Every finding on record at Life Care Center of Elyria

Based on interview and medical record review, the facility failed to ensure residents had ophthalmologist recommendations followed up in a timely manner. This affected one (#54) of two reviewed for ancillary services. The census was 92. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] and diagnoses including chronic kidney disease, congestive heart failure, dementia, and polyneuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and had adequate vision with corrective lenses. Review of progress note dated 01/17/23 revealed Resident #54 had a vision appointment. Review of an eye care provider note dated 01/17/23 revealed Resident #54 complained of blurry vision. The assessment indicated Resident #54 was provided a prescription for new glasses and would be ordered pending insurance or payer approval. Review of a progress note dated 02/27/23 revealed Resident #54's daughter requested information on the glasses. The facility's vision service was contacted about the glasses and provided with a Medicaid number. The progress note further revealed the eye care provider would send a technician to visit Resident #54 to measure for the glasses. Review of a progress note dated 03/03/23 revealed a eye care provider technician visited Resident #54 to measure Resident #54's face for new pair of glasses. Review of a progress note dated 03/16/23 revealed Resident #54's daughter again requested information on glasses. Review of a progress note dated 03/20/23 revealed Resident #54's new glasses arrived to facility and the daughter was notified. Interview on 04/18/23 at 1:12 P.M. with Resident #54 revealed she received new glasses, and indicated the ancillary services were slow at the facility. Interview on 04/19/23 at 11:15 A.M. with Social Services Director confirmed Resident #54 was seen by the facility eye care provider on 01/17/23 and had an order for new glasses. Social Services Director indicated she usually sent the Medicaid number to the eye care provider for billing. Social Services Director indicated she was unsure why there was a delay from 01/17/23 to 02/27/23 to get Resident #54's new glasses ordered, and confirmed there was a delay in ordering Resident #54's new glasses.

