Every finding on record at Laurie Ann Nursing Home

Based on observation, staff interviews and facility policy review, the facility failed to ensure the garbage and refuse was maintained in a sanitary condition. This had the potential to affect all 56 residents residing in the facility. Findings include: Observation of the facilities outside dumpster area with Dietary Supervisor (DS) #224 on 06/16/25 at 7:26 A.M. revealed there were two dumpsters in the area. The dumpster on the right-hand side had both lids closed on top and both sliding doors on each side were closed. The dumpster on the left side had both lids closed and the sliding door on the right side of the unit was closed. On the left side of the dumpster, there was an opening in the dumpster where the sliding door should have been with the black sliding door located on the ground under the back left-hand corner of the dumpster. Located on the ground around the dumpsters was a buildup of debris which included five white plastic surgical gloves, one clear plastic cup, one empty pudding cup container, two medicine cups, multiple pieces of plastic wrap of various sizes, one brown cardboard box approximately 12 inches wide by nine inches tall and two-inches deep which was labeled fabric softener sheets, three blue surgical gloves, one straw, and numerous plastic spoons. Interview with DS #224 at the time of observation on 06/16/25 verified the above findings. Interview on 06/17/25 at 5:16 P.M. with Maintenance Supervisor #202 revealed he was made aware of the dumpster situation when he got to work on 06/16/25. He stated the door to the dumpster would slide off and people didn't want to pick up the door on the ground after it had slid off the dumpster. He confirmed the area had debris which he helped clean up, and it was the responsibility of the maintenance and housekeeping departments to keep the dumpster area clean. Review of the facility policy Trash/Dumpster Receptacle, dated 08/27/19, revealed all trash dumpsters and receptacles would be kept covered at all times. Employees who took trash and garbage to dumpsters were to close the lids after refuse was deposited, and trash was not to be deposited on the ground for any reason. If for any reason the receptacle lids could not be closed, maintenance would be notified right away for assistance, and maintenance would notify the trash pickup vendor if any problems occurred which impeded the facility's ability to store trash.

Based on observation, interview, record review and facility policy review, the facility to ensure Turbersol serum was dated upon opening per manufacturers instruction for efficacy. This had the potential to affect 15 (Residents #15, #19, #21, #51, #52, #106, #107, #156, #157, #206, #207, #208, #209, #256 and #257) identified as new admissions on the 100 unit in the last 30 days. The facility also did not ensure pills were not left at the bedside for Resident #35. This had the potential to affect seven (Residents #11, #24, #43, #106, #157, #208, and #257) who were identified as cognitively impaired and independently mobile on the 100 unit. The facility census was 56. Findings include: 1. On 06/16/25 at 8:20 A.M. an inspection of the medication storage room on the 100 unit revealed a one milliliter vial of Turbersol (a serum used to aid in the diagnosis of tuberculosis) that was opened and undated. The Director of Nursing (DON) verified the opened vial of Tubersol as being undated at the time of the observation. A review of the package inserts for Tubersol revealed a vial of Tubersol which has been opened and in use for 30 days should be discarded. A review of the facility policy titled; Medication Storage in the Facility, dated of 07/01/21, revealed medications and biologicals are stored safely, securely and properly following manufacturers recommendations. The policy further stated certain medications, once opened, require an expiration date shorter than the manufacturers expiration date to ensure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial shall be dated. 2. A review of medical records for Resident #35 revealed a date of admission of 08/27/24. Significant diagnosis included personal history of malignant melanoma. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS of 15 (cognitively intact). A review of a care plan dated 05/05/25 revealed Resident #15 could keep artificial tears at bedside for self-administration. The care plan did not include antibiotic medication to be left at the bedside for self-administration. The care plan also revealed Resident #35 to have inappropriate behaviors at times related to refusal of medications. Interventions included to administer medications as ordered. A review of assessments within the medical record did not reveal a completed self-medication administration assessment (an assessment completed to ensure a resident can safely self-administer medications). Review of the physician's orders for Resident #15 included an order dated 06/12/25 for Cephalexin (an antibiotic used for infection) 500 milligrams (mg), give one by mouth one time a day for infection for seven days. A review of the medication administration record (MAR) for June 2025 the Cephalexin was signed off as administered at bedtime on 06/15/25. On 06/16/25 at 8:52 A.M. an observation of the bedside table for Resident #35 revealed a pink capsule in a medication cup. Resident #35 stated they got the pill last night and did not take it as she thought she was to take it in the morning. An interview with Registered Nurse (RN) #239 at the time of the observation revealed the capsule to be the Cephalexin. Resident #35 stated the capsule was given last night, and she did not take it as she thought it was to be taken in the morning. RN #239 then instructed Resident #35 that the Cephalexin was ordered once a day at bedtime. RN #239 removed the pink capsule from the room. On 06/16/25 at 3:32 P.M. an interview with the Director of Nursing (DON) verified the lack of a self-administration assessment within the medical record of Resident #35. There were seven (Residents #11, #24, #43, #106, #157, #208, and #257) who were identified as cognitively impaired and independently mobile on the 100 unit. A review of the facility policy titled; Specific Medication Administration Procedures, dated 07/01/21, revealed once removed from the package or container, unused or partial doses of medication should be disposed of in accordance with the medication destruction policy.

Based on observation, staff and family interviews, record review and facility policy review, the facility didn't ensure indwelling urinary catheter bags were timely covered in a dignified manner. This affected one (Resident #8) out of two residents reviewed for dignity and had the potential to affect four additional (Residents #15, #37, #41, and #206) the facility identified as having indwelling urinary catheters. The facility census was 56. Findings include: Review of the medical record for Resident #8 revealed an admission date of 05/19/25 and a readmission date of 06/12/25. Pertinent diagnoses included retention of urine, obstructive and reflux uropathy (blockage in body which makes it difficult or impossible to urinate), disorder of kidney and ureter (small tubes of muscle that transport urine from kidneys to the urinary bladder), and chronic kidney disease. Review of the readmission Minimum Data Set (MDS) assessment revealed it was in process of being completed. Review of the 06/02/25 discharge MDS assessment revealed the staff had assessed Resident #8 as having modified cognitive status and an indwelling urinary catheter. Further review of Resident #8's medical record revealed physician orders dated 06/13/25 for a 16 French (F) Foley catheter with 10 cubic centimeters (cc) balloon (indwelling urinary catheter) to continuous drainage and to change the Foley drainage bag every 30 days and PRN (as needed). Observation on 06/16/25 at 9:04 A.M. revealed Resident #8 was lying in bed, and there was an uncovered indwelling urinary catheter collection bag of urine hanging on the left side of the bed, which was visible from the hallway and was one third full of urine. Interview on 06/16/25 at 9:17 A.M. with Therapy Manager #266 and Physical Therapy Assistant #267 confirmed Resident #8's indwelling urinary catheter bag wasn't covered, and they stated there was usually a privacy cover on the bag. Observation on 06/17/25 at 8:14 A.M. revealed Resident #8 was lying in his bed. His indwelling urinary catheter collection bag was hanging on the left side of the bed which was visible from the hallway, but the collection bag now had a blue privacy covering. Continued review of Resident #8's medical record revealed a progress note dated 06/17/25 and authored by Assistant Director of Nursing Registered Nurse (ADON/RN) #266 which indicated ADON/RN #266 had changed Resident #8's indwelling urinary catheter bag to a fig leaf privacy bag. Interview on 06/17/25 at 9:27 A.M. with ADON/RN #266 stated the indwelling urinary catheter collection bag which the resident had come back from the hospital with hadn't had a privacy covering attached. He stated normally the facility would change the collection bag to one with a privacy cover on it, but the facility hadn't gotten around to changing Resident #8's collection bag until he changed the collection bag on 06/17/25. Interview on 06/17/25 at 12:19 P.M. with family members of Resident #8 revealed the catheter collection bag hadn't been covered until 06/16/25 when it was covered with a pillowcase. They stated on 06/17/25 the indwelling urinary catheter collection bag had been changed to one with a privacy covering. Review of facility policy/procedure Foley Catheter Care Procedure, dated January 2025, revealed there was nothing in the policy/procedure indicating the indwelling urinary catheter drainage bag should have a privacy covering. Review of the undated facility policy Resident Rights revealed the resident had the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality.

Based on medical record review, interview and facility policy review, the facility failed to ensure residents' wishes regarding end-of-life measures were signed by the physician. This affected two (Residents #6 and #47) of three residents reviewed for Advanced Directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/08/24. Diagnoses included dementia, depression, diabetes and kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. She required set up help for eating, oral and personal hygiene, partial assistance for showering and substantial assistance for toileting. Review of the physicians' orders for June 2025 for Resident #6 revealed an order for Do Not Resuscitate, Comfort Care only, comfort care will be provided, even before a cardiac or respiratory arrest occurs (DNRCC). Review of the Do Not Resuscitate (DNR) form dated 01/08/24 revealed no evidence that the required signature of the physician had been obtained. 2. Review of the medical record for Resident #47 revealed an admission date of 12/20/24. Diagnoses included cirrhosis of the liver, repeated falls, congestive heart failure and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 was cognitively intact. She required set up help for eating, oral and personal hygiene, supervision for toileting and dressing and partial assistance for showering. Review of the physician' orders for June 2025 for Resident #47 revealed an order for a DNRCC. Review of the DNR form dated 12/20/24 revealed no evidence the required signature of the physician had been obtained. Interview on 06/17/25 at 8:50 A.M. with Certified Nurse Aide (CNA) #205 confirmed neither DNR form for Resident #6 or #47 had been signed by the physician. Review of the facility policy titled Advance Directives, dated 08/01/22, did not address the completion of the DNR form.

