evaluation for 07/07/24, 07/11/24, 08/31/24 and 09/28/24. No further evidence was provided for additional dates for pre-dialysis and post dialysis assessments as required. Review of the paper medical record revealed last available Dialysis Communication Form was from 06/18/24. There was no evidence of additional documentation or monitoring or Resident #33's status. Interview on 10/24/24 at 11:03 A.M. with Licensed Practical Nurse (LPN) #939 confirmed it was the most recent dialysis communication form in the medical record. Interview on 10/23/24 at 2:57 P.M. with LPN #812 confirmed the facility is to print and send pre-dialysis assessment paperwork located in the electronic medical record with Resident #33 when she goes to dialysis. Upon return, the nurse is to complete the post dialysis assessment form. Interview on 10/23/24 at 3:48 P.M. with the Director of Nursing (DON) confirmed the facility provides morning care and completes a pre-dialysis assessment prior to going to dialysis as well as completed a post dialysis assessment in the electronic medical record. The DON confirmed the pre and post dialysis assessments were not being completed as required. Review of the undated facility policy called, Hemodialysis Care and Monitoring, revealed the facility will provide resident centered care that meets the psychosocial, physical and emotional needs and concern of the residents. Pre-dialysis evaluation will be completed within four hours of transportation to be sent to dialysis and include accurate weight, blood pressure, pulse, respirations and temperature, and medication information. Post dialysis evaluation information will be completed by the nurse upon return from dialysis and uploaded into the electronic health record or placed in the hard medical record.

THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THE ON-SITE INVESTIGATION. Based on observation, medical record review, staff interviews, review of a police report, review of a facility investigation, review of written statements, and review of facility corrective action documents, the facility failed to provide adequate supervision to prevent Resident #50, who had moderately impaired cognition, a diagnosis of vascular dementia with behavioral disturbances, and a previous incident of attempting to exit the facility, from leaving the facility unsupervised. This resulted in Immediate Jeopardy on 07/14/24 between approximately 3:00 P.M. and 5:44 P.M. when Resident #50 was able to presumably enter a locked elevator on the second floor with a group of community members and exit the locked front entrance with the group without staff knowledge and exit the facility unsupervised. The potential for serious life-threatening harm and/or injury occurred when the resident was missing for up to two hours and 45 minutes, ultimately being found by law enforcement at a local high school approximately three miles from the facility. This affected one (#50) of three residents reviewed for accident hazards/elopement. The facility identified four additional residents (#18, #63, #66, and #67) who were assessed at risk for elopement. The facility census was 91. On 09/05/24 at 10:06 A.M., the Administrator, the Director of Nursing (DON), and Corporate Clinical Support Nurse (CCSN) #600 were notified Immediate Jeopardy began on 07/14/24 at approximately 3:00 P.M. when staff last observed Resident #50 in the facility. Between 3:00 P.M. and 5:44 P.M., the resident was able to exit the facility unsupervised, after entering a locked elevator on the second floor with a group of community members visiting the facility, taking the elevator to the first floor, and exiting the facility with the group through the locked front entrance. Facility staff were unaware Resident #50 was missing until approximately 3:00 P.M. when the facility initiated an elopement protocol, and the resident was found by law enforcement at approximately 5:15 P.M. at a local high school located three miles from the facility and near heavily traveled roads with speeds up to 50 miles per hour. The resident was returned to the facility on [DATE] at 5:44 P.M. and assessed with no injuries or change in condition. The Immediate Jeopardy was removed and corrected on 07/15/24 when the facility implemented the following corrective actions: On 07/14/24 at approximately 3:00 P.M., Resident #50 was not able to be located in the facility and an elopement protocol was initiated by Licensed Practical Nurse (LPN) #130. All other facility residents were accounted for during a head count completed at 3:02 P.M. Local law enforcement was notified to assist in the search for the resident who ultimately located Resident #50 at a local high school at 5:15 P.M. approximately three miles from the facility. Interview with Resident #50 revealed a female let him out of the front door and stated he did not know where he was going. On 07/14/24, the Administrator and Physician #700 were notified of Resident #50's elopement from the facility. On 07/14/24 at 5:44 P.M., Resident #50 was returned to the facility and at 5:45 P.M. was assessed by LPN #130 with no injuries or change in condition. On 07/14/24 at approximately 5:45 P.M., Resident #50 was place on one-on-one direct care of staff pending an investigation. Resident #50 remained on one-on-one care with staff until discharge from the facility on 07/25/24. On 07/14/24, Resident #50 was re-assessed for elopement and unsafe wandering risk by LPN #130 and was placed at risk for elopement. Resident #50's care plan was updated on 07/14/24 to include the resident's elopement risk. On 07/14/24 at 5:45 P.M., the DON began education with all staff members regarding the facility's elopement management policy. All staff members completed education by the DON on 07/15/24 at 11:00 A.M. On 07/14/24 at 6:06 P.M., LPN #130 notified Resident #50's responsible party to provide information regarding the resident's elopement from the facility. On 07/14/24 at 7:00 P.M., Registered Nurse (RN) #210 obtained statements from staff working at the time Resident #50 eloped from the facility. On 07/14/24 at 8:00 P.M., wandering observation tools were completed on all residents by LPN #100, LPN #130, and RN #210, and overseen by the DON, to identify any other residents at risk for elopement. All facility elopement books were reviewed to ensure accuracy and all resident care plans were reviewed and revised as necessary to ensure all interventions were current and in place. On 07/15/24 at 9:10 A.M., Unit Manager LPN #150 completed an elopement drill with no concerns identified. On 07/17/24, 07/24/24, 07/30/24, and 08/07/24, Assistant Director of Nursing (ADON) #535, in collaboration with the DON, completed elopement drills with all staff following protocols and no concerns noted. Results of the elopement drills were reviewed in Quality Assurance and Performance Improvement (QAPI) meetings. The facility QAPI committee held meetings on 07/31/24 and 08/29/24, with Physician #700 in attendance, to discuss results of the elopement drills with no further concerns. Review of two (#13 and #18) additional resident medical records reviewed for elopement risk revealed no concerns. Review of the facility incident log between 06/20/24 to current revealed the facility had no other residents elope from the facility since Resident #50's elopement on 07/14/24. Observation on 09/05/24 at 12:05 P.M., revealed the locking mechanism to enter the elevator on the second floor was working appropriately. Observation on 09/05/24 between 12:10 P.M. and 12:15 P.M. with Receptionist #500 verified the locking mechanisms on the first-floor front exit door and elevator were working appropriately. Interviews on 09/09/24 between 9:13 A.M. and 2:10 P.M. with Receptionist #500, LPN #100, LPN 120, State tested Nurse Aide (STNA) #320, and STNA #370 revealed all staff were knowledgeable of the facility elopement policy and verified they were educated on the facility's elopement policy and protocol including what to do when a resident was missing. Findings included: Review of Resident #50's medical record revealed an admitted [DATE]. Diagnoses included vascular dementia with behavioral disturbances, cerebral infarction, and homelessness. Review of Resident #50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with moderately impaired cognitive function and was independent with ambulating and all activities of daily living (ADLs). The resident did not require an assistive device for walking. Review of Resident #50's Nursing Assessment Evaluation dated 07/11/24 revealed the resident was admitted to the facility on [DATE] at 9:00 A.M. for a change in mental status. The resident was assessed as alert and oriented to three spheres (person, place, and time) with no exit-seeking behaviors or wandering since admission, and it was unknown if the resident had a history of exit-seeking. Resident #50 required no assistance with transfers and the resident was assessed as not at risk for elopement. Review of Resident #50's care plan dated 07/12/24 revealed the resident was independent for ADLs and ambulation. Review of Resident #50's nursing progress note dated 07/13/24 at 11:22 A.M. revealed the resident exhibited agitation and attempted to leave the facility. The staff were unable to redirect the resident, so a one-time dose of an antipsychotic medication (Seroquel) was ordered to calm him. A urinalysis and blood work were also ordered by the physician. Further review of Resident #50's care plan and physician orders revealed no immediate interventions were put in place to address Resident #50's exit-seeking behaviors. Additionally, there was no documentation of a repeat assessment completed to determine the resident's elopement risk related to the incident on 07/13/24. Review of Resident #50's nursing progress note dated 07/14/24 revealed the resident was unable to be located for medication administration and was not found in the immediate area. An elopement alert was initiated, and contacts were notified including the medical director and local police department. Resident #50 was found by the police and returned to the facility at 5:45 P.M. A head-to-toe assessment of the resident found no acute changes or injuries. The resident was immediately placed on one-to-one observation and all parties were notified of Resident #50's return to the facility. Review of a police incident report dated 07/14/24 at 5:15:37 P.M. revealed an incident was initiated for a suspicious condition related to Resident #50. Further review revealed an entry was created on 07/14/24 at 5:43:30 P.M. that an officer was flagged down by an unnamed male at 5:15 P.M. On 07/14/24 at 5:44:15 P.M., the officer took Resident #50 back to the facility and the resident was released to the staff. Review of the facility incident report dated 07/14/24 revealed Resident #50 was last seen in the common area at 3:00 P.M. and the resident was wearing a black colored t-shirt and jeans. The weather was warm and cloudy. Resident #50 was interviewed on 07/14/24 at 6:08 P.M. and he indicated a lady let him out of the front door and he walked through to the outside. Resident #50 indicated he did not know where he was going. Resident #50 was last seen on 07/14/24 at 3:00 P.M. downstairs by the front door and was noted as missing at 5:00 P.M. when he could not be located for medication administration. The elopement process was initiated, with the resident located and returned to the facility without injuries or pain. The resident was placed on one-to-one observation pending results of the investigation and alternate placement. Review of a written statement dated 07/14/24 by LPN #130 revealed Resident #50 was last observed by her on 07/14/24 at 3:00 P.M. and was wearing a black shirt and jeans. There was an elopement search initiated, no leave of absence (LOA) for Resident #50 was found, and contacts were made regarding Resident #50's whereabouts. Further review of the written statement revealed Resident #50 returned to the facility on [DATE] at 5:45 P.M. with a head-to-toe assessment completed with no pain or discomfort voiced by the resident. The written statement also noted the temperature was 80 degrees Fahrenheit (F) and it was cloudy and humid. Interview with the DON on 09/04/24 at 8:11 A.M. revealed Resident #50 attempted to elope the facility on 07/13/24 and a one-time dose of an antipsychotic medication was administered per physician orders. The DON stated the medication helped to calm the resident. On 07/14/24, Resident #50 had on street clothes, got on the elevator, and walked out of the facility with a large group of visitors. At approximately 3:00 P.M., the resident was unable to be located for medication administration and an elopement alert was initiated. The resident was found by the local police department at the local high school and returned to the facility at 5:45 P.M. The DON stated Resident #50 was assessed with no injuries upon return to the facility. Resident #50 was immediately put on one-on-one care and remained under on-on-one care until he was discharged to a memory care facility on 07/25/24. Interview with Receptionist #500 on 09/04/24 at 9:13 A.M. revealed she was working on 07/14/24 and felt Resident #50 left with a large church group. Receptionist #500 verified that staff must put in a code to get down the elevator from the second floor where Resident #50 resided, and an additional code had to be put in to exit the front doors. Receptionist #50 verified she never saw Resident #50 in the group of visitors that left on 07/14/24. Observation of the facility environment on 09/05/24 between 12:00 P.M. and 12:15 P.M. revealed all residents in the facility resided on the second floor and the elevator and stairway both were locked and required a code to exit the unit. Further observation revealed, once downstairs, the front doors were locked, and a coded keypad was available, or the receptionist had a lock release button at the desk to open the doors. Observation of all keypads revealed all locking and releasing mechanisms were in good working order. Observation of the exterior environment on 09/05/25 between 12:15 P.M. and 12:35 P.M. revealed the facility was located along a heavily traveled four-lane road with maximum speed limits of 50 miles per hour. There was a Great Lake ([NAME]) located just north of the facility approximately one-quarter of a mile walking distance from the facility. Further observation of the exterior environment revealed the driving distance from the facility to the local high school where Resident #50 was located on 07/14/24 was three miles. Review of a website for historical weather conditions at, https://www.wunderground.com/history/daily/us/oh/Lorain/KCLE/date/2024-7-14 revealed the outside temperature was 86 degrees F on 07/14/24 at 2:51 P.M., reached a high of 88 degrees F at 4:51 P.M., and returned to 86 degrees F at 5:51 P.M. The humidity level ranges between 53 percent (%) and 58% and it was cloudy to mostly cloud during that timeframe. Review of the undated facility policy titled, Elopement Management, revealed failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe area and are unaccounted for was considered elopement. Following location of the involved resident the facility leadership will review preventions systems to identify performance opportunities. This deficiency represents an incidental finding discovered during investigation of Master Complaint OH00157563, Complaint Number OH00156113, and Complaint Number OH00156104.