Based on interview and record review, the facility failed to timely notify the appropriate state mental health authority when a resident with a level II mental illness had a significant change in condition. This affected one (#51) of four residents reviewed for Preadmission Screening and Resident Review (PASARR). The census was 92. Findings include: Review of Resident #51's medical record revealed an admission to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, impulse disorder, vascular dementia with agitation and mood disturbance, Moyamoya disease, and psychosis. Review of the Medicare Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had moderate cognitive impairment. The assessment indicated Resident #51 had physical and verbal behaviors directed towards others and rejected care. Review of social services progress note dated 01/15/23 revealed Resident #51 was sent to the hospital for evaluation. Review of nursing progress note dated 01/17/23 revealed Resident #51 was transferred for a geriatric psychiatric evaluation. Review of a case management progress note dated 02/10/23 revealed Resident #51 was readmitted to facility on 02/09/23 after a lengthy hospital stay including an inpatient psychiatric stay for increased agitation and behavioral disturbance. Review of the PASARR identification screen dated 02/27/23 revealed Resident #51 had a level II mental illness and a readmission from the psychiatric facility. Review of the PASARR outcome explanation dated 03/25/23 revealed the needed information for PASARR determination was not provided to complete the assessment and the case was closed. Review of the electronic medical record (EMR) for Resident #51 revealed he returned to the facility on [DATE] with no evidence the facility notified the appropriate state mental health authority of his admission to the psychiatric hospital in a timely manner as indicated. Further review of the EMR for Resident #51 revealed no level II PASARR results were provided, which indicated an evaluation was not thoroughly completed. Interview on 04/20/23 at 11:03 A.M., with Case Manager #512 confirmed Resident #51 had inpatient psychiatric hospital stay. Case Manager #512 confirmed the PASARR screening was not completed until 02/27/23. Case Manager #512 indicated when she realized the hospital had not completed the PASARR screening she completed it and submitted it to The Ohio Department of Mental Health.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to provide timely nutritional supplements as ordered. This affected one (#305) of two resident reviewed for nutrition. The census was 92. Findings include: Review of the medical record for Resident #305 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, moderate protein calorie malnutrition, psychosis, dementia, depression, bradycardia, anxiety disorder, and hypotension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #305 was cognitively intact, required supervision for eating, and had an active diagnosis of malnutrition. Review of the comprehensive care plan dated 04/10/23 revealed Resident #305 had nutritional problems of moderate malnutrition and a revision to the care plan on 04/19/23 revealed Resident #305 had weight loss. Goals identified within the care plan revealed Resident #305 would maintain adequate nutritional status as evidenced by maintaining weight within five percent of the resident's admission weight of 145.2 pounds. Interventions included medications to be administered as ordered, obtain food preferences and honor requests within limits of the diet ordered, provide and serve diet as ordered, provide and serve supplements as ordered, weekly weights for four weeks and then monthly if stable, and for the registered dietician to evaluate and make diet change recommendations as needed. Review of a nutritional assessment completed on 04/10/23 revealed Resident #305 had no known food allergies, was on a regular diet, and had a weight of 145.2 pounds which was below the ideal body weight identified as 178 pounds. Resident #305 had a diagnosis of moderate malnutrition. Interventions recommended included a house shake (supplement) twice a day. Review of a written paper physician order dated 04/10/23 revealed a diet change to mechanically altered and a house shake 120 milliliters (ml) twice a day. Review of current physician orders for Resident #305 revealed an order written on 04/04/23 for weekly weights and an order dated 04/17/23 at 4:30 P.M. for a house supplement 120 ml twice a day. Review of the medication administration record from 04/04/23 to 04/20/23 revealed the house supplement was first administered on 04/17/23 at 4:30 P.M., on 04/18/23 at 7:30 A.M. and 4:30 P.M., on 04/19/23 at 7:30 A.M. and 4:30 P.M. and on 04/20/23 at 7:30 A.M. with one hundred percent of the house supplement consumed by Resident #305 at each administration. Review of the the weekly weights for Resident #305 revealed an admission weight of 145.2 pounds on 04/04/23, a weight of 140 pounds on 04/11/23, and a weight of 135.1 pounds on 04/18/23. A weight of 139.7 pounds was obtained on 04/20/23. Interview with the Director of Nursing (DON) on 04/20/23 at 10:52 A.M. verified the order for dated 04/10/23 for Resident #305 to receive the house shake 120 ml twice a day for moderate malnutrition was not entered or implemented until 04/17/23. Review of the facility policy titled, Physician Diet Orders and Diet Changes, dated 04/27/22, revealed each resident is prescribed a diet by the physician that provides adequate nutrition and hydration consistent with the resident's nutritional needs. Residents are offered sufficient fluid intake to maintain proper hydration and health and when there is a nutritional problem, the health care provider orders the therapeutic diet and nutritional care needed and ensures nutritional care is provided in accordance with the resident's assessment and plan of care. The policy also revealed the nurse is responsible for dining service and information pertinent to the identified nutritional concerns.

Based on record review, resident and staff interview, and policy review the facility failed to ensure residents who were survivors of trauma were assessed and care planned appropriately to address such trauma to maintain the residents highest practical well being. This affected one (#4) of one resident reviewed for trauma informed care. The census was 92. Findings include: Review of Resident #4's medical record revealed and admission dare of 08/06/17 with diagnoses that included multiple sclerosis, bipolar disorder, and posttraumatic stress disorder (PTSD). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact and required extensive assistance of two staff persons for completing her activities of daily living. Review of the psychiatric progress note dated 02/08/23 revealed Resident #4 was abused sexually by her cousin, babysitter, and her step father's father. The progress note also revealed Resident #4 was hospitalized in a psychiatric setting three times for suicidal ideation and attempted suicide one time by slicing her wrists. Interview with Resident #4 on 04/18/23 at 3:45 P.M. stated she was abused constantly as a child and it messed her up for life. Observation of Resident #4 during the interview revealed she was emotional during the interview while speaking of the past abuse and trauma. Review of assessments for Resident #4 revealed she was not assessed for needs related to her trauma until 04/19/23. Review of the care plan goal related to managing and assisting Resident #4's PTSD was noted as the resident will identify ways of increasing meaningful relationships by the review date. The only interventions noted were to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears, and encourage participation from the resident who depends on others to make own decisions. Interview on 04/19/23 at 4:45 P.M., with Social Worker #638 verified Resident #4's care plan had no specific goals or interventions related to Resident #4's trauma history, and Resident #4 was not assessed for her care needs related to her trauma until 04/19/23. Review of the policy titled, Trauma-Informed Care, dated 10/04/22, revealed the faciliy will use a multi-pronged approach to identifying a resident with PTSD or history of trauma. This approach would included assessing the resident for indicators of trauma upon admission/readmission and with change in condition. This assessment will include asking the resident about triggers that may be stressors or may prompt recall of of a previous traumatic events.