Based on observations, interviews, record reviews, tray ticket and facility policy reviews, the facility failed to ensure fluid restrictions were followed as ordered for Residents #26 and #158. This affected two (Residents #26 and #158) out of four residents reviewed for nutrition and had the potential to affect one additional (Resident #36) identified by the facility as being on a fluid restriction. Additionally, the facility failed to ensure weekly weights were obtained as ordered for Residents #26. This affected one (Residents #26) out of four residents reviewed for nutrition. The facility census was 56. Findings include: 1. Review of the medical record for Resident #158 revealed an admission date of 05/12/25 and a reentry date of 06/07/25. Diagnoses included acute on chronic combined systolic and diastolic heart failure (CHF), Non-ST elevation (NSTEM) myocardial infarction (heart attack), cardiomyopathies (disease of the heart muscle), hypertension (high blood pressure), and hyperlipidemia. Review of Resident #158's history and physical dated 05/13/25 revealed the resident was admitted to the facility after being hospitalized from [DATE] to 05/12/25 for new onset of CHF. During hospitalization, a CHF nurse was consulted and completed education with the resident. Due to new onset CHF, dyspnea (shortness of breath) on exertion, and lower extremity edema, the physician ordered a fluid restriction for the resident along with the resident being weighed three times a week. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #158 was cognitively intact, did not reject care, required setup or cleanup assistance from staff for eating, and was on a therapeutic diet. Review of the physician orders revealed an order dated 05/13/25 for an 1800 ml (milliliter)/day fluid restriction due to CHF with nursing giving 120 ml each medication pass (480ml/day) and dietary providing 1320 ml/day. The 1800 ml fluid restriction order was discontinued on 06/07/25, and a 2000 ml fluid restriction was started on 06/07/25 with nursing providing 250 ml each medication pass (1000 ml/day) and dietary providing 1000 ml/day. Review of Resident #158's care plan dated 05/13/25 revealed the resident was at risk for fluid volume excess due to CHF and edema. Interventions included fluid restriction as ordered, encourage fluids within fluid restriction, and observe for edema and report to physician as needed. Observation on 06/17/25 at 8:06 A.M. revealed there was one large white Styrofoam cup with a lid full of water and ice on Resident #158's over bed table. At the time of observation, Resident #158 stated she was not aware she was on any special diet or fluid restriction, and the Styrofoam cup was full of ice water, which had just been brought to her by a staff member. Interview on 06/17/25 at 8:25 A.M. with Activity Aide #325 and Activity Supervisor #277 revealed the activity department would pass water to residents every day. They stated they were made aware of who was on a fluid restriction via the dashboard of the electronic medical record (EMR), which would show any changes, or by the nurses verbally telling them. They stated they were unaware Resident #158 was on a fluid restriction and Activity Aide #325 confirmed she had given Resident #158 a full cup of ice water, which was a 20-ounce cup (591 ml). Interview on 06/17/25 at 11:06 A.M. with Dietary Supervisor #224 revealed for residents who were on a fluid restriction, nursing would let him know how much fluids dietary were allowed in a day, and he would divide that number by three and then put on the dietary ticket how much fluids a resident was allowed for each meal. He stated the tray tickets would go down with the beverage cart prior to the meal so the aides could take the meal orders and would know who was on a fluid restriction. After the beverages were passed and meal orders were taken, the aides would return the meal tickets with the meal orders written on them. Interview on 06/17/25 at 11:28 A.M. with Certified Nurse's Aide (CAN) #206, who normally worked the day shift on the unit where Resident #158 resided, revealed she believed there wasn't anyone on the unit who was on a fluid restriction, and if a resident was on a fluid restriction, the resident shouldn't have a water pitcher in the room. She indicated she wasn't always able to see in the EMR if a resident was on a fluid restriction, and if she had a question about a fluid restriction, she would ask the nurse. Interview on 06/17/25 at 2:37 P.M. with CNA #263, who normally worked afternoon shift on the unit where Resident #158 resided, revealed she was unaware Resident #158 was on a fluid restriction. Review of Resident #158's lunch meal ticket dated 06/17/25 revealed there was nothing noted on the meal ticket indicating the resident was on a fluid restriction. An additional interview on 06/18/25 at 8:07 A.M. with Dietary Supervisor #224 confirmed after reviewing Resident #158's lunch meal ticket dated 06/17/25 there was nothing noted on Resident #158's meal ticket to indicate the resident was on a fluid restriction. He stated normally he would note the fluid restriction at the bottom of the ticket, which he stated he hadn't done. He went on to state the CNAs used the tray tickets as a means of knowing who was on a fluid restriction. Interview on 06/12/25 at 9:05 A.M. with Dietitian #270 stated a fluid restriction should be noted on a resident's tray ticket. 2. Review of the medical record for Resident #26 revealed a date of admission of 09/26/24 with diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, congestive heart failure and prediabetes. Significant orders included reduced concentrated sweets diet, mechanical soft texture, thin liquid consistency, weights three times a week on Monday, Wednesday, and Friday for CHF dated 02/17/25, 1800 ml in 24 hours fluid restriction, 480 ml nursing (120 ml each medication pass) and 1320 ml dietary dated 04/17/25, and Bumex (a diuretic to remove excess water from the body) one milligram (mg), one tablet daily for CHF dated 02/13/25. Review of the nurse practitioner note dated 02/12/25 revealed Resident #26 was noted to have a weight gain. The assessment and plan within the note revealed a diagnosis of CHF with weight gain. The plan was to continue weights three times a week as well as adding a fluid restriction of 1800 ml daily. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #26 was cognitively intact. The MDS further revealed a weight gain of 5% or more while not on a physician prescribed weight gain regimen. Review of the care plan dated 05/09/25 revealed Resident #26 had the potential for fluid volume excess or decreased fluid volume related to diet and medicine use. Interventions included, dietary to review meal intakes, weights, and fluid needs as needed, fluid restrictions as ordered, weights as ordered, observe for edema and report to the physician as needed. The care plan further revealed Resident #26 was at risk for altered nutrition related to medical diagnosis including diabetes mellitus type two, risks and weight fluctuations associated with diuretic use, daily fluid restriction, variable meal intakes and significant weight variances. Interventions included providing and serving diet as ordered, obtaining weights as ordered, and providing fluid restrictions as ordered. Review of the medication administration records (MARs) dated 02/01/25 through 06/17/25 revealed no orders on the record for the nursing staff for weights three times weekly on Monday, Wednesday and Friday. A review of the MARs dated 04/01/25 through 06/17/25 revealed no orders on the records for 1800 ml fluid restrictions. Review of the dietician progress note dated 06/05/25 revealed a current weight of 175 pounds reflecting a continued weight gain. Significant weight gain noted for three and six months. The note further revealed potential for weight fluctuations related to the history of edema and diuretic therapy. Recommendations were to continue weights on Monday, Wednesday, and Friday per order, and 1800 ml daily fluid restriction. A review of documented weights for Resident #26 revealed the following: • 02/14/25: 166.0 pounds • 02/17/25: 165.0 pounds • 02/21/25: 166.1 pounds • 02/28/25: 162.0 pounds • 03/03/25: 158.4 pounds • 04/01/25: 171.6 pounds • 04/16/25: 176.0 pounds • 04/21/25: 178.2 pounds • 05/02/25: 173.4 pounds • 06/03/25: 175.0 pounds The weights were documented as being taken on a seated scale. A review of the facility diet list dated 06/17/25 revealed Resident #26 was not listed for a dietary fluid restriction. On 06/17/25 at 4:00 P.M. an interview with the Director of Nursing (DON) verified the MARs dated 02/01/25 through 06/17/25 had no orders for weights three times weekly on Monday, Wednesday and Friday. The DON further verified the MARs dated 04/01/25 through 06/17/25 had no orders for the 1800 ml fluid restrictions. The DON stated the orders were entered incorrectly and therefore not carried out resulting in Resident #26 not having weights three times weekly on Monday, Wednesday and Friday and no fluid restriction of 1800ml. A review of the policy titled; Weight Management Program and Weight Loss Policy, revised 11/29/24, revealed all residents will be weighed monthly and as ordered. The policy further revealed weights will be reviewed by the dietitian and designated nurse monthly and as needed. The DON or designee will maintain a list of residents in the weekly weight program and the dietitian weekly reports. The DON or designee will review the dashboard for high-risk weight changes progress notes daily and address accordingly. The dietitian will review all residents' monthly weight reports during the weight committee meeting. Any issues or trends in resident weights will be discussed and documented. The interdisciplinary team will meet weekly to discuss all resident weight issues, including dietitian recommendations. The team will ensure all recommendations have been implemented. A review of the policy titled; Nutrition/Hydration, revised 06/17/25, revealed a resident's diet will be recorded on the physician orders and dietary communication form to the kitchen. Any changes must be reflected in a physician order and written communication to the dietary department. The policy further revealed upon admission the residents baseline weight and height will be obtained and recorded in point click care period new residents and readmitted residents will be weighed weekly for four weeks. Weekly weights may be continued according to the recommendation of the dietician. Nutritional meetings will be held weekly with the dietitian. All recommendations will be communicated as soon as possible to the physician and new orders will be implemented. The policy also stated all residents will be reviewed at least quarterly by the facility dietitian and more often as needed based on skin changes, changing condition, changing intakes, weight concerns or other clinical changes. Recommendations may be generated and will be communicated as soon as possible to the physician and new orders will be implemented. A review of the policy titled Policies and Procedures Manual Policy/Procedure Dietary, dated 01/22/25, revealed the purpose of the policy is to manage fluid overload in the body, particularly when there is an issue with the heart, kidney or liver. The procedure to divide fluids was stated as follows: • Count the number of medication passes the resident has. • Decide the least amount of fluid the resident needs at each medication pass. If possible try to use only 120 ml at each medication pass. • Add the milliliters from each medication pass to get the total amount of fluid allotted to nursing. • Subtract the amount of nursing milliliters from the total fluid restriction amount to get the amount dietary can use for meals. • Notify the dietary department of the amount of fluid allotted for meals.

Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure respiratory equipment was dated and monitored for routine replacement. This affected two (Residents #41 and #48) of four residents reviewed for respiratory care but had the potential to affect an additional 10 (Residents #2, #7, #9, #12, #20, #33, #34, #43, #157, and #158) the facility identified as using oxygen. The facility census was 56. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 01/29/25 with diagnoses including pneumonia, atrial fibrillation (irregular heart rhythm), anxiety disorder, vascular dementia, acidosis (too much acid in the body fluids), bradycardia (heart beats more slowly than expected), atherosclerotic heart disease, hypertension (high blood pressure), right bundle branch block (an obstacle in the right bundle branch of the heart that makes the heartbeat late and creates an irregular heart beat), and old myocardial infarction (heart attack). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely impaired cognitively, was dependent on staff for all activities of daily living (ADL) and mobility, was under Hospice services, and used oxygen. Review of Resident #41's physician orders dated 06/06/25 revealed an order for oxygen at three liters via nasal cannula and may titrate to maintain SPO2 (blood oxygen level) greater than 90 percent and an order to change oxygen tubing every week and PRN (as needed). Observation on 06/16/25 at 9:38 A.M. revealed Resident #41's oxygen tubing was not dated. Observation on 06/16/25 at 9:53 A.M. of Resident #41's oxygen tubing and interview with Assistant Director of Nursing Registered Nurse (ADON/RN) #265 revealed ADON/RN #265 confirmed no date was present and should have been dated when oxygen tubing was changed. ADON/RN #265 stated he was just getting ready to go around and date the oxygen tubing. Observation of ADON/RN #265 at time of interview revealed he had a roll of white surgical tape and black marker in hand. 2. Review of Resident #48's medical record revealed an admission date of 06/01/25 with diagnoses including atherosclerotic heart disease, cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. Review of the admission MDS assessment revealed Resident #48 was moderately impaired cognitively, required substantial/maximum assistance from staff for toileting hygiene, bathing, and to transfer from bed/chair to chair, and used oxygen. Review of Resident #48's physician orders dated 06/02/25 revealed an order for continuous oxygen at two liters per minute and an order to change the nasal canula every Thursday. Observation on 06/16/25 at 8:44 A.M. revealed Resident #48's oxygen tubing was not dated. Interview on 06/16/25 at 9:31 A.M. with Registered Nurse (RN) #220 revealed oxygen tubing was to be changed weekly during the night shift, and the tubing should be dated when changed. Observation of Resident #48's oxygen tubing at the time of interview with RN #220 revealed RN #220 confirmed no date was present and should have been dated when the oxygen tubing was changed. Review of the facility policy Oxygen Therapy, revised 08/07/14, revealed oxygen tubing must be dated/initialed and changed weekly.