Based on medical record review, review of controlled drug administration records, staff interview, and review of facility policy, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected three residents (Residents #07, #17, and #92) of three residents reviewed for controlled medications. The facility census was 91. Findings include: 1. Review of the medical record for Resident #07 revealed an admitted [DATE]. Diagnoses included paraplegia, chronic pain, muscle weakness, and morbid obesity. Review of Resident #07's plan of care, revised 10/18/23, revealed Resident #07 to be at risk for pain related to diagnoses of chronic pain, low back pain, discitis and polyneuropathy. Interventions included to provide non-pharmacological interventions, follow physician's orders for complaint of pain, and observe for pain every shift. Additionally, the plan of care stated to provide medications per orders, monitor for signs and symptoms of side effects and evaluate the effectiveness of the medication. Review of Resident #07's physician's orders revealed an order dated 12/01/23 for oxycodone (an opioid analgesic medication used for pain relief) five milligrams (mg) give two tablets by mouth every six hours as needed (PRN) for pain. Reconciliation of Resident #07's Controlled Drug Administration Record (CDAR) and Medication Administration Record (MAR) for December 2023 revealed the following discrepancy related to oxycodone: 12/10/23 - four doses signed out on the CDAR, three doses recorded on the MAR 2. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included fractures of the left tibia, right fibula, left humerus, and the lumbar vertebrae, an injury to the external genitals, muscle weakness, and depression. Review of Resident #17's plan of care, revised 10/16/23, revealed Resident #17 was at risk for pain related to multiple fractures. Interventions included to provide non-pharmacological interventions, follow physician's orders for complaint of pain, and observe for pain every shift. Additionally, the plan of care stated to provide medications per orders, monitor for signs and symptoms of side effects and evaluate the effectiveness of the medication. Review of Resident #17's physician's orders revealed an order dated 10/19/23 for oxycodone five mg, give one tablet by mouth every six hours PRN for pain. Reconciliation of Resident #17's MAR and CDAR for December 2023 revealed the following discrepancies related to oxycodone: 12/01/23 - two doses signed out on the CDAR, zero doses recorded on the MAR 12/02/23 - two doses signed out on the CDAR, one dose recorded on the MAR 12/03/23 - two doses signed out on the CDAR, zero doses recorded on the MAR 12/04/23 - two doses signed out on the CDAR, one dose recorded on the MAR 12/06/23 - two doses signed out on the CDAR, one dose recorded on the MAR 12/07/23 - two doses signed out on the CDAR, one dose recorded on the MAR 12/08/23 - two doses signed out on the CDAR, one dose recorded on the MAR 12/09/23 - three doses signed out on the CDAR, one dose recorded on the MAR 12/11/23 - one dose signed out on the CDAR, zero doses recorded on the MAR 3. Review of the medical record for Resident #92 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, chronic respiratory failure, and alcohol abuse with withdrawal. Review of Resident #92's physician's orders revealed an order dated 12/08/23 for lorazepam (a benzodiazepine medication used to reduce anxiety) one mg, give one tablet by mouth every six hours PRN for anxiety or alcohol withdrawal, with additional instructions to hold the medication if Resident #92 was drowsy. Reconciliation of Resident #92's CDAR and MAR for December 2023 revealed the following discrepancies related to lorazepam: 12/08/23 - one dose signed out on the CDAR, zero doses recorded on the MAR 12/10/23 - one dose signed out on the CDAR, zero doses recorded on the MAR Interview on 12/11/23 at 11:10 A.M. with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #300 verified the CDAR and the MAR did not match for Residents #07, #17 and #92. The DON and RDCS #300 verified nurses should document on the paper CDAR and the MAR, as both records should match. Review of the policy titled Medication Administration, undated, revealed the MAR to be the legal documentation for medication administration. The policy identified that medications will be charted when given and narcotics will be signed out when given. Documentation of medications will follow accepted standards of nursing practice. This deficiency represents non-compliance investigated under Complaint Number OH00148404.

Based on observation, medical record review, review of a meal ticket, and staff interview, the facility failed to ensure residents were served food and drinks according to the menu and meal tickets. This effect one (#4) of four residents reviewed for provision of food and drinks. The facility census was 98. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses that included hemiplegia, major depressive disorder, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed Resident #4 was severely cognitively impaired and required extensive assistance of two staff persons for completion of her activities of daily living (ADLs). Interview with Licensed Practical Nurse (LPN) #150 on 11/03/23 at 10:17 A.M. stated residents having food and drink items missing from their trays or food not served according to the menu happened multiple times a week. Interview with LPN #100 on 11/03/23 at 12:12 P.M. verified Resident #4 was missing coffee on her meal tray, and indicated it happened all the time. Observation on 11/03/23 at 12:14 P.M. confirmed there was no coffee on Resident #4's lunch tray. Review of Resident #4's lunch meal tray ticket, during the observation on 11/03/23 at 12:14 P.M., revealed Resident #4 was to receive six ounces of hot coffee with every meal. This deficiency represents non compliance investigated under Complaint Number OH00146803.

Based on interview, record review, review of the facility concern form, and the facility abuse, neglect and misappropriation policy and procedure, the facility failed conduct a thorough investigation of an allegation of misappropriation. This affected one resident (Resident #85) of three reviewed for misappropriation. The facility census was 84. Findings Include: Review of Resident #85's medical record revealed an admitted [DATE] with diagnoses including dementia, hypertension, anxiety, and dysphagia (difficulty swallowing). Resident #85 was discharged from the facility on 06/08/23. Review of the profile sheet in Resident #85's medical record revealed Resident #85 was his own self representative and did not have a power of attorney for healthcare of finances. Review of the facility's July 2023 concern log revealed on 07/24/23 Resident #85's niece filed a concern for missing guitar and television. The notes related to the concerns indicated unable to locate the television and a family member took the guitar. Review of the concern form dated 07/24/23 revealed Resident #85 passed away on 06/08/23. The guitar was not with Resident #85's personal belongings. Under follow-up actions the response indicated the activity staff reported a family member took the guitar. Interview on 08/08/23 at 10:12 A.M. with Licensed Social Worker (LSW) #200 revealed she was not aware of the missing guitar and television until the concern was reported. Through her investigation it was determined a family member took the guitar. LSW #200 stated there was a television in storage but the niece indicated it was not Resident #85's. LSW #200 said the niece was not concerned about the television. LSW #200 did not have documentation regarding her investigation including staff statements, resident statements, or statements from any other party that may have had knowledge of the missing items. Review of the facility's undated policy titled Ohio Abuse, Neglect and Misappropriation. revealed in the event a situation was identified as abuse, neglect or misappropriation, an investigation by the executive leadership would immediately follow up. Statements would be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witness. This deficiency represents non-compliance investigated under Complaint Number OH00145012.