Based on medical record review and staff interview, the facility failed to coordinate a level II assessment for a resident with a diagnosis of intellectual disabilities as required. This affected one (#316) of two residents reviewed for pre-admission screening and resident review (PASARR) status. The census was 92. Findings include: Review of Resident #316's medical record revealed an admitted [DATE] with diagnoses that included unspecified intellectual disabilities, impulse disorder, major depressive disorder, and anxiety disorder. Review of the PASARR form completed prior to admission revealed the form did not address any of Resident #316's mental illnesses or intellectual disability which would have required a referral for a level II evaluation to the state agency. Further review of the medical for Resident #316 revealed no evidence of a corrected PASARR assessment or referral to the state agency as required. Interview on 04/18/23 at 4:44 P.M., with Social Worker #638 verified the facility did not address the incorrect PASARR or coordinate referral to the state agency for a level II evaluation as required.

Based on record review, staff interview, resident interview, observation, and review of the facility's policy, the facility failed to ensure the resident's medications were not left unattended. This had the potential to affect three residents who were cognitively impaired and mobile. The facility census was 79. Findings include: Review of Resident #79's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated 05/30/21, revealed the resident had a high cognitive function. Review of Resident #79's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] .), [MEDICATION(S)] (vitamin supplement) one mg., [MEDICATION(S)] (immunosuppressive) 2.5 mg., [MEDICATION(S)] (antihypertensive) 7.5 mg., [MEDICATION(S)] (steroid) five mg., and vitamin D2 2,000 units. Observation and interview with Resident #79 on 07/26/21 at 10:18 A.M. revealed medications were observed on the resident's bedside table in a cup. Resident #79 stated the nurse left the medications there so she could take them at her convenience. There was no nurse in the room or in sight during the observation. Interview with Licensed Practical Nurse (LPN) #100 on 07/26/21 at 10:21 A.M. verified the nurse left Resident #79's medications unattended on the bedside table. Review of the facility's policy titled General Dose Preparation and Medication Administration, dated 01/01/13, revealed during medication administration, the facility staff should take all measures required by facility policy and applicable law, including but not limited to observing the resident's consumption of the medication(s). This deficiency substantiates Complaint Number OH 027.