Based on medical record review, staff interview and facility policy review, the facility failed to ensure pharmacy recommendations were reviewed and responded to timely by the physician and/or practitioner. This affected two (Residents #17 and #20) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: 1. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, chronic atrial fibrillation, type two diabetes, hypertension, peripheral vascular disease, lymphedema, benign prostatic hyperplasia, osteoarthritis, hypothyroid, hypomagnesemia, ulcerative colitis, post traumatic disorder, metabolic encephalopathy, major depressive disorder, heart failure, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 had intact cognition and was receiving antidepressant medication, anticoagulant medication, diuretic medication, antiplatelet medication and hypoglycemic medication during the assessment period. Review of the medication orders revealed on 03/29/25 Resident #17 received an order to administer Remeron oral tablet 15 milligram (mg) (antidepressant) one time a day for sleep. Review of facility document titled Note to Attending Physician/Prescriber dated 04/27/25 revealed a pharmacy recommendation made to the physician to clarify the supporting diagnosis for the medication Aricept so that nursing could update the orders in Point Click Care (PCC), the electronic medical record (EMR). Further review of the physician/prescriber response revealed a prescriber agreed with and wrote changed diagnosis to dementia. A prescriber signature and date were missing from the response. Review of Resident #17 medication records, treatment records, progress notes, physician response documentation and physician orders revealed there was no documentation of a response from the physician to the pharmacy of facility staff regarding the recommendations made by pharmacy on 04/27/25 and 05/29/25. Review of facility document titled Note to Attending Physician/Prescriber dated 05/29/25 revealed the pharmacy stated hypnotic drug have a Gradual Dose Reduction (GDR) attempt quarterly when used routinely. The pharmacy requested an attempt for a dose reduction or trial as needed use to verify the resident was on the lowest possible dose. The pharmacy also stated if a GDR was not appropriate at this time, please document a clinical rational for continuing therapy. Further review of the undated Physician/Prescriber Response revealed a note that Resident #17 would be seen by psych team on next scheduled visit 06/26/25. The document was not signed or dated by the practitioner. Review of Resident #17 medication orders revealed an updated order on 06/17/25 for Aricept oral tablet five mg (improves mental function) one tablet by mouth daily. 2. Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, protein calorie malnutrition, hypertension, insomnia, chronic pain syndrome, anxiety, atrial fibrillation, hypotension, syncope, hyperlipidemia, Vitamin D deficiency, Vitamin B12 deficiency, history of falling, changes in retinal vascular appearance, drug induced constipation, major depressive disorder, other symptoms and signs concerning food and fluid intake, gastro esophageal reflux, pain in hand, partial intestinal obstruction, muscle weakness, abnormal posture, abnormal gait. Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had moderately impaired cognition. The resident received antidepressant medication and anticoagulation medication during the seven-day assessment reference period. Review of the physician orders revealed on 11/25/24 Resident #20 was ordered to receive Reglan oral tablet five mg (antiemetic). (Reglan has a black box warning for the serious side effect of tardive dyskinesia, which is a potentially irreversible movement disorder). Review of the facility document the pharmacy monthly medication review dated 04/27/25 for Resident #20 revealed the pharmacy recommended Abnormal Involuntary Movement Scale (AIMS) testing completed upon initiation of Reglan and every six months thereafter. The pharmacy wrote at the time of the review that an AIMS test was not available in PCC and suggested nursing complete an AIMS test at their earliest convenience. It was noted that a boxed warning for Reglan chronic or high dose use had been linked to tardive dyskinesia which continues even after discontinuation of the drug. Those at greatest risk were the elderly and recommended Reglan treatment not to exceed three months. Further review of the document revealed the physician/prescriber did not respond, sign or date the recommendation but a written statement from the Director of Nursing (DON) dated 06/17/25 revealed an AIMS test was performed on 06/17/25. Further review of the medical records for Resident #20 including progress notes, medication orders, and physician progress notes revealed no evidence the physician responded to the pharmacy recommendation dated 04/27/25. Interview on 06/18/25 at 8:36 A.M. with the DON revealed the facility utilized Wellness Director #271 to direct all the pharmacy recommendations and GDR to the physician or practitioner through email, or a folder was given to the practitioner to review upon visits to the facility. Wellness Director #217 ensured the pharmacy recommendations were signed and dated by the practitioner. Interview on 06/18/25 at 9:00 A.M with the DON verified there was not a physician signature or date regarding the pharmacy recommendation dated 04/27/25 for a supporting diagnosis of dementia, additionally the DON verified a practitioner did not sign or date they received the pharmacy recommendation dated 05/29/25 for Resident #17 GDR recommendation. The DON verified she wrote the response Resident #17 would be seen by the psych team on the next scheduled visit with her signature. Lastly, the DON verified the practitioner did not sign or date that they received the pharmacy recommendation dated 04/27/24 regarding Resident #20's recommendation for an AIMS test and the boxed warning regarding long term use of Reglan. The DON verified she wrote an AIMS test was done 06/17/25, and the nurse practitioner assessed Resident #20 on 04/11/25 and 06/04/25. Interview on 06/18/25 at 9:07 A.M. with Wellness Director #271 revealed her responsibility was to email the pharmacy recommendations to the DON and to put the recommendation in a folder to be provided to the practitioner upon their visits to review and sign. Wellness Director #271 stated she did not know why the recommendations for Resident #17 and Resident #20 were missed and not addressed until 06/17/25. Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendation, dated 07/01/21, revealed the consultant pharmacist worked with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies were communicated to those with authority or responsibility to implement the recommendations , and were responded to in an appropriate timely fashion.

Based on record review, interview and facility policy review, the facility failed to ensure medications had the appropriate diagnosis for administration. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/21/22. Diagnoses included Parkinson's disease, delusions, kidney disease, diabetes, paranoid schizophrenia and high cholesterol. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. He required set up help for eating and personal hygiene, supervision for oral hygiene and toileting and partial assistance for showering. Review of the gradual dose reduction (GDR) form dated 02/28/25 revealed a recommendation by Pharmacist #268 to clarify the diagnosis for Namenda, which had been prescribed for paranoid schizophrenia. The recommendation was made to correct the diagnosis to dementia, which was signed by Nurse Practitioner #269 on 03/05/25. Review of the physician's orders for June 2024 revealed an order for Namenda (used to treat dementia) five milligrams (mg) by mouth two times per day for paranoid schizophrenia. Interview on 06/18/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #271 confirmed Resident #28 was prescribed Namenda and did not have the appropriate diagnosis for the medication. Review of the facility policy titled Consultant Pharmacist Reports, dated 07/01/21, revealed pharmacy recommendations would be acted upon and documented by the facility staff and/or prescriber.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review, the facility failed to ensure Resident #55 was free from staff-to-resident physical abuse. This affected one resident (#55) of three residents reviewed for abuse. The facility census was 54. Findings include: Review of the medical record for Resident #55 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included sepsis, muscle weakness, epilepsy, bipolar disorder, anxiety, and paraplegia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed resident #55 was cognitively intact. He was completely dependent on staff for eating, oral care, personal hygiene, showering, toileting, and dressing. Review of the care plan dated 08/06/24 revealed Resident #55 had inappropriate behaviors such as agitation and combativeness, aggression with staff, cursing at staff, and refusing to lie down. Interventions included approaching the resident in a slow, calm manner, bringing the resident to a quiet environment as needed, and observing for possible environmental causes of behaviors. Review of SRI tracking number 252677 dated 10/06/24 at 10:41 A.M. revealed Resident #55 reported a facility nurse slapped him. The perpetrator was identified as Registered Nurse (RN) #205 who was suspended pending an investigation. Review of the facility investigation for SRI tracking number 252677 revealed Resident #55 reported RN #205 was providing care when he became verbally aggressive with RN #205. He alleged RN #205 slapped his mouth. Resident #55 reported RN# 205 left his room after the occurrence. Interview with RN #205 confirmed Resident #55's report, stating she utilized the back of her hand to slap Resident #55's mouth, then exited the room. An interview with Certified Nurse Aide (CNA) #206 revealed she was present in the room and confirmed both Resident #55 and RN #205's reports of what occurred. Like residents were interviewed as well as all staff working at the time of the incident, and no further issues were noted. Resident #55 was assessed, and no injuries were noted, vital signs were obtained and reported blood pressure was 110/75, pulse 88, respirations 16, temperature 97.5 degrees Fahrenheit (F) and oxygen saturation was 98%. Review of the progress note dated 10/07/24 at 11:59 P.M. written by Advanced Practice Registered Nurse (APRN) #203 revealed Resident #55 had an altercation with another person (RN #205) and was struck in the face. An examination was completed, and the resident had no bruising swelling or redness noted to either side of the face. The resident was noted to be in good spirits. Interview on 11/03/24 at 9:44 A.M. revealed the facility was aware of the abuse of Resident #55 by RN #205. The facility had completed the investigation and substantiated the allegation of abuse. RN #205 was terminated as a result of the incident. Interview on 11/03/24 at 9:52 A.M. with RN #205 revealed she reported the incident of abuse to her immediate supervisor within an hour of the occurrence. She would provide no further information regarding the incident. Interview on 11/03/24 at 10:02 A.M. with CNA #200 revealed she came in to work at approximately 4:30 A.M. on 10/06/24. RN #205 told her she had called the on-call manager and was being sent home. CNA #200 revealed talking to Resident #55 who asked to speak with the Administrator, whom she called immediately. She had no knowledge of any other concerns regarding any incidences or suspicions of resident abuse. Interview on 11/03/25 at 10:35 A.M. with Licensed Practical Nurse (LPN) #204 revealed she was the manager on duty on 10/06/24 when she received a call at approximately 4:30 A.M. from RN #205. RN #205 admitted she slapped a resident. LPN #204 instructed RN #205 to write a witness statement, clock out, and go home. LPN #204 revealed she notified the Director of Nursing (DON) and Administrator, came to work and immediately started collecting witness statements and performing skin checks on residents. Review of the personnel file for RN #205 revealed her last shift worked was 10/05/24 from 7:00 P.M. to 10/06/24 at 4:30 A.M. She was terminated on 10/11/24 for poor work performance. Review of the facility policy titled Abuse, dated 01/31/20, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. The facility would not tolerate abuse, neglect or exploitation, and residents had the right to be free from abuse including corporal punishment, involuntary seclusion, and physical or chemical restraint. The deficient practice was corrected on 10/08/24 when the facility implemented the following corrective actions: RN #205 was suspended on 10/06/24 immediately after reporting the abuse. Her employment was terminated on 10/11/24. On 10/06/24, Resident #55 was assessed and interviewed regarding the abuse; no injuries were noted or reported. On 10/06/24 all staff working at the time of the incident were interviewed, and residents were either assessed for injuries or interviewed. On 10/07/24, Resident #55 was assessed by APRN #203. There were no new orders. On 10/06/24, all staff education regarding abuse identification, prevention and requirements of reporting began, and was completed on 10/07/24. On 10/06/24, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the occurrence and perform a root cause analysis. On 10/07/24, RN #205 was reported to the Board of Nursing. On 10/08/24 at approximately 11:45 A.M. a police report was filed by the facility, incident #24-14722. Resident #55 was adamant a police report was not necessary. Resident #55 was his own responsible party. On 10/08/24 a follow-up psychosocial assessment was completed for Resident #55 with no changes noted. One 10/08/24, the facility began weekly audits of staff's understanding of abuse prevention, identification and requirements of reporting for a period of four weeks. This deficiency represents non-compliance investigated under Master Complaint Number OH00159222 and Complaint Number OH00158827.