Based on record review and staff interview, the facility failed to ensure an allegation of misappropriation was reported to the state agency as required. This affected one resident (Resident #85) of three reviewed for misappropriation. The facility census was 84. Findings include: Review of Resident #85's medical record revealed an admitted [DATE] with diagnoses including dementia, hypertension, anxiety, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had memory impairment and required extensive assistance with bed mobility, transfers, and hygiene. Resident #85 was discharged from the facility on 06/08/23. Review of the facility's July 2023 concern log revealed on 07/24/23 Resident #85's niece filed a concern for missing guitar and television. The notes related to the concerns indicated unable to locate the television and a family member took the guitar. Review of the concern form dated 07/24/23 revealed Resident #85 passed away on 06/08/23. The guitar was not with Resident #85's personal belongings. Under follow-up actions the response indicated the activity staff reported a family member took the guitar. Interview on 08/08/23 at 10:12 A.M. with Licensed Social Worker (LSW) #200 revealed she was not aware of the missing guitar and television until the concern was reported. Through her investigation it was determined a family member took the guitar. LSW #200 stated there was a television in storage but the niece indicated it was not Resident #85's. LSW #200 said the niece was not concerned about the television. LSW #200 did not report the allegation of misappropriation to the State agency. Review of the facility's undated policy titled Ohio Abuse, Neglect and Misappropriation revealed for alleged violations of misappropriation of resident property the facility must report the allegation no later than 24 hours. This deficiency represents non-compliance investigated under Complaint Number OH00145012.

Based on medical record review, staff interview, and policy review, the facility failed to notify the resident representative of changes in the resident's condition. This affected one (#89) of three residents reviewed for notification of changes in condition. The facility census was 86. Findings include Review of the medical record for Resident #89 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cerebral infarction, end stage renal disease, diabetes mellitus type two, atrial fibrillation, hypertension, and a pulmonary embolism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 had severe cognitive impairment. Review of two medication administration notes dated 05/05/23 at 8:03 P.M. and 8:04 P.M. noted the resident was in the emergency department. There was no documentation when Resident #89 was sent to the emergency department. Also, there was no documentation the resident's family was notified Resident #89 was sent to the emergency department. Review of a nursing note dated 05/07/23 at 4:04 A.M. revealed Resident #89's corpak (an enteral feeding tube device) could not be flushed and was clogged. Resident #89 was ordered to be sent to the emergency room via non-emergency transport. There was no documentation the family was notified Resident #89 was sent to the emergency room until the resident's daughter came to the facility to visit the resident on 05/07/23 at 12:21 P.M. Review of a nursing note dated 05/15/23 at 3:47 P.M. revealed a new order was received to increase the resident's insulin Lantus to 30 units subcutaneously in the morning. There was no documentation the family was notified. Review of a nursing note dated 05/15/23 at 6:39 P.M. revealed the resident's blood sugar was 586. Resident #89 was ordered a one-time dose of 10 units of the insulin Humulin R. There was no documentation the resident's family was notified. Interview on 06/27/23 at 1:30 P.M. with the Director of Nursing (DON) verified the family was not notified the Resident #89 was sent to emergency roiagnom on [DATE] and 05/07/23. The DON also verified the family was not notified of the new order for the insulin Lantus or when the resident's blood sugar level was elevated at 586. Review of the undated facility policy titled Notification of Change in Condition revealed the attending practitioner is promptly notified of significant changes in condition and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. When a change in condition is noted, the nursing staff will contact the resident representative. This deficiency represents non-compliance investigated under Complaint Number OH00143719 and Complaint Number OH00142999.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident received medications without a significant medication error when a resident was not administered an epilepsy medication per physician orders. This affected one (#90) of three residents reviewed for medication administration. The facility census was 86. Findings include Review of the medical record revealed Resident #90 had an admitted [DATE] and a discharge date of [DATE]. Diagnoses included epilepsy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had intact cognition. Review of the physician orders dated 05/22/23 revealed Resident #90 was ordered ethosuximide 250 milligrams (mg) two capsules by mouth every morning and at bedtime for epilepsy. Review of the medication administration record revealed Resident #90 had not received the medication ethosuximide 250 mg two capsules for the bedtime dose on 05/27/23, 05/28/23, and 05/29/23. Resident #90 had not received the morning or the bedtime dose on 05/30/23 and had not received the morning dose on 05/31/23. Interview on 06/26/23 at 3:23 P.M. with the Director of Nursing (DON) verified Resident #90 was not administered the medication ethosuximide 250 mg, two capsules for the bedtime doses on 05/27/23, 05/28/23, 05/29/23 and 05/30/23. The DON verified Resident #90 had not received the morning doses of the medication on 05/30/23 and 05/31/23. Review of the undated facility policy titled Medication Administration revealed medications would be administered within the time frame of one hour before up to one hour after time ordered. This deficiency represents non-compliance investigated under Complaint Number OH00143719 and Complaint Number OH00143432.