Based on record review, review of the facility's Self-Reported Incident and investigation, review of the police report, staff interview, and facility policy review, the facility failed to ensure the resident's medications were free from misappropriation. This affected one (Resident #56) of three residents reviewed for narcotic medications. The facility identified 15 residents who required anti-anxiety medications while in the facility. The facility census was 79. Findings include: Review of Resident #56's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 07/20/21, revealed the resident had a low cognitive function. Review of the care plan revealed the resident used anti-anxiety medication related to anxiety disorder. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . on 07/16/21 at 10:07 A.M. and 6:01 P.M., 07/17/21 at 9:14 A.M. and on 07/18/21 at 9:00 A.M. No Lorazepam was charted as administered on 07/12/21 through 07/15/21. Review of the facility's Self-Reported Incident, control number 1, dated 07/18/21, revealed the facility management was notified by a nurse that during the narcotic count it was found Resident #56 had 100 missing Lorazepam one mg. tablets. The Administrator and Interim Director of Nursing (DON) reported to the facility immediately and began an investigation. The Interim DON, in the presence of a licensed practical nurse (LPN) and the Administrator counted the remaining pills in the Lorazepam bottle resulting in 165 pills counted. The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review identified the resident had received the following doses since admission to this facility: On 07/15/21 at 4:00 P.M., 07/16/21 at 10:00 A.M., 07/16/21 at 6:00 P.M., 07/16/21 at 10:00 P.M. and on 07/17/21 at 9:14 A.M. The medication was stored in medication cart two on the 100 hall in the locked narcotic drawer. The cart itself was kept locked with only the nurse assigned to that cart on that shift having a key. Aside from this the narcotic drawer was an automatic self-locking device that can only be accessed by a key kept on the same key chain assigned to that nurse who was working the cart for the shift. The cart was thoroughly searched for the missing narcotic to no avail. Interviews were conducted with all nurses having access to the medication cart since the time of admission. Interviews did not identify source of missing narcotic. The facility's Pharmacy #500 was notified of the drug diversion. A police report was filed with the Elyria police department. The facility substantiated the allegation of misappropriation. Review of the facility's investigation report revealed Resident #56's Lorazepam failed to be counted at shift change on 07/15/21 at 2:00 P.M. and at the 10:00 P.M. shift change, on 07/16/21 at the 2:00 P.M. shift and the 10:00 P.M. shift. On 07/17/21, LPN #160 came to work and counted the medication with LPN #180 and found the count to be correct. Later in the day on 07/17/21, LPN #180 placed the Lorazepam pills into small baggies of 10 to make them easier to count and found only 166 pills resulting in the 100 missing Lorazepam pills. Review of the police report, dated 07/18/21, revealed a report of the incident was taken and the Administrator was advised that a report would be on file to contact the police of any video surveillance or new information became available. Interview with the Administrator on 07/26/21 at 12:56 P.M. revealed on 07/18/21 the Administrator was notified by the interim DON that LPN #160 notified her that Resident #56 was missing 100 Lorazepam tablets. Resident #56 was admitted on [DATE] from home and her husband brought in a bottle of Lorazepam one mg. tablets which contained 270 tablets. The medication was counted and confirmed on admission. After being notified that 100 pills were missing, the interim DON and Administrator arrived at the facility and began an investigation. The nurses recounted the Lorazepam and found 165 pills. The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications were stored in cart number two in the locked narcotic drawer. The cart key was kept on the keying and only the one nurse assigned to that cart has access to the key. Interviews were conducted for all staff that worked and it was found that the narcotics were not counted on each shift. The family had obtained the medications from the residents local pharmacy. Interim DON #500 and LPN #160 inspected all of the carts and refrigerator and all narcotic counts were accurate. The Administrator revealed no staff were sent for drug testing because they felt no one was suspicious. The local police department was contacted that same day and a report was completed. Review of the facility's undated policy titled Narcotic Medication Record Keeping revealed at the change of shift, the on-coming and out-going nurses jointly count all controlled medications, including discontinued or expired medications awaiting destruction. The out-going nurse will read the individual resident's narcotic record book pages while the on-coming nurse examines the containers of controlled medications. The shift change controlled substance inventory count sheet will be signed by both the out-going and the on-coming nurse at each change of shift, if the count is verified by two nurses. This deficiency substantiates Control Number OH 378.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was stored properly when staff failed to cover foods stored in the freezer. This had the potential to affect all 95 residents that resided in the facility who consumed food from the kitchen. Findings include: Observation on 09/16/19 at 10:36 [NAME]M. revealed a metal cart sitting in the walk-in freezer. On the shelf of the cart there were five baking sheet trays with breaded fish and one baking sheet tray with hushpuppies. None of the baking sheet trays were covered to protect the food. Interview on 09/16/19 at 10:37 [NAME]M., with the Executive Chef (EC) #172 revealed all foods stored in the walk-in freezer were to be covered to protect the food. EC #172 confirmed there were five trays of breaded fish and one tray of hushpuppies stored on a metal cart, in the walk-in freezer, uncovered. Review of a facility policy titled, Food Safety, most recent revision date 11/28/17, revealed staff were to store food in a clean, safe and sanitary manner.