Based on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, staff interview, and policy review, the facility failed to ensure residents with chronic wounds and those with indwelling medical devices were placed in enhanced barrier precautions (EBP) as required. This affected four residents (#8, #10, #26, and #39) of five residents reviewed for infection control. The facility census was 50. Findings include: On 06/17/24 from 8:50 A.M. to 9:00 A.M., observations during tour of the facility revealed there were no residents in EBP. There were several residents throughout the facility that had indwelling urinary catheters or wounds that were not in EBP as required. 1. A review of records for Resident #8 revealed an admitted [DATE] with diagnoses including obstructive uropathy. The resident had an indwelling urinary catheter. Review of the care plan updated on 05/21/24 revealed Resident #8 was at risk for infection related to the indwelling urinary catheter, and staff was to wear a gown and gloves when providing resident care. On 06/17/24 at 8:55 A.M. an observation of Resident #8 room revealed no EBP were in place. The observation was verified by Wellness Coordinator (WC) #126 at the time of the observation. 2. A review of records for Resident #10 revealed an admitted [DATE] with diagnoses including reflux uropathy. Significant orders included Glucerna 1.5 (nutritional supplement) at 50 milliliters (ml) per hour continuously via a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the abdomen to administer nutrition). The medical records also revealed Resident #10 had a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) on his coccyx. Review of the care plan updated on 05/21/24 to indicate Resident #10 was at risk for infection related to the PEG tube, and staff were to wear a gown and gloves when providing resident care. On 06/17/24 at 8:55 A.M. an observation of Resident #10 room revealed no EBP were in place. The observation was verified by WC #126 at the time of the observation. 3. A review of records for Resident #39 revealed an admitted [DATE]with diagnoses including obstructive uropathy. The resident had a supra-pubic catheter (a tube inserted directly into the bladder through the abdomen for urine drainage). Review of the care plan updated on 05/21/24 revealed Resident #39 is at risk for infection, and staff was to wear gown and gloves with high contact resident care. On 06/17/24 at 8:57 A.M. an observation of Resident #39 room revealed no EBP were in place. The observation was verified by WC #126 at the time of the observation. 4. A review of records for Resident #26 revealed an admitted [DATE] with diagnoses including retention of urine, unspecified. The resident had an indwelling urinary catheter. Review of the care plan revealed no interventions in place for EBP. On 06/17/24 at 9:00 A.M. an observation of Resident #26 room revealed no EBP were in place. The observation was verified by WC #126 at the time of the observation. On 06/17/24 at 10:00 A.M., an interview with the Director of Nursing (DON) revealed they did not have any residents in EBP as she was going to institute the precautions today. Review of CMS's QSO-24-08-NH dated 03/20/24 pertaining to Enhanced Barrier Precautions in Nursing Homes revealed CMS was issuing new guidance for State survey agencies and long-term care facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now included use of EBP's for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug resistant organism (MRDOs status. The new guidance related to EBP's was being incorporated into F880 Infection Prevention and Control. Guidance under F880 indicated EBP's referred to an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP's were to be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Review of the undated facility policy on Enhanced Barrier Precautions (EBP) that revealed EBP should be in place for residents with indwelling medical devices and wounds. This deficiency represents non-compliance investigated under Complaint Number OH00154138

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of the medication error report review, facility policy review, the facility failed to ensure the proper route of medication administration for Resident #51. This affected one resident (#51) of eight residents reviewed for proper medication administration. The facility census was 50. Findings include: Review of the medical records revealed Resident #51 was admitted to the facility on [DATE] and discharged on [DATE]. Significant diagnoses included paraplegia, bacteremia, stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the right and left buttocks, diabetes mellitus type II, and infection and inflammatory reaction due to cardiac valve prothesis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact. Review of the physician's orders revealed an order dated 04/18/24 through 05/17/24 for ceftriaxone sodium (an antibiotic) intravenous (IV) use 2000 milligrams (mg) IV two times a day and an order dated 04/18/24 through 05/17/24 ampicillin sodium injection solution (an antibiotic), use 2000 mg IV every four hours. On 05/17/24 a new order was obtained for ampicillin sodium injection solution use 2000 mg IV every four hours for two weeks. A review of a progress note dated 05/03/24 at 6:26 A.M. revealed LPN #177 misread the order for ampicillin and gave the 05/02/24, 8:00 P.M. dose intramuscularly (IM) instead of intravenously. The resident's wife was notified. The nurse practitioner was notified and stated the medication was okay to be given IM and no adverse reaction was expected. The nurse spoke with the pharmacist who said the medication was okay to be given IM. No redness or swelling was noted to the injection site. The resident stated he was not having pain. A review of the document titled, Country Club Retirement Center Medication and Treatment Errors and Omissions dated 05/03/24 signed by LPN #177 and the Director of Nursing (DON) revealed ampicillin 2000 mg was administered IM instead of IV as ordered on 05/02/24 at 8:00 P.M. by LPN #177. On 06/17/24 at 1:45 P.M. an interview with the DON verified that LPN #177 gave ampicillin 2000mg IM instead of IV as ordered and corrective actions were taken immediately. The nurse practitioner and the spouse were notified. A review of the policy titled, Specific Medication Administration Procedures, dated 07/01/21, stated the nurse is to review the five rights of medication administration three times before administering medication. The deficient practice was corrected on 05/04/24 when the facility implemented the following actions: On 05/03/24 LPN #177 received a verbal warning regarding the medication error. On 05/03/24 LPN #177 was educated on the Five Rights of Medication Administration: Right Patient, Right medication, Right dose, Right route and Right time by the DON. On 05/03/24 an ad hoc quality assurance and performance improvement (QAPI) meeting was held. Random medication administration competencies would be done by the DON for two weeks. Resident #51 was assessed on 05/03/24 by the DON and found to have no ill effects. On 05/03/24 all nursing staff were educated the DON on the Five Rights of Medication Administration: Right Patient, Right medication, Right dose, Right route and Right time. Nurses who were not present in the facility were in-served via phone by Wellness Director #126. The sign in sheets were verified on 06/18/24. On 05/03/24 medication administration competencies were conducted by the DON for LPN #126 and Registered Nurse (RN) #121 with no negative findings. On 05/09/24 medication administration competencies were conducted by the DON for LPN #177 and RNs #173 and #168 with no negative findings. On 05/14/24 medication administration competencies were conducted by the DON for LPN #133 with no negative findings. This deficiency represents non-compliance investigated under Complaint Number OH00154138.

Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures to prevent the spread of COVID-19 infection. This affected two residents (Resident #14 and #23) but had the potential to affect all 51 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE]. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed resident had impaired cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #14 medical record reviewed they were diagnosed with COVID-19 on 04/07/23. Review of physician orders dated 04/07/23 revealed the resident was to be on transmission based precautions (TBP) for ten days duration. Interview on 04/17/23 at 8:39 A.M. with Infection Preventionist (IP) #150 revealed the facility was in a COVID-19 outbreak status. IP #150 reported staff were to wear N95 masks, surgical mask over top of N95 mask, eye protection, gown, and gloves to enter in the COVID-19 rooms. IP #150 reported before exiting the COVID-19 rooms staff were to doff (take off) surgical mask, gown, gloves, and then upon exit disinfect their goggles or face shields and perform hand hygiene. Observation on 04/17/23 at 9:31 A.M. revealed STNA #103 donned (put on) personal protective equipment (PPE) to enter Resident #14's room with her goggles on her head. Resident #14 was observed to be on TBP. STNA #103 exited the room at 9:36 A.M. and her goggles still on her head. STNA #103 preceded to go down the hall. STNA #103 did not disinfect her goggles as required due to COVID-19 outbreak status at the facility. Interview on 04/17/23 at 9:37 A.M. with STNA #103 revealed she forgot to wear the goggles correctly as she entered Resident #14's COVID-19 positive room room to perform personal care and exited the room with the goggles remaining on her head. STNA #103 proceeded to head down the hall without disinfecting her goggles. She reported I just forgot. STNA #103 confirmed she did not wear her goggles correctly and did not clean goggles after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. Interview on 04/17/23 at 12:15 P.M. with Director of Nursing (DON) regarding observation of STNA #103 revealed staff were to wear a N95 mask, surgical mask over N95 mask, gown, gloves, and eye protection to inter a COVID-19 positive room and upon exit remove the surgical mask gown, and gloves. DON reported upon exit staff are to clean their goggles or face shield and perform hand hygiene. 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. Review of MDS dated [DATE] revealed resident had intact cognition and required extensive assistance for bed mobility, transfers, dressing and was dependent for toileting and bathing. Resident #23's medical record revealed the resident was diagnoses with COVID-19 on 04/10/23. Review of physician orders dated 04/10/23 revealed Resident #23 was to be in TBP for ten days duration. Observation on 04/17/23 at 9:41 A.M. of Housekeeping Supervisor (HKS) #119 revealed she had donned PPE to enter Resident #23 to answer a call light. Resident #23 was observed to be in TBP. Upon exiting the room at 9:44 A.M. after deactivating the call light (HKS) #119 did not disinfect her goggles or perform hand hygiene. Interview on 04/17/23 at 9:45 A.M. with (HKS) #119 revealed she didn't know how to clean her goggles and was going to use the hand sanitizer at the end of the hall. (HKS) #119 was asking this surveyor what she was supposed to do and how to clean the goggles. HKS #110 reported I was going to use the hand sanitizer at the end of the hall. HKS #110 confirmed she did not clean her goggles and did not perform hand hygiene after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. Interview on 04/17/23 at 12:15 P.M. with DON regarding observation of HKS #119 revealed staff are to wear N95 mask, surgical mask over N95 mask, gown, gloves, and eye protection to inter a COVID-19 positive room and before exit remove the surgical mask gown, and gloves. DON reported upon exit staff are to clean their goggles or face shield and perform hand hygiene. Review of facility policy, Novel Coronavirus Prevention and Response, revised 07/24/22, revealed N95 mask, eye protection, gloves and gown to be worn and hand hygiene performed. Review of the CDC guidance updated 09/27/22 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed health care personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, medical record review, interview and policy review, the facility failed to ensure a resident's complaints of constant pain with ineffective pain interventions were addressed in a timely manner. This affected one (Resident #32) of four residents reviewed for pain. The facility census was 42. Actual harm occurred to Resident #32 on 03/01/23 when Resident #32 informed Licensed Practical Nurse (LPN) #39 he had constant pain and ordered Tylenol was ineffective in managing the pain. The resident described the pain as a shocking/stabbing sensation to the left hip/leg/feet. LPN #39 failed to report the pain to the physician and no changes were made to pain management until 03/02/23 which resulted in a lack of effective pain relief and suffering for the resident for an extended period of time. Findings include: Review of Resident #32's medical record revealed diagnoses including cerebral infarction, neuropathy, type two diabetes mellitus, and osteoarthritis. The admission nursing assessment did not have any documentation in the pain section indicating whether he did or did not have pain. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated a pain assessment interview should be done but the interview was not completed. A care plan initiated 01/06/23 indicated Resident #32 had an alteration in musculoskeletal status related to osteoarthritis, generalized muscle weakness, dorsalgia (ache, strain, discomfort in the back), abnormal posture, hemiplegia (paralysis of one side of the body) and neuropathy (a group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet). The goal was for Resident #32 to remain free from pain or at a level of discomfort acceptable to the resident. Interventions included administering analgesics (pain medication) as ordered by the physician and monitoring and documenting for side effects and effectiveness. On 03/01/23 between 8:10 A.M. and 8:16 A.M., LPN #39 was observed administering routinely ordered medication to Resident #32. After returning to the medication cart to sign the administration of the medications, LPN #39 asked Resident #32 if he was having pain. Resident #32 responded he had pain all the time. When asked to rate the pain, Resident #32 rated it at a severity of eight on a scale of zero to ten (zero being no pain at all and 10 being severe pain). LPN #39 recorded the response but offered no means of pain relief at that time. LPN #39 proceeded to prepare and administer medication to Resident #29 at 8:28 A.M. At 8:32 A.M., LPN #39 was asked by the surveyor whether Resident #32 had anything ordered for pain as LPN #39 had not been observed offering pain medication or non-pharmacological interventions for pain rated severity of eight out of ten. LPN #39 looked at the medication orders and stated Resident #32 had orders for Tylenol on an as necessary basis. LPN #39 offered Resident #32 Tylenol to which he responded it did not help in relieving pain. LPN #39 reported the physician was going to be making rounds that same day and she would have the pain addressed. On 03/02/23 at 9:06 A.M., Registered Nurse (RN) #74 stated the pain interview section of the MDS was not completed because the staff member who had been assigned to do the interview did not have it completed by the assessment reference date. On 03/02/23 at 9:14 A.M., LPN #22 verified she did rounds with the physician on 03/01/23 but she was not told by LPN #39 that Resident #32 was complaining of constant pain and that ordered Tylenol was not effective in helping relieve pain. LPN #22 stated pain was assessed every shift but did not know about comprehensive pain assessments. At 9:22 A.M. LPN #22 stated pain assessments were completed on admission but verified the admission assessment was blank for pain. On 03/02/23 at 9:27 A.M., LPN #22 interviewed Resident #32 and he reported he had constant pain, describing it as a shocking/stabbing sensation. The pain was in the left hip/leg/feet. LPN #22 informed Resident #32 she would contact the physician. At 9:58 A.M. LPN #22 stated she spoke with the physician and he gave an order for Ultram 50 milligrams (mg) every six hours as needed for pain. Review of the facility's Pain Management policy, revised 06/12/17, indicated staff nurses were to complete the initial admission nursing assessment within 24 hours and initiate a pain flow record for all new admissions. All residents would be reviewed upon admission, quarterly and as necessary for acute, chronic, or no pain. On an individual basis, each resident was assessed every shift to evaluate new onset pain or effectiveness of pain management interventions. The nurse would use a numeric pain distress scale or the Wong-Baker faces pain scale for recorded pain.