Based on record review, observation and interviews, the facility failed to follow the physicians order to change oxygen tubing weekly on night shift and label with a date. This affected five residents (#17, #28, #43, #46, and #47) out of seven residents observed using oxygen. In addition, the facility failed to ensure a physicians order was in place for the use of oxygen for one resident (Resident #438) out of seven residents reviewed for oxygen therapy. The facility census was 95. Findings include: 1. Observation on 04/11/22 from 10:13 A.M. through 04/13/22 at 9:21 A.M. of the oxygen tubing for Resident #17, #28, #43, #46 and #438, revealed Resident #28's oxygen tubing was dated 02/28/22 and Resident #46's oxygen tubing was dated 02/21/22. Resident #17, #43, #47, and #438's oxygen tubing did not have a label and was not dated. Record review revealed Residents #17, #28, #43, #46 and #47 had physicians' orders to have oxygen tubing changed every Sunday evening on night shift. Interview with Licensed Practical Nurse (LPN) #190 on 04/11/22 at 10:26 A.M., interviews with LPN #135 on 04/13/22 at 2:31 P.M. and LPN #207 on 04/13/22 at 2:33 P.M. verified oxygen tubing was indicated on Residents #17, #28, #43, #46, #47 and #438 were to be changed weekly on the Sunday evening shift per order and dated. Interview with the Infection Prevention Coordinator on 04/14/22 at 10:00 A.M. verified the oxygen tubing should be changed weekly per order, and the tubing should be dated. 2. Record review for Resident #438 revealed resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #438's physicians orders revealed she did not have any orders to be on oxygen. Review of Resident #438's quarterly minimum data set (MDS) 3.0 dated 03/30/22 under section O/special treatments, procedures and programs revealed she was on oxygen. Review of the care plan dated 03/21/22 revealed Resident #438 had [CONDITION(S)] with shortness of breath while lying flat. Interventions included elevate the head of the bed as needed to prevent shortness of breath. Monitor vitals and report any abnormal findings to the medical provide, the resident and the residents representative. Observe for signs and symptoms of [CONDITION(S)]. Oxygen therapy as ordered and change tubing per facility policy. Observation of Resident #438 on 04/11/22 at 10:13 A.M. revealed she was on two liters (L) of oxygen via nasal cannula (NC). Interview on 04/11/22 at 10:13 A.M. with Resident #438 stated she had been on oxygen two L per NC since being admitted to the facility on [DATE]. Interview on 04/11/22 with LPN #190 at 10:26 A.M. verified Resident #438 was on oxygen two L. Interview on 04/14/2022 at 11:15 A.M. with the Director of Nursing verified Resident #438 should have had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, observation, staff interview, and policy review the facility failed to store a resident's medication safely. This affected one resident (#80) out of three residents reviewed. The facility census was 95. Findings include: Review of Resident #80's medical record revealed an admitted [DATE]. Diagnoses included nontraumatic intracerebral hemorrhage, cerebral infarction, [CONDITION(S)], [CONDITION(S)], dysphagia, diabetes mellitus, [CONDITION(S)], [CONDITION(S)], and right side [CONDITION(S)]. Review of Resident #80's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was severely cognitive impaired. The resident required an extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Review of Resident #80's most recent care plan revealed he had behaviors which indicated dementia. The resident had activity preferences of watching television and sports. He required simple step by step instruction. Resident #80 had a communication problem due to a head injury. Observation on 04/11/22 at 10:52 A.M. revealed a bottle of Fish Oil supplement was sitting on Resident #80's tray table next to his bed. Interview with Licensed Practical Nurse (LPN) #190 on 04/12/22 at 11:29 A.M. revealed the fish oil was on the resident's bedside table and she verified that Resident #80 did not have an order for self administration of medication. According to the website www.nccih.nih.gov revealed large amounts of fish oil could be related to bleeding issues. Review of the facility titled Storage of Medications dated 08/2020 revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medications rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

Based on record review and staff interview the facility failed to complete a care plan regarding pain. This affected one resident (#12) of six residents reviewed for pain control. The facility census was 95. Findings include: Review of Resident #12's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #12's most recent care plan revealed there was no mention of pain control. Review of Resident #12's physician note dated 03/14/22 revealed the residents pain was not being controlled. He had been on [MEDICATION(S)] and [MEDICATION(S)] gel and had an appointment scheduled with pain management. Review of Resident #12's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also apply to the low back topically as needed for pain. In addition, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff was to monitor the pain every shift. Interview with Resident #12 on 04/11/22 at 11:13 A.M. revealed the resident had ongoing low back pain and it was not controlled. Interview with the Director of Nursing on 04/14/22 at 10:10 A.M. verified that the facility failed to complete a pain care plan for Resident #12.

Based on record review and staff interview, the facility failed to complete quarterly care plan conferences for residents. This affected one resident (#80) out of two residents reviewed for care conferences. The facility census was 95. Findings include: Review of Resident #80's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive deficits. The resident required an extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. The resident was documented as refusing care. Review of Resident #80's most recent care plan revealed he had behaviors which indicated dementia. The resident had activity preferences of watching television and sports. He required simple step by step instruction. Resident #80 had suffered an intracranial hemorrhage due to extreme [CONDITION(S)], and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #80's care plan conference notes provided by the Licensed Social Worker (LSW) revealed on care plan had not been completed since 09/08/21. Interview with the Director of Nursing on 04/14/22 at 9:24 A.M. revealed every resident should have been provided a quarterly care conference with the resident and family invited. Interview with the LSW on 04/14/22 at 10:34 A.M. revealed Resident #80 had not been provided a care plan meeting since 09/08/21. She said the resident refused to participate in conferences when offered on 12/22/21 and family was not able to attend. At that time the facility staff did not complete a care conference.

Based on observation, record review, staff interview, and facility policy review, the facility failed to assist residents in activities of daily living (ADL). This affected two residents (#18, #438) out of four residents reviewed for ADL's . The facility census was 95. Findings include: 1. Review of Resident #18's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderate cognitive function. He required a one person extensive assistance for personal hygiene. Review of Resident #18's most recent care plan revealed he had a self care performance deficit and required extensive assistance with hygiene Review of the State tested Nursing Aide (STNA) documentation dated 03/10/22 through 04/11/22 revealed the resident received hygiene care five to six times weekly. Observations on 04/11/22 at 11:54 A.M. revealed Resident #18 was laying in bed awake. The resident had long finger nails extending approximately 3/4 inch from the fingertips. Further observation on 0 4/12/22 at 8:11 A.M. revealed the resident remained with long fingernails. Interview with Resident #18 on 04/11/22 at 11:56 A.M. revealed he would have liked his fingernails cut, but could not get the staff to do so. Interview with the Director of Nursing (DON) on 04/13/22 at 1:20 P.M. revealed the STNA's should have trimming the resident's finger nails on shower days which failed to be completed. 2. Observation on 04/11/22 at 10:13 A.M. of Resident #438 fingernails was found to be long and full of debris. Interview on 04/11/22 at 10:13 A.M. with Resident #438 stated her daughter usually took care of her nails but had not been in the facility for a while. She stated if she had a nail file, she would take care of her fingernails herself because the staff does not. Interview on 04/13/22 at 11:07 A.M. with Licensed Practical Nurse (LPN) #190 stated she would give her a nail file. Observation on 04/14/22 at 11:00 A.M. revealed Resident #438 still had debris under her nails. Interview on 04/14/22 at 11:30 A.M. with DON verified Resident #438 had fingernails that needed to be groomed. Review of the facility policy titled Nail and Hair Hygiene Services dated 04/14/17 revealed residents will have routine nail hygiene and hair hygiene as part of the bath or shower. Nails should be trimmed immediately after bathing or alternatively, soaking nails in warm soapy water prior to trimming or filing to reduce tearing and provide ease of trimming and filing.