Based on record review, review of the Ohio Administrative Code (OAC) for Prescription Processes, observation of medication administration and interview the facility failed to ensure nurses followed acceptable standards of practice for obtaining medication orders. This affected two (Residents #45 and #151) of five residents reviewed for medication administration. The facility census was 42. Findings include: 1. Record review for Resident #151 revealed an admitted [DATE] and a physician order dated 02/19/23 for vitamin B12 oral tablet 500 micrograms (mcg) give 500 mcg by mouth one time a day. On 03/01/23 at 8:52 A.M., Registered Nurse (RN) #28 was observed administering medication to Resident #151. While preparing Resident #151's medication for administration RN #28 stated he was unable to locate the appropriate dose of guaifenesin (expectorant) or vitamin B12, stating he would have to administer them later. A request was made for RN #28 to notify the surveyor when the medication was located for observation. 2. Record review for Resident #45 revealed and admitted [DATE] and a physician order dated 01/27/23 for Calcium-Magnesium oral tablet 500-250 milligrams (mg) give one tablet by mouth one time a day. On 03/01/23 between 9:22 A.M. and 9:31 A.M., RN #28 was observed administering medication to Resident #45. While preparing Resident #45's medication for administration he stated he was unable to locate the ordered Calcium-Magnesium 500-250 mg to give to Resident #45. A request was made for RN #28 to notify the surveyor when the medication was located for observation. On 03/01/23 at 10:44 A.M., RN #28 approached the surveyor and revealed the following information related to the B12 oral tablet for Resident #151 and the Calcium-Magnesium tablet for Resident #45 RN #28 had been unable to locate and administer to these residents during the medication administration observation: RN #28 explained Resident #151 had orders for vitamin B12 500 mcg but he only had 1000 mcg tablets which were not scored (an indented line in the middle of the tablet so the tablet could be cut in half). Since RN #28 only had vitamin B12 available in 1000 mcg doses, RN #28 had spoken to the Director of Nursing (DON) who told him she (the DON) was told by the physician previously that when giving over the counter medication such as the B12 and Calcium-Magnesium supplement it was okay to re-write the order to reflect what the facility had in stock and without RN #28 getting the order directly from a prescriber. RN #28 indicated he planned to re-write Resident #151's order for vitamin B12 for 1000 mcg every day and re-write Resident #45's order for Calcium-Magnesium for 600-400 mg tablet because that is all he had available to give to Resident #45. When asked if the DON had prescribing authority for RN #28 to accept an order from her he stated she did not, but he trusted her, so he would re-write the orders. After again asking if it was appropriate to change an order based on something told to him by the DON or another nurse who was not a certified nurse practitioner who could act as a prescriber he verified it was not and stated he would check with the physician about the orders. On 03/01/23 at 11:14 A.M., RN #72 verified a nurse should never instruct another nurse to write an order or give a change in medication orders absent the legal authority to prescribe medications. At 12:12 P.M. RN #72 stated although the DON was given an order approving the change to the original orders it was not appropriate for another nurse to write orders he or she had not personally received from the physician. Review of the OAC 4729:5-5 for prescription processes stated a prescription, to be valid, must be issued for a legitimate medical purpose by an individual prescriber acting in the usual course of the prescriber's professional practice.

Based on medical record review and interview, the facility failed to ensure appropriate treatments were applied to a pressure ulcer for one resident (Resident #5) of five residents reviewed for pressure ulcers. The facility census was 42. Findings include: Review of Resident #5's medical record revealed diagnoses included left hip fracture, diabetes mellitus, and macular degeneration. An order dated 02/21/23 indicated the wound bed on the coccyx was to be irrigated with normal saline then covered with calcium alginate (a treatment for wounds) and a foam dressing every day and as necessary. A wound consultant note dated 02/27/23 indicated Resident #5 had a stage three pressure ulcer on the coccyx (full thickness tissue loss without bone, tendon or muscle being exposed). Instructions revealed to continue calcium alginate to aid in autolytic debridement of the wound. On 03/02/23 between 11:00 A.M. and 11:20 A.M., Licensed Practical Nurse (LPN) #22 was observed gathering supplies to complete Resident #5's dressing change to the pressure ulcer on her coccyx. LPN #22 gathered normal saline, gauze, a tube of santyl (an ointment used to debride a wound), a cotton applicator, and a foam dressing. When asked if Resident #5 had an order for santyl, LPN #22 stated she would have to check with Registered Nurse (RN) #28 because she was not sure of the order. The orders were not in view and LPN #22 was not heard asking RN #28 for verification of the orders. When the old dressing was removed LPN #22 observed there was a piece of calcium alginate on the wound and she sent RN #28 to obtain calcium alginate from the cart. When placing the new dressing on the pressure ulcer site, LPN #22 placed santyl on a piece of calcium alginate and applied it to the pressure ulcer then covered it with a foam dressing. On 03/02/23 at 1:40 P.M., LPN #22 verified she had applied santyl and calcium alginate to the wound bed. LPN #22 verified she had not reviewed the treatment order before applying the dressing, stating she did it on the fly. LPN #22 stated she figured RN #28 would tell her if the order was incorrect. Review of the facility's Wound and Skin Care policy, revised 06/07/16 revealed treatments would be initiated as ordered by the physician.

Based on record review and interview, the facility failed to thoroughly and consistently record bowel movements for assessment of constipation for Resident #9. This affected one (Resident #9) of 12 residents interviewed regarding constipation. The facility census was 42. Findings include: Review of Resident #9's medical record revealed an admitted [DATE] and diagnoses including right hip fracture, traumatic subarachnoid hemorrhage, arthritis, pain in the right leg and neuropathy. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #9 was able to make herself understood. Resident #9 was dependent for toilet use. A plan of care initiated 02/15/23 indicated Resident #9 had potential for constipation related to decreased mobility and medications. The stated goal was for Resident #9 to have a bowel movement at least every three days. Interventions included observing for and documenting bowel movements, observing for complaints of abdominal discomfort and abdominal distention, and administering medications as ordered. Resident #9 had an order for psyllium husk powder one unit every day for constipation. Review of bowel movement records revealed no record of a bowel movement from 02/04/23 through 02/11/23. No bowel movement was recorded between 02/16/23 and 02/23/23. Review of the February 2023 Medication Administration Record (MAR) revealed the following orders for treatment of constipation with start dates of 02/03/23: Colace (stool softener) 100 milligrams (mg) every 12 hours as needed, one Dulcolax suppository as needed if no results were achieved within eight hours of administration of Milk of Magnesia (MOM). If there were no results within 15 to 20 minutes of administration of the Dulcolax suppository, it could be repeated; one Fleet enema as needed if no results were achieved from administration of the suppository, and MOM 30 milliliters as needed if there was no bowel movement within six shifts. The February MAR nor the progress notes revealed administration of any of the medications ordered on an as necessary basis for constipation. There was no documentation of Resident #9 being interviewed or assessed related to the extended periods without documentation of a bowel movement. During an interview on 02/27/23 at 10:00 A.M., Resident #9 verified she did have constipation and had not received any medications to promote bowel movements. On 03/03/23 at 1:15 P.M., Registered Nurse (RN) #72 stated the electronic health record provided an alert to the nurse when a resident did not have a bowel movement. If alerted, nurses should check with aides to ensure they had documented bowel movements for each resident and if they had not, the nurse should offer something for constipation in accordance with the orders. On 03/03/23 at 1:45 P.M. RN #72 verified the lack of documentation of bowel movements for Resident #9.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and policy review the facility failed to ensure transfers according to physician's orders. Actual Harm occurred on 07/15/22 when staff failed to follow a physician's order for transfers resulting in a fall and fracture to Resident #19's right ankle. This affected one Resident (#19) of three residents reviewed for accidents. The facility census was 50. The deficiency was corrected on 07/22/22 when the facility implemented the following corrective actions: · On 07/15/22 at approximately 12:30 P.M. the physician was notified of the incident with an order received for x-ray examination by Licensed Practical Nurse (LPN) #203. · On 07/15/22 at approximately 12:30 P.M. Resident #19's sister/emergency contact was notified of the incident and physician order for x-ray examination by LPN #203. · On 07/15/22 at approximately 2:00 P.M. counseling/education was provided to State tested Nurse Aide (STNA) #204, involved in the incident, by LPN Unit Manager #206. · On 07/15/22 at approximately 9:00 P.M. a root cause analysis was conducted with determination causative nature of the incident by LPN Unit Manager #206, Administrator, and Regional Nurse #207. · On 07/15/22 at approximately 9:56 P.M. an education notice regarding mechanical lift requirements completed for all licensed nurses and STNA staff. The education was completed with signatures verified by 07/22/22 by the Director of Nursing (DON) and LPN Unit Manager #206. · On 07/15/22 at approximately 10:00 P.M. an audit of records for all residents requiring mechanical lift transfer was completed with orders and tasking initiated by LPN Unit Manager #206. · On 07/19/22 at approximately 1:30 P.M. the employment of STNA #204 was terminated by the DON. · Audits of mechanical lift requirements to be conducted for three residents three times a week for four weeks. The audits consist of observations and resident interviews to verify compliance with use. The audits will by completed by the DON. · Audit findings will be presented to Quality Assurance and Performance Improvement (QAPI) committee weekly for recommendations. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], asthma, diabetes, and [CONDITION(S)]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition and was totally dependent on two staff for transfers. Review of the plan of care dated 06/20/22 revealed Resident #19 required assistance with activities of daily living (ADL) due to asthma, arthritis, knee pain, and weakness. Interventions included assistance with ambulation, transfers, and toileting as needed. Review of the physician orders for July 2022 identified an order dated 05/05/22 for a Hoyer (manual hydraulic) lift for all transfers. Review of the nurse's notes dated 07/15/22 at 12:42 A.M. revealed Resident #19 was complaining of right ankle/foot pain. The physician was notified and ordered an x-ray of the right foot/ankle. Review of the nurse's note dated 07/15/22 at 11:12 P.M. stated Resident #19's x-ray revealed a subacute lateral malleolar fracture with subtle adjacent periosteal reaction. The physician was notified, and Resident #19 was transferred to the hospital. Review of the nurse's note dated 07/16/22 at 10:30 A.M. stated Resident #19 returned from the hospital with a closed avulsion fracture (a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) of the right ankle. Resident #19 had a soft cast to the right lower extremity. Review of the facility investigation of the incident revealed a witness statement dated 07/15/22 authored by State tested Nurse Aide (STNA) #204 stating she was helping Resident #19 into her wheelchair when Resident #19 slipped, and she lowered her to the ground before getting help from STNA #205. A witness statement from STNA #205 revealed she observed Resident #19 sitting on the floor beside her bed when she entered her room. Interview on 07/25/22 at 8:25 A.M. with Resident #19 stated, STNA #204 did not want to use the Hoyer lift, so she lifted me, and my foot slipped under the chair, and my ankle was chipped. Interview on 08/01/22 at 7:49 A.M. with the Director of Nursing (DON) revealed STNA #204 attempted to transfer Resident #19 without using the Hoyer lift, and the resident was lowered to the ground and suffered an avulsion fracture. Resident #19 told STNA #204 she normally used a Hoyer lift but agreed to transfer without it. STNA #204 was terminated for failure to follow fall protocol and physician's orders. Review of the facility policy titled Transfer for Resident for Sit to Stand and Hoyer Lift, updated 07/31/14, revealed resident's incapable of transferring independently or with an assist of one person are to always have a minimum of two nursing personnel involved in the transfer. Two persons were required for those using a Hoyer lift. This deficiency substantiates Complaint Number OH 280.

Based on medical record review, review of the facility policy and procedure titled Transfer and Discharge, review of the facility policy and procedure titled Disposal of Medications and Medication - Related Supplies, observation of pictures of medications dispensed, review of hospital records and staff and family interview, the facility failed to provide a safe and orderly discharge for Resident #47, who was discharged from the facility on 04/29/22 with medications prescribed for another resident (Resident #48) and for which the resident did not have physician's orders. Resident #47 took the medications at home as directed by the discharging nurse, Licensed Practical Nurse (LPN) #116 until she experienced an acute change in condition which resulted in an intensive care hospitalization on [DATE]. This resulted in Immediate Jeopardy, on 04/29/22 when Resident #47 was discharged home with medications prescribed for Resident #48. The medications were taken by the resident based on the directions on the medication label. Actual harm occurred when upon hospital admission the resident was assessed to have an acute mental status change, [CONDITION(S)] (low blood pressure), [CONDITION(S)] (low pulse), electrocardiogram (EKG) (a test that measures electrical activity of the heartbeat) changes, concerns for beta- blocker (medication that reduces blood pressure) medication overdose and inability to maintain her airway. The resident was intubated and admitted to the intensive care unit for treatment. This affected one resident (#47) of five residents reviewed for discharge. The facility census was 44. On 06/08/22 at 1:21 P.M. Regional Director of Operation #136, the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 04/29/22 when the facility failed to provide a safe and orderly discharge home for Resident #47, who was discharged home with another resident's medications. Resident #47 took the medications as directed by the discharging nurse, LPN #116 until she experienced as acute change in condition resulting in an intensive care hospitalization on [DATE]. The Immediate Jeopardy was removed on 06/08/22 when the facility implemented the following corrective actions: · LPN #116 did not work in the facility after 04/29/22 and was subsequently terminated on 06/08/22. · On 06/03/22 at 6:00 P.M. the DON contacted Primary Care Physician #140 (who was the facility medical director) via text message to notify him of the occurrence, investigation and actions taken by the facility. · On 06/03/22 the DON sent a text message to LPN #116 regarding the onsite investigation and notifying her she sent the wrong medications home with Resident #47, family questioning her about them being wrong and being told they were mislabeled. The DON requested a statement from the LPN regarding the incident. No formal statement was obtained from LPN #116. · On 06/03/22 the DON contacted the pharmacy and verified five medications, ordered for Resident #48 had to be re-ordered on 04/30/22 due to the medications being unavailable in the facility. The medications were on an auto-refill schedule and not due to be sent to the facility until 05/09/22. The facility denied any investigation of this incident between 04/30/22 and 06/03/22. · On 06/03/22 at 7:00 P.M. Licensed Practical Nurse (LPN)/ Social Service Designee (SSD) #102, Registered Nurse (RN)/ Minimum Data Set (MDS) #135, RN/Assistant Director of Nursing (ADON) #98 and LPN/Programs Nurse #63 completed audits of all current residents to ensure medications were available and correct. This was reviewed and verified as completed on 06/08/22 at 8:05 A.M. · On 06/03/22 at 6:15 P.M. a Root cause analysis/ Quality Assurance Performance Improvement (QAPI) meeting was conducted. Participants included the Director of Nursing (DON), RN/ADON #98, LPN/Programs Nurse #63, LPN/SSD #102, RN/MDS #135, RN/MDS regional #137, Administrator, RN/Corporate Nurse. The root cause analysis indicated licensed nursing staff were non-compliant with the discharge reconciliation process. Medication cards do not clearly indicate resident/medication name. This was reviewed and verified as completed on 06/08/22 at 11:45 A.M. · On 06/03/22 at 6:07 P.M. the DON provided education to 8 of 17 facility licensed nurses regarding the five rights of medication administration. · On 06/07/22 at 7:00 A.M. Regional MDS/RN #137 reviewed resident discharges for Residents #49, #52, #53, #51, #54, #55, #56, #57, #58, #59 and #60 discharged between 04/29/22 and 06/07/22 for medication reconciliation and to ensure medications sent home with residents identified supportive documentation confirming appropriate/proper medications provided. · On 06/08/22 the Regional Director of Care Services revised the facility Transfer and Discharge policy to include Medication Reconciliation and a new process for two staff to reconcile medications for all residents being discharged with actual medications. A new form was created titled Medications to be included in the resident's discharge plan of care. · On 06/08/22 at 4:00 P.M. the DON, RN/ADON #98, LPN/Programs Nurse #63, and LPN/SSD #102 educated all licensed nursing staff regarding the discharge process in relation to medication verification and reconciliation including signature of performance verification by two licensed nurses. Sixteen of 16 facility nurses were provided this education either in person of via phone. · On 06/08/22 at 3:22 P.M. the DON notified the Ohio Board of Nursing regarding the incident involving LPN #116. · On 06/08/22 the facility initiated a Discharge Medication Reconciliation Process audit form to verify appropriate medication documentation and reconciliation was completed for each discharge for six weeks by the DON/designee. · On 06/08/22 from 4:48 A.M. to 4:55 P.M. and on 06/09/22 from 11:12 A.M. to 11:41 A.M. interviews with Registered Nurse (RN) #72, RN #127, LPN #101, LPN #112 and LPN #129 revealed they had received the training and were knowledgeable regarding the five rights of medication administration. · On 06/08/22 from 4:48 A.M. to 4:55 P.M. and on 06/09/22 from 11:12 A.M. to 11:41 A.M. interviews with RN #72, RN #127, LPN #101, LPN #112 and LPN #129 revealed they had received the training and were knowledgeable regarding the discharge process. Although the Immediate Jeopardy was removed on 06/08/22, 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings Include: Review of Resident #47's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to home on 04/29/22. Resident #47 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of baseline care plan, dated 04/19/22 and completed per LPN/SSD #102 for Resident #47 revealed a goal for the resident to stay at the facility to get stronger and then go home. Review of vital sign documentation, including Blood Pressure Summary dated 04/24/22 to 04/29/22 revealed Resident #47's blood pressures had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The drop in blood pressure may be sudden): On 04/24/22 at 8:56 A.M. the resident's blood pressure was 93/57, on 04/26/22 at 11:04 A.M. her blood pressure was 82/42, on 04/26/22 her blood pressure was 82/42, on 04/29/22 her blood pressure was 90/48. (Normal blood pressure 120/80). Review of the Medicare five-day MDS 3.0 assessment, dated 04/25/22 revealed Resident #47 had intact cognition with a Brief Interview for Mental Status score of 14 out of 15. The assessment revealed the resident required extensive assistance from one person for bed mobility and required staff supervision with set up help for transfers and walking in her room. Review of a physician telephone order, dated 04/28/22 and written by the DON revealed an order indicating may send medications home with Resident #47. The telephone order was signed by Primary Care Physician #140 with no date. Review of the resident's physician medication orders, current as the resident's discharge on 04/29/22 revealed orders for [MEDICATION(S)]/Budesonide 3 milligrams (mg) delayed release capsule give three capsules by mouth one time a day for [CONDITION(S)] (the medication is a corticosteroid), [MEDICATION(S)] pen injector insulin solution 100 units per milliliter 10 units subcutaneously (SQ) one time a day for diabetes, [MEDICATION(S)] delayed release 40 mg tablet one tablet by mouth one time a day for gastroesophageal reflux disease, [MEDICATION(S)] packet 4 grams one packet by mouth two times a day, [MEDICATION(S)] insulin solution 100 units per ml 5 units SQ three times a day for diabetes with meals, [MEDICATION(S)] 10 mg tablet two tablets by mouth three times a day with meals for orthostatic [CONDITION(S)], and Sodium [MEDICATION(S)] 650 mg tablet give one tablet by mouth four times a day for electrolyte imbalance. Review of a nursing note, dated 04/29/22 at 5:40 P.M. and authored by LPN #116 revealed Resident #47 was discharged at 5:30 P.M. The nursing note documented LPN #116 went over the medications and remaining medicines were sent home with resident. The nursing note included the resident's vital signs, blood pressure 92/50, pulse 90 per minute, respirations 20 per minute, oxygen saturation rate 99 percent on room air and temperature 98.5 degrees Fahrenheit. Review of a facility form labeled Discharge Plan of Care, dated 04/29/22 revealed the form contained no information regarding the resident's medications at all. The discharge instructions included the resident was admitted on [DATE] with an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The sections on the form for dietary and nutritional needs, scheduled appointments, lab work and treatments were blank. The nursing discharge assessment included the vital signs as noted in the above nursing progress note and contained no further special instructions. The discharge instructions were signed and dated 04/29/22 by Resident #47 and LPN #116. The discharge plan of care/instructions did not include any information at all regarding medications that were prescribed upon discharge, instructions regarding how to take any of the prescribed medication or any information regarding the medication or amount of medication that was discharged with Resident #47. A blank copy of the Discharge Plan of Care paperwork provided by the facility during the onsite investigation, revealed a page in the paperwork should have also included a page labeled, List of Medication. However, this page was missing from Resident #47's discharge paperwork and was not available from the facility to review. Review of a Physician Discharge Summary form for Resident #47 documented an admitted [DATE] and discharge date was 04/29/22. The summary revealed Resident #47's condition was per chart and the resident was to be discharged with home services. The physician discharge summary contained documentation medications discarded. No other information was contained in the discharge summary. The summary was signed by Primary Care Physician #140 but was not dated. Review of a Medication Disposition Sheet, dated 04/30/22 and completed by LPN #110 revealed the following medications were returned to the pharmacy for Resident #47: one (1) card of [MEDICATION(S)] 40 mg tablets that contained 12 tablets, two (2) cards of [MEDICATION(S)] 10 mg tablet that contained a total of 37 tablets and one card of Budesonide 3 mg capsules that included 16 capsules. Review of hospital admission paperwork, dated 05/07/22 for Resident #47 revealed she was a direct admission to this hospital on 05/07/22 from another local hospital emergency room for altered mental status. The hospital paperwork revealed per husband, patient discharged with prescriptions under different person called the facility to verify. He was told that the medication given are the appropriate medication, and in fact she has been taking those medication during her 10 days stay at the SNF. Husband was confused but continued to give medication to the patient that she was discharged on . The paperwork revealed Resident #47 started on 05/04/22 and 05/05/22 having confusion, lethargy, urinating and defecating in her bed. Husband and resident's daughter tried to re-orient Resident #47 many times but were unable and took Resident #47 to the local hospital emergency room . The paperwork revealed Resident #47 presented at the local emergency room with [CONDITION(S)], [CONDITION(S)], showed abnormal lab values including elevated liver function test, [CONDITION(S)], elevated lactic acid, and abnormal EKG with significant [CONDITION(S)]. She was started on fluids, [MEDICATION(S)] infusion (used to treat severe kidney disease), started on [MEDICATION(S)] (used to treat life threatening low blood pressure), given [MEDICATION(S)] for concern of beta blocker overdose, intubated and life flighted to (this) current hospital. A hospital history and physical, dated 05/07/22 and completed by Physician #141 revealed Resident #47 was discharged from a nursing home one week ago and was fine until two days ago when she became very tired and having difficulty with incontinence. Physician #141 revealed Resident #47's family reported Resident #47 received medication from the facility with a different person's name on the medication, but the family member revealed when he brought this concern to the nursing homes attention, the family member was told to continue to give the medications. The history and physical revealed Resident #47 had received medications including the (diuretic medication) [MEDICATION(S)] ([MEDICATION(S)]), ([CONDITION(S)] medication) [MEDICATION(S)], (cholesterol medication) [MEDICATION(S)] ([MEDICATION(S)]) and (the anti-hypertensive medication) [MEDICATION(S)] ([MEDICATION(S)]) that were not prescribed for her. Hospital vital signs included blood pressure 72/50 (low), pulse 49 beats per minute (low), respirations 18 per minute and temperature was low at 92.7 degrees Fahrenheit. The resident was admitted to the intensive care unit with concerns for being administered the wrong medications and was to be continued on a mechanical ventilator support at that time. Review of photos (dated 05/25/22) provided by Resident #47's brother of the medication card labels that were sent home with Resident #47 upon discharge revealed the labels all contained another resident's name (Resident #48) on all the cards, all were dispensed per the facility's pharmacy, and all the medications revealed they were ordered by Primary Care Physician #140. The card labels included: one card containing [MEDICATION(S)] 10 mg tablet with the directions to take one tablet by mouth daily related to [CONDITION(S)] dispensed to the facility on [DATE], two cards containing [MEDICATION(S)] 25 mg tablet to take one tablet by mouth twice a day (one card for AM and one care for PM) related to hypertension dispensed to the facility on [DATE], one card containing [MEDICATION(S)] 125 micrograms (mcg) take one tablet by mouth daily related to [CONDITION(S)] dispensed to the facility on [DATE], one card containing [MEDICATION(S)] 20 mg tablet take one tablet by mouth daily related to chronic kidney disease dispensed to the facility on [DATE], and one card containing [MEDICATION(S)] 50 mg tablet to take one tablet by mouth daily for depression dispensed to the facility on [DATE]. On 06/03/22 at 4:19 P.M. and 6:22 P.M. and on 06/08/22 at 8:35 A.M. interview with Resident #47's fiancé revealed Resident #47 was discharged from the facility on 04/29/22 with the following medication cards: one card containing [MEDICATION(S)] 10 mg tablets, two cards containing [MEDICATION(S)] 25 mg tablets, one card containing [MEDICATION(S)] 125 mcg tablets, one card containing [MEDICATION(S)] 20 mg tablets and one card containing [MEDICATION(S)] 50 mg tablets. The resident's fiancé revealed there were a total of six medication cards he was given upon discharge. He revealed all the cards had a different resident name on the cards (identified to be another facility resident, Resident #48). The resident's fiancé revealed he questioned the discharging nurse, LPN #116 regarding the cards having a different name on the cards when she handed him the cards, but LPN #116 told him to give the medications anyways as it was fine that the name on the medications were different. During the interview, the resident's fiancé revealed he was also given one medication box that contained [MEDICATION(S)] packets (4 grams). The [MEDICATION(S)] box was the only medication he was provided with Resident #47's name on it. He revealed he did not receive any other medications from the discharging nurse, LPN #116, including any insulin for the resident. The resident's fiancé revealed LPN #116 just handed him the cards and did not review the discharge instructions including a review of the actual medications or instructions on how or when to take the medications. The resident's fiancé also revealed a lack of communication regarding the resident's diet, fluid restrictions or any follow-up care required. He stated LPN #116 just had Resident #47 sign the discharge paperwork. During the interview, the fiancé revealed he administered the medications given to him by LPN #116 from 04/29/22 until 05/04/22 when the resident started not acting right, she was not responding as she was tired and had incontinence. The resident's fiancé revealed over the next couple days the resident continued to not respond so he took her to the emergency roiagnom on [DATE] and the emergency room intubated Resident #47 and life flighted her to another hospital. On 06/08/22 at 7:36 A.M., 10:19 A.M. and 12:37 P.M. interview with the Director of Nursing (DON) verified the pictures that were submitted by Resident #47's brother had Resident #48's name on the cards and that the cards with the resident name, dose and instructions of the medications that were prescribed for Resident #48 and had come from their facility pharmacy. She verified the copy in the medical record of Resident #47's discharge instructions did not include any information regarding medications and the instructions that were provided to the resident upon discharge. She also verified the discharge instructions did not include what medications were actually sent home with Resident #47 or the amounts of medications that were sent home. The DON revealed the facility's policy was to document and include this information as part of the resident's medical record. The DON revealed the nurse was to either write out the medications on the discharge plan of care and/ or provide a printout of the medications. In addition, the expectation was for the nurse to review each medication and the instructions of each medication and then have the resident and/or responsible party sign that they received the medication and instructions. A copy was to be maintained as part of the resident's medical record. During the interview, the DON revealed on 06/03/22 after being asked about this incident, the DON spoke to Pharmacist #143 and learned the facility had to re-order Resident #48's medications on 04/30/22 (as they were unavailable) despite the pharmacy reporting the medications should not have had to be refilled until 05/09/22. The DON revealed prior to 06/03/22 she had not investigated into why Resident #48's medications were not available and needing to be refilled early. In addition, the DON revealed on 06/03/22 she reviewed the medication disposition sheet and discussed with Pharmacist #143 that only four cards of nine medication cards were returned to the pharmacy for credit for Resident #47. The DON had no idea where the remaining medication cards were for Resident #47 as of that time. The DON indicated she checked all of the mediation carts and nursing stations and was unable to locate any other medications prescribed for Resident #47 on this date. On 06/08/22 at 8:16 A.M. interview with LPN/SSD #102 revealed she started the discharge process for Resident #47 by utilizing the facility packet labeled, Discharge Plan of Care prior to the resident's discharge on 04/29/22. She revealed the discharge packet included a form labeled, List of Medication that the nurse was responsible for filling out. LPN/SSD #102 verified on the medication list form that it included medication, dose, frequency, time last dose was given, reason of medication, number of medications sent home and if the pharmacy was called. LPN/SSD #102 revealed if the nurse did not fill out this form that they could just print out the medication list from the computer and include this list with the discharge instructions, but they needed to write on the printout if medications were sent home and the number of medications. She revealed the nurse, after completing the sections including the medication list and/or print out, was to make a copy of the packet including the printout if used, reviewed with the resident and/or responsible party and had the responsible party sign the packet including the printout if used and place a copy in the medical chart. LPN/SSD #102 revealed she could not remember if she left the discharge packet in Resident #47's chart and/or if she had given the packet to a nurse. On 06/08/22 at 9:38 A.M. telephone interview with LPN #116 revealed she worked for the facility on an as needed basis and usually worked night shift. LPN #116 revealed the last day she had worked at the facility was on 04/29/22. She was asked if she remembered Resident #47 and indicated she did not remember residents by their name and did not remember Resident #47. LPN #116 revealed she did however remember on 04/29/22 she had worked 7:00 A.M. to 7:00 P.M. and that it had been a hectic day as she had two discharges and one admission but could not remember the names of the residents. LPN #116 revealed she had never discharged a resident at the facility before and that she did not remember receiving any training/education upon hire on the facility's process of how to discharge a resident including discharging a resident with medication. LPN #116 revealed a couple days ago she had received a text message from the DON questioning if she had given Resident #47 the incorrect medications when she went home. LPN #116 revealed she received the discharge paperwork for Resident #47 but could not remember who she got the discharge paperwork form. She revealed she could not remember but did not believe she filled out any information on the discharge paperwork including diet, medications, labs, treatments or upcoming appointments. LPN #116 indicated she thought she printed out a medication list and put it with the discharge instructions. She revealed she did not make a copy of the medication printout that she had provided to the resident upon discharge to be maintained as part of the medical record. LPN #116 revealed she went then to the medication cart and grabbed Resident #47's medications and thought they had the resident's name on them. She revealed she had just grabbed the medications from the slot in the cart and verified she did not go one by one to check against the physician orders to ensure the medication matched the orders including the five rights of medication administration. LPN #116 revealed she handed the medications to Resident #47's fiancé and had Resident #47 sign the discharge instructions. She verified she did not go over the discharge instructions including the medications or the instructions of the medications with the Resident #47 and/or Resident #47's fiancé'. During the interview, LPN #116 denied Resident #47's fiancé brought to her attention that the name on the medication cards were different than Resident #47's name and stated she did not recall telling Resident #47's fiancé that it was ok to take the medication despite having a different name on the card. Review of LPN #116's personnel file revealed a hire date of 02/17/22. The LPN had a current/valid nursing license and had previous employment at other long term care facilities and assisted living facilities noted under previous work experience. Review of employee orientation packet labeled, Charge Nurse Orientation revealed on 02/18/22 LPN #116 was oriented by LPN/SSD #102 regarding discharges including discharge plans, medications, home instructions and appointments. The orientation was initialed by LPN/SSD #102 as completing the training but under the section of charge nurse signature revealed no evidence LPN #116 had completed/received the training. This section was blank. On 06/08/22 at 12:39 P.M. interview with LPN/SSD #102 revealed as part of a new nurse orientation she verbally goes over how to discharge a resident. She revealed she instructs the nurse to educate the resident and or resident responsible party on each medication and the instruction of each medication. She revealed she verbally instructs the nurse to either print out a medication list and/or fill out the medication list on the discharge packet and to have the resident and/or responsible party to sign that they had received the medications and instructions to maintain as part of their medical record. LPN/SSD #102 revealed the training normally took approximately 15 to 30 minutes and she had nothing formal that she reviewed or anything in writing that she provided the nurse. Review of facility policy titled Transfer and Discharge, dated 11/01/16 revealed medication reconciliation of all pre-discharge medications with the residents' post discharge medications would be completed. The post discharge plan of care would be developed with the participation of the resident and the resident representative and would include any arrangements that had been made for the resident's follow up care and any post discharge medical and non-medical services. The policy revealed a copy of the plan would be provided to the resident and a copy in the medical record. Review of facility policy titled Disposal of Medications and Medication - Related Supplies, dated 07/01/21 revealed medications were sent home with a resident upon discharge to the facility on ly under conditions that protect the resident and assure compliance with State laws. The policy revealed medications were to be sent home with a resident on discharge if ordered by the prescriber of the medication and the prescriber should list the medication to be released upon discharge. The policy revealed the labels on the discharge medications were to be verified for completeness and accuracy by reconciling the medications against the most recent physician orders. The policy revealed the directions for use of the medications were to be reviewed with the resident and/ or responsible party. The policy revealed discharge medication information was to be listed on the medication release form. The resident and/ or responsible party would sign the medication release form as proof of chain of custody and the nurse should document the number of doses of each medication were discharged to the patient or responsible party on the medication release form. Review of undated facility discharge forms labeled, Discharge Plan of Care revealed the second page labeled, List of Medication of the discharge instruction that went home with the resident upon discharge were to include medication, dose, frequency including when and what time the medication was for last dose given, reason of the medication, number of pills that were sent home and if the pharmacy was called. This deficiency substantiates Complaint Number OH 814.