Based on record review and interview, the facility failed to ensure wound dressings were changed per physicians order for residents. This affected one resident (#438) of three residents reviewed with wound care orders. The facility census was 95. Findings include: Review of Resident #438 medical record revealed resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #438 on 04/13/22 at 11:07 A.M. revealed Licensed Practical Nurse (LPN) #190 followed physicians' order to cleanse coccyx/sacral wound with normal saline and cover calcium alginate, apply Medi Honey and cover with nine-by-nine-inch comfort foam dressing every day. Record review of the Resident #438's treatment administration record revealed the dressing change was not signed off on 03/22/22, 03/23/22, 04/01/22, 04/03/22, 04/04/22, 04/06/22, 04/07/22, 04/08/22, 04/09/22 and 04/11/22 per physician's order. Interview with the Director of Nursing on 04/14/22 at 1:30 P.M. revealed the dressings were not done on 03/22/22, 03/23/22, 04/01/22, 04/03/22, 04/04/22, 04/06/22, 04/07/22, 04/08/22, 04/09/22 and 04/11/22 per physician's order. Review of the facility policy, skin care and wound management, dated 05/30/19 revealed the facility did not follow their policy for providing wound care per order.

Based on observation, resident and staff interview and review of facility policy, the facility failed to ensure meals were palatable to taste and temperature. This had the potential to affect 88 of 88 residents receiving meals from the kitchen. One resident (#93) received no food by mouth. The facility census was 89. Findings include: Interview on 02/22/22 at 4:14 P.M., Resident #62 revealed the food was served cold sometimes. Interview on 02/22/22 at 4:25 P.M., Resident #27 revealed the food needed to be warmer. Observation on 02/25/22 revealed the dietary staff completed plating of resident meals and one meal test tray for the 2300 hall at 11:38 A.M. The meals were delivered to the 2300 hall at 11:41 A.M. Three staff delivered the meal trays to the residents from 11:41 A.M. through 11:59 A.M. Observation on 02/23/22 at 12:00 P.M., of a meal test tray with Dietary Manager (DM) #190 revealed the Brussels sprouts, turkey and sweet potatoes were not palatable to taste or temperature. The food temperatures on the test tray were taken by DM #190 using three different thermometers. The Brussels sprouts and the turkey measured 111 degrees Fahrenheit (F) and the sweet potatoes measured 60 degrees F. The turkey, Brussels sprouts and sweet potatoes were not warm and appetizing. The Brussels sprouts were mushy and overcooked. Also, a biscuit served with the meal was not evenly cooked. The bottom of the biscuit was soft and the top of the biscuit was very hard. Interview on 02/23/22 at 12:05 P.M., DM #190 verified the Brussels sprouts were soft, the biscuit was hard, and the food was not warm enough. DM #190 revealed the three different thermometers used on the test tray may not be correct and she would replace the thermometers. Interview on 02/23/22 at 2:03 P.M., Resident #15 revealed she had not liked her lunch meal today. Resident #15 revealed she does not like Brussels sprouts. Resident #15 revealed she ate a couple bites of the turkey but the biscuit was too hard and she could not eat it. Interview on 02/23/22 at 3:11 P.M., Resident #41 revealed the food provided by the facility was often cold. Resident #41 revealed she ordered out for food and often chose not to eat the food provided by the facility. Review of the policy tilted, Food: Quality and Palatability, revised 09/2017, revealed food would be prepared by methods that conserve nutritive value, flavor and appearance. Food would be palatable, attractive and served at a safe and appetizing temperature. This deficiency substantiates Complaint Number OH 102.

Based on observation, staff interview, record review, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure interventions were implemented following development of a pressure ulcer to Resident #37's coccyx. This resulted in actual harm when the facility failed to seek alternative treatments/interventions when Resident #37 developed a stage two pressure ulcer (partial thickness tissue loss) resulting in deterioration to an unstageable pressure ulcer (slough and/or eschar known but not stageable due to cover of wound bed by slough and/or eschar). The facility also failed to implement a dressing ordered for Resident #94's right buttock. This affected two (#37 and #94) of three residents reviewed for pressure ulcers. The facility census was 92. Findings include: 1. Medical record review for Resident #37 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 02/12/15 for potential for pressure ulcer development had interventions to educate resident, family, and/or caregivers causes of skin breakdown, turn and reposition the resident every two hours, and place an air mattress on the resident's bed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #37 was cognitively intact, had no behaviors, and no rejection of care. She required extensive assistance of two staff for bed mobility. The resident had no pressure ulcers. Interventions to prevent skin breakdown included pressure reducing cushion to her chair and mattress. Review of the Braden Observation Tool for assessing risk of the development of pressure ulcer dated 11/19/17 indicated Resident #37 was at moderate risk. She was chair fast with very limited ability to change body positions and a problem with friction/shearing. Review of the Skin Grid Pressure assessment dated [DATE] revealed Resident #37 developed a new pressure ulcer, stage two (partial thickness skin loss) to her coccyx. The wound measured 1.0 centimeter (cm.) long by 0.5 cm. wide by 0.1 cm. deep. There was no drainage. The resident's peri-wound area was white or gray pallor or hypo-pigmented. Review of the record revealed no evidence of new interventions, including a treatment order for the coccyx, following the skin breakdown. On 11/21/17, the resident's nutritional supplement with high calorie and protein (Med Plus 2.0) was increased from twice daily to four times daily. Review of a wound assessment by Nurse (NP) #100 dated 11/28/17 indicated Resident #37 presented with an unstageable pressure ulcer obscured by full thickness skin tissue loss, measuring 3.0 cm. long by 3.5 cm. wide by 0.1 cm. deep. The wound bed was covered by 76 to 100 percent slough and 1 to 25 percent eschar (non-viable tissue). The NP documented the facility's current treatment to the coccyx was barrier cream. The facility reported the resident has had a physical decline within the past month or so. The resident would not eat meals except when up in a chair or when her husband was present. Review of physician orders [REDACTED].) twice daily and add a liquid protein 30 ml. twice daily, turn/reposition the resident every two hours, and the resident to be placed in a chair for meals and limit sitting in the chair to two-hour intervals at most, and to the change the dressing order. Review of the dressing order dated 11/28/17 indicated to cleanse the coccyx ulcer with normal saline, apply Santyl (a [MEDICATION NAME] agent) to ulcer then normal saline moistened gauze, cover with abdominal pad and [MEDICATION NAME] tape. This was to be changed daily and as needed. On 02/28/18 at 10:38 A.M., observation of a dressing change revealed Wound Physician #98 changed the dressings to Resident #37's coccyx. The physician measured the sacral wound as being 3.0 centimeters (cm.) long by 5.4 cm. wide by 2.3 cm. deep with undermining from 2 o'clock to 10 o'clock. The physician agreed the wound bed was a beefy red color. After cleaning the wound with normal saline, he placed calcium alginate into the wound bed, covered with a foam dressing, and secured with paper tape. He stated Calcium alginate was a highly absorbent dressing used to promote healing. On 02/28/18 at 4:40 P.M., an interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #102 confirmed the facility did not obtain a physician order [REDACTED].