Based on observation, record review and interview the facility failed to ensure initial and/or quarterly care conferences were planned and held for Resident #9 and Resident #41 to allow the residents to participate in their overall plan for care. This affected two residents (Resident #9 and #41) of two residents reviewed for care conferences. Findings include: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the 30-day Minimum Data Set (MDS) 3.0 assessment, dated 09/6/18 revealed Resident #41's had a Brief Interview of Mental Status (BIMS) score of 13. Review of Resident #41's care plan with an initiation date of 08/22/18 revealed the resident was having difficulty coping with current condition related to corneal transplant with post-operative complications leaving Resident #41 legally blind in left eye and in pain. Resident #41 has [DIAGNOSES REDACTED].#41 included encourage resident to set realistic goals, increase communication between resident, family and caregivers about care and living environment, and provide opportunities for the resident and family to participate in care. Interview on 09/17/18 at 09:38 A.M. with Resident #41 revealed that she had not been invited or that she had not attended a meeting to discuss her plan of care since she had been admitted to the facility. Resident #41 revealed she would like to know what her goals were to be able to be discharged back home. Interview on 08/18/18 01:26 P.M. with Corporate Registered Nurse (RN) MDS Director #300 and Assistant Director of Nursing/ Social Service Designee #301 verified that a care conference for Resident #41 was never set up or held since admission as the facility does not have a full time MDS coordinator and was going through a transition at this time. Review of the facility policy titled, Plan of Care Meeting with a revision date of 01/26/17 revealed each resident would be encouraged to exercise the right to participate in planning their care. The policy included upon admission to the facility the initial care plan meeting will be held within 72 hours whenever possible. Resident goals for discharge would be reviewed at this meeting. 2. Record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 was discharged from the facility and hospitalized [DATE] for a left above the knee amputation. Resident #9 returned to the facility for rehabilitation 05/20/18. Review of the significant change MDS 3.0 assessment, dated 05/27/18 revealed Resident #9 had declined in areas of activities of daily living and functional status. However, the same MDS revealed Resident #9 remained alert and oriented with no cognitive deficit. Resident #9 was observed in physical therapy on 09/17/18 at 03:23 P.M. Resident #9 expressed some frustration to the therapist regarding her progress. The therapist was encouraging and Resident #9 was actively participating. An interview was completed with Resident #9 immediately following the physical therapy session. Resident #9 revealed she had hoped to return home but her son thought she needed 24 hour assistance. Resident #9 revealed she would like to consider assisted living but did understand the requirement for admission. As the conversation continued, it became clear Resident #9 was not aware, or did to understand, what progress, skills/strengthening or timeline she needed to meet for a potential discharge to the assisted living center. Resident #9 denied any knowledge or experience with a plan of care, or plan of care meetings. She stated, I just don't know what the plan is. I'm still here and it just goes on and on. Resident #9 verified she would like to meet with the social service, therapy and nursing staff. Resident #9 revealed it was important to include her son. On 09/18/18 at 12:59 P.M., the son of Resident #9 sought out this surveyor to ask about the discharge planning conversation this surveyor had had with his mother the previous day. Resident #9 explained he was unable to care for his mother at his home because she would need full time care, perhaps on a permanent basis. The son revealed he had explained this to his mother, but at times, she would still reference going home. The son of Resident #9 revealed he had had discussions with several staff nurses and State tested nursing assistants (STNAs) but more related to day-to-day activities with no planning process or discharge addressed. Resident #9 revealed he and his mother were very satisfied with the care and services provided at the nursing home. However, his mother had mentioned the possibility of assisted living as a discharge plan. The son verified he had had a meeting many months ago with the interdisciplinary team but a discharge plan was not addressed at that time, and there had been no other meetings since. The son of Resident #9 verified it would be very helpful if he was not the only person who had to respond and reinforce to Resident #9 that she could not safely return home. On 09/18/18 at 1:36 P.M., an interview was completed with corporate Registered Nurse (RN) #300 and the former assistant director of nursing, Licensed Practical Nurse (LPN) #301. LPN #301 had recently accepted the position as the Social Service Designee (SSD). Corporate RN #300 explained the facility had been in transition with a change in ownership and in management staff. Review of an interdisciplinary Care Plan Conference Summary dated 04/09/18 was completed. Corporate RN #300 verified it was the only evidence of an interdisciplinary Care Plan Conference the facility could provide. The plan for discharge potential and return to the community revealed Resident feels confident that she can return home alone. During the same interview, Corporate RN #300 revealed Resident #9 should have had an interdisciplinary care plan meeting on 08/22/18. However, the meeting had never been scheduled. Review of the facility Policy and Procedure revised 01/26/17 for Plan of Care Meeting revealed each resident would be encouraged to exercise their right to participate in planning their care. And, all residents would have a care plan meeting scheduled at least every 90 days.