#37's skin breakdown to her coccyx on 11/19/17. They confirmed turning and repositioning was initiated on 11/28/17 following deterioration of the ulcer. On 02/28/18 at 5:20 P.M., the DON confirmed she had no evidence Resident #37 was being turned and repositioned prior to 11/28/17. 2. Closed medical record review for Resident #94 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had care plans in place for potential for impaired skin integrity dated 08/18/14 and for resistive to care dated 05/12/17. Review of the resident's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #94 was cognitively intact, had no behaviors, and no rejection of care. He needed extensive assistance of two staff for bed mobility. He had no pressure ulcers and had interventions in place to prevent skin breakdown. Review of wound assessments by Nurse Practitioner (NP) #100 completed 11/28/17 and 12/05/17 revealed on 12/05/17 there was a new pressure ulcer to Resident #94's right buttock. The ulcer was described as unstageable, measuring 0.4 cm. long by 0.3 cm. wide, and covered by 76 to 100 percent slough. On 12/05/17, the NP ordered normal saline cleanse to right buttock wound, skin prep peri wound, and cover with [MEDICATION NAME] (an absorbent, self-adhesive, waterproof dressing). Change every three days and as needed. Review of the treatment administration record (TAR) for (MONTH) (YEAR) revealed Resident #94's dressing to the right buttock was never initiated. Review of the wound documentation by the facility dated 12/12/18 revealed the right buttock wound did not deteriorate. The resident was discharged on [DATE]. Interview on 02/28/18 at 4:40 P.M. with the DON and LPN #102 confirmed the dressing order for Resident #94's right buttock was never initiated. On 02/28/18 at 4:55 P.M., a phone interview with CNP #100 revealed she assessed Resident #94's wounds twice, on 11/28/17 and 12/05/17. The wounds to the left buttock had not gotten worse when seen on 12/05/17. The right buttock was found on 12/05/17. She agreed she ordered skin prep to be applied to the peri wound and a [MEDICATION NAME] dressing to the area. The CNP did not believe not having a dressing would have made a big difference due to the small size of the wound. Review of information from the NPUAP revealed an unstageable pressure ulcer is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. The NPUAP further instructed to offload the pressure injury and to turn and reposition the individual. This deficiency substantiates Complaint Number OH 221.

Based on medical record review, observations, staff interview, physician interview, review of a clinical practice guideline, review of an enteral nutrition manufacturer's label, and review of facility policy, the facility failed to ensure one (#175) of five residents reviewed for enteral nutrition care and treatment received appropriate care and services for the management of the assessed nutritional needs of the resident. This resulted in Immediate Jeopardy for one (#175) resident who was assessed at high risk of weight loss and nutritional impairment, and whose only means of nutritional intake was via gastrostomy tube, when it was discovered that this resident was knowingly provided enteral nutrition in an amount significantly below her assessed kilocalorie per day energy needs for a period of 26 days. In addition, the facility failed to accurately monitor weight status and initiate efforts to ensure Resident #175 received sufficient nutritional supports in order to maintain the highest practicable physical well-being and quality of life during this time period. The facility identified a total of five residents currently receiving enteral nutrition. On 03/19/14 at 2:44 P.M., the Administrator, Director of Nursing (DON), Regional Director of Nursing Services (RDNS) #1, and Regional Director of Regulation and Quality Assurance (RDRQA) #2 were notified Immediate Jeopardy began on 02/19/15 when Resident #175's enteral nutrition orders were changed from a rate that provided 1,710 kilocalories and met the resident's assessed caloric energy needs to a rate that was 632 calories below the resident's daily assessed caloric requirements. Additionally, no attempts were made to increase Resident #175's daily enteral nutrition amount through inter-professional collaboration in order to evaluate options for dietary supplementation to meet the resident's complex nutritional needs. The Immediate Jeopardy was removed on 03/20/15, when Registered Dietitian (RD) #1 began conducting on-site nutrition screenings, assessments, care plan revisions, including recommendations for all current residents receiving enteral nutrition, and the facility implemented the following corrective actions: · On 03/19/15, the DON obtained revised physician orders for Resident #175's enteral nutrition which were congruent with the resident's assessed caloric needs. · On 03/19/15, the facility nursing staff began administering Resident #175's enteral nutrition in an amount to meet assessed needs. · On 03/19/15, the facility's Maintenance Director #1 performed a visual inspection of all four weight scales in use at the facility. · On 03/19/15, the facility developed a "Nutrition and Hydration QAPI Plan," delineating their identified deficient practices regarding the provision of nutritional care and outlining interventions to address these deficient areas and for reviewing the results of these interventions via monthly quality assurance processes. · On 03/20/15, the facility had all four scales examined and calibrated by an outside vendor. · On 03/20/15, the facility nursing staff obtained new weights on all residents receiving enteral nutrition. · On 03/20/15, corporate RD #2 conducted in-service training for RD #1 and Dietary Manager #1, regarding the facility's policy on monthly weight monitoring and process for accurately documenting weights using the electronic health record. · On 03/20/15, RDNS #1 conducted in-service training with the nursing department on weight monitoring, procurement, and nutritional weight loss prevention strategies. · On 03/20/15, RD #2 conducted in-service training for RD #1, regarding completion of accurate assessments of nutritional status for residents receiving enteral nutrition and on the "Nutritional Care Process and Model". Although the Immediate Jeopardy was removed, 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 has not fully implemented monitoring and auditing of all residents identified at nutritional risk and has not implemented a comprehensive nutritional plan of care for Resident #175. Findings include: Review of the medical record for Resident #175 revealed the resident was originally admitted on [DATE], discharged