Based on record review and interview the facility failed to ensure the medication, [MEDICATION NAME], was administered as ordered for Resident #44 to prevent a significant medication error. This affected one resident (Resident #44) of three residents reviewed for transfer/discharge. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission physician order [REDACTED]. [MEDICATION NAME] is classified as a laxative. It is used to treat constipation, as well as, hepatic [MEDICAL CONDITION]. Hepatic [MEDICAL CONDITION] is defined as neuropsychiatric abnormalities as a result of liver failure. It is characterized by changes in personality, consciousness and reflexes. The [MEDICATION NAME] is used to lower the amount of ammonia in the blood of patients with liver disease. [MEDICATION NAME] draws the ammonia from the blood into the colon where it is removed from the body. Review of the bowel movement report from admission through discharge to the hospital on [DATE] at 2:00 P.M., was completed. Resident #44 resided in the facility for 32 days. Resident #44 had no bowel movement documented on one of the 32 days; one documented bowel movement on five of the 32 days; two documented bowel movements on 18 of the 32 days; three documented bowel movements on eight of the 32 days; and four bowel movements on one of the 32 days. Review of the documented doses of [MEDICATION NAME] in the 32 day admission revealed Resident #44 received six doses in the 32 day admission and should have received 31 doses in 32 days. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] and the MDS 3.0 assessment, dated 07/09/18 and interdisciplinary progress notes from 07/20/18 through the resident's transport to the hospital 07/27/18 at 2:23 P.M., was completed. Record review revealed Resident #44 was alert and oriented and always continent of bowel movements. Review of a nursing progress note, dated 07/20/18 at 2:42 A.M., revealed Resident #44 complained of severe abdominal pain. The physician was notified and Resident #44 was transported and evaluated in the emergency room . Resident #44 returned to the facility the same day with no change in physician orders. Review of a nursing progress note dated 07/21/18 at 4:45 A.M., revealed Resident #44 had an episode of blood in his urine. Resident #44 had no complaints of pain, burning or frequency. The resident's vital signs were within normal limits. The physician was notified. There were no new orders. Review of a nursing progress note dated 07/23/18 at 5:50 A.M., revealed Resident #44 was transported to a scheduled physician visit. The visit was with the resident's [MEDICATION NAME]. Review of the Patient Encounter Form dated 07/23/18 revealed Resident #44 reported he was having five to six loose stools daily. The physician recommended discontinuing the [MEDICATION NAME] due to 'no need'. However, the resident's primary physician did not discontinue the order. Review of the Medication Administration Record [REDACTED].M. An ammonia level was drawn the following morning, 07/27/18 at 7:18 A.M. On 07/27/18 at 8:09 A.M., the resident's family voiced concern about the resident's health and the [MEDICATION NAME] order to be given, as needed. The family reported Resident #44 took [MEDICATION NAME] twice a day while at home. The physician was notified. The [MEDICATION NAME] order was changed from twice a day, as needed, to scheduled twice a day. On 07/27/18 at 2:13 P.M., Resident #44 was assessed for a change in his mental status. Resident #44 was having some confusion. The resident's vital signs were within normal limits. The physician was notified. The ammonia level results were not yet available and the resident's family wanted him sent to the emergency room . The physician ordered the transport. At 2:23 P.M., Resident #44 was admitted to the hospital and did not return to the facility. The facility received the ammonia level drawn on 07/27/18 the following morning, 07/28/18. Review of the result revealed an elevated ammonia level of 100. The same report revealed a normal range of the ammonia level was 18-75. However, review of the ammonia level drawn upon arrival to the hospital 07/27/18 at 3:00 P.M., revealed a normal value of 44 with a normal range of 16 - 60.0. An interview was completed with Corporate Registered Nurse (RN) #300 on 09/19/18 at 5:12 P.M. RN #300 verified, based on the documentation of the number of bowel movements daily, the [MEDICATION NAME] was not administered, as ordered.