to a hospital on [DATE], and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The record indicated the resident's advance directives were for full measures. Review of admission physician orders dated 02/18/15, revealed the resident was ordered to receive continuous enteral nutrition at a rate of 60 milliliters (ml) per hour. These admission orders [REDACTED]. Review of nurses notes dated 02/19/15 at 11:55 P.M., revealed the resident experienced three episodes of emesis and had a firm "slightly distended" abdomen. Review of untimed physician orders dated 02/19/15, revealed the physician ordered to change enteral nutrition administration from a continuous rate to bolus administration at 200 ml four times daily. Review of the Medication Administration Record, [REDACTED]. Review of a dietary nutritional assessment dated [DATE], revealed RD #1 identified the resident's sole means of nutrition was via gastrostomy tube. This nutritional assessment revealed the resident's height was 66 inches, actual weight was 111.8 pounds, usual body weight was 110 pounds, and an ideal body weight range of 135 pounds (plus or minus five percent). Additionally, the assessment denoted the resident's estimated energy needs were based on a 30 kilocalorie per kilogram ideal body weight, which identified the resident as requiring an estimated daily energy need of 1,582 kilocalories. Further review of the assessment identified the resident was receiving "continuous" enteral feeding via gastrostomy tube. In addition, this assessment identified the resident's nutritional goals were for "weight maintenance" within three percent (%) of previous weight, tolerance of feeding, and laboratory findings within normal results. The assessment indicated the plan will be to monitor enteral feeding tolerance and "consider change in rate", and monitor weekly weights. Review of physician orders from 02/20/15 to 03/18/15, revealed no evidence of attempts to gradually increase the amount of enteral nutrition the resident was receiving. Review of the care plan in effect from 02/04/15 to 03/18/15, revealed no interventions to address the type or method of enteral nutrition provided. This plan failed to address interventions for ensuring the resident's caloric needs are met and for methods of monitoring nutritional status (e.g., laboratory testing and types of anthropometric measurements. The facility revised the resident's care plan on 03/19/15; however, the revised care plan not only lacked the same interventions that were missing on the 02/04/15 care plan, but also lacked directions for weight monitoring. Review of the resident's weights in the electronic health record (EHR) revealed the facility recorded the resident as weighing 111.9 pounds on 01/31/15, 120.9 pounds on 02/05/15, 111.9 pounds on 02/19/15, and 98.2 pounds on 03/18/15. Despite these significant weight fluctuations, there was no documented evidence of the resident being re-weighed for accuracy. In addition, there was no documented evidence of weekly weights being completed since readmission on 02/18/15 as ordered by the physician. Review of the manufacturer's labeling for the enteral nutrition supplied to Resident #175, revealed each can contained 280 calories per 240 ml. A calculation of the amount of enteral nutrition provided to the resident based on this information and the prescriber's orders revealed the resident was receiving 950 calories. This was 632 calories below RD #1's assessment findings indicating Resident #175 required an estimated 1,582 kilocalories. Interview with Resident #175's primary care physician (#1) on 03/18/15 at approximately 9:15 A.M., revealed the physician stated he did not feel increasing Resident #175's amount of enteral nutrition was necessary due to her poor prognosis. The physician verified the resident currently had directives for full measure of life support in place. Interviews with RD #1 on 03/18/15 at 2:58 P.M. and 3:28 P.M., verified the disparities in the resident's weights recorded in the EHR. She verified she was not made aware of the 02/20/15 physician orders that changed the resident from receipt of a continuous rate enteral administration to a bolus enteral administration. RD #1 verified the 02/20/15 physician order for [REDACTED]. Interview with RDRQA #2 on 03/19/15 at 10:54 A.M., verified Resident #175's family, desires the resident to receive full life support measures. RDRQA #2 verified the resident's prescribed enteral nutrition was not sufficient to meet her assessed caloric needs as outlined in the dietary assessment. Review of the facility policy titled, "Enteral Formulary", effective May 2014, revealed the policy indicated the registered dietitian "will be responsible for ensuring that the plan of care for each resident is in concert with the residents (sic) expressed wishes for care and services ". This policy also indicated the registered dietitian "will make recommendations as indicated based on the clinical condition of the resident/patient " . Review of the facility policy titled, "Monthly Weight Monitoring" effective 08/03/04, revealed if a resident experiences a significant change in weight, nursing staff will complete a re-weigh within four days. In addition, this policy denoted " if a significant weight change is verified, the resident may be weighed on a weekly basis until the weight is stabilized" . Review of clinical practice guidelines titled, "Oncology evidence-based nutrition practice guideline effective 2013, revealed "adult oncology patients who have been identified to have pre-cachexia [MEDICAL CONDITION] cachexia, prompt and aggressive intervention to address nutrition impact symptoms and preserve or prevent loss of lean body mass (LBM) and weight should be initiated by the Registered Dietitian Nutritionist". This guideline indicated "earlier rather than later intervention to prevent weight loss in this population is more likely to be effective". Interview with the DON, Administrator, the Director of Operations, RD #1, RD #2, RDNS #1, and RDRQA #2 on 03/20/15 at 11:00 A.M., verified the facility administered Resident #175's enteral nutrition at a rate and/or frequency significantly below the assessed daily caloric needs. The individuals also verified the facility failed to attempt any increases to the resident's enteral nutrition from 02/18/15 to 03/18/15. These individuals verified there were no inter-professional discussions about and/or no attempts to determine Resident #175's ability to tolerate increased amounts of enteral nutrition. The facility verified Resident #175's plan of care failed to contain the aforementioned interventions. The facility verified the resident's medical record contained no evidence of weekly weights being completed upon readmission on 02/18/15 and the facility did not conduct re-weighs of the resident following significant changes in weight as required by the facility policy and procedure. The facility further verified no laboratory monitoring had been ordered or completed for Resident #175 since admission. Additionally, the facility indicated the resident's family has issued no directives to engage in restricting nutrition or hydration. The facility staff in attendance, verbalized agreement that ensuring Resident #175 received adequate nutrition and hydration in accordance with her assessed needs, did not constitute "aggressive" treatment.