Based on medical record review, observations, staff interview, and facility policy review, the facility failed to ensure infection control was maintained during a pressure ulcer dressing change for one resident (#75) of three residents reviewed for infection control. The facility census was 95. Findings include: Review of Resident #75's medical record identified admission to the facility occurred on 04/19/19 with medical [DIAGNOSES REDACTED]. The resident was identified as being cognitively intact. Observation of Resident #75's wound dressing change on 09/17/19 at 11:21 [NAME]M., with Registered Nurse (RN) #19 and State tested Nursing Assistant (STNA) #116 revealed following following removal of the old dressing RN #19 changed gloves, however did not perform hand washing between the soiled gloves and placing on the new pair. Interview with RN #19 on 09/17/19 at 11:45 [NAME]M. confirmed he did not clean his hands following the removal of the old dressing and changing gloves to place the clean dressing on. The interview further confirmed Resident #75 was currently on isolation precautions for [MEDICAL CONDITION] ([MEDICAL CONDITION]/infection). Review of the facility hand hygiene policy identified the facility utilized Lippincott Procedures from the Internet for all facility policies. The policy identified washing with soap and water is appropriate when the hands are viably soiled or contaminated with with blood or other body fluids, when exposure to potential spore-forming pathogens, such as [MEDICAL CONDITION] is strongly suspected or proven. The policy identified the hand washing should be preformed when moving from contaminated body site to clean body site during care.

Based on medical record review, resident and staff interviews, the facility failed to ensure adequate treatment of [REDACTED].#85) of one for psychosocial well being. The facility census was 95. Findings include: Review of Resident #85's medical record identified admission occurred on 08/14/19 following hospitalization for amputation of his right leg. The record revealed Resident #85 had the [DIAGNOSES REDACTED]. Review of an physician visit dated 08/15/19 identified Resident #85 was admitted to the facility following identification of gangrene of the right foot with maggot infestation resulting in [MEDICAL CONDITION]. The physician wrote an order to consult with the facility psychiatrist due to the [DIAGNOSES REDACTED]. Review of progress note dated 08/29/19 at 6:25 P.M. identified Resident #85 appeared agitated when asked to perform therapy. The notes identified Resident #85 was smoking more and refusing care. The notes identified the physician felt he needed to see his psychiatrist. The progress note further revealed a call would be placed on 08/30/19 for a meeting with Resident #85's sister. Progress note dated 08/30/19 at 2:33 P.M. revealed at the meeting with Resident #85's sister she requested for him to receive a psychiatry evaluation because she believed he was escalating with care refusal and anger. Resident #85's sister revealed he was exhibiting similar behavior prior to his last inpatient psychiatric hospitalization . Progress note dated 09/02/9 at 1:28 P.M. revealed the Social Services Designee (SSD) #101 was informed by staff Resident #85's younger brother passed away on 09/01/19. Progress note dated 09/04/19 at 9:21 [NAME]M. revealed Resident #85's psychiatrist office called the facility and scheduled an appointment for 09/10/19 at 6:00 P.M. and was placed on the cancellation list to get in early if able, Resident #85 and his sister were made aware. Further review of Resident #85's progress notes through 09/16/19 identified Resident #85 had not been to see his psychiatrist. Interview with Resident #85 on 09/16/19 at 3:55 P.M. confirmed he missed a psychiatry appointment because there was a lack of communication in the facility between staff and residents. Resident #85 revealed the facility never scheduled transportation for his appointment, therefore it was missed. Interview with Licensed Practical Nurse (LPN) #171 on 09/18/19 at 12:12 P.M. confirmed Resident #85 was not provided transportation from the facility and missed his psychiatry appointment on 09/10/19 at 6:00 P.M. Interview with the facility appointment scheduler on 09/18/19 at 2:59 P.M. revealed she did not schedule Resident #85's appointment or transportation because she was not aware of it. The scheduler revealed the facility did not provide transporting that late in the evening as the appointment was scheduled for 6:00 P.M.

Based on medical record review, staff interview and review of a facility policy, the facility failed to notify a resident's physician, responsible party and Hospice provider of a change in a wound status and to timely notify a resident's family of a fall. This affected two residents (#13 and #94) of 21 residents reviewed for notification. The facility census was 95. Findings include: 1. Medical record review revealed Resident #13 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired. Review of a nursing progress note dated 09/07/19 at 3:04 P.M., revealed the resident's dressing on her right leg was completed. A large amount of greenish, brown drainage was noted on the old dressing with a foul odor. There was no evidence in the medical record the physician, responsible party or the Hospice provider were notified. Interview on 09/18/19 at 2:49 P.M., with the Director of Nursing (DON) confirmed there was no evidence Resident #13's physician, responsible party or the Hospice provider were notified of the change in the status of the resident's wound. 2. Medical record review revealed Resident #94 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment, dated 08/03/19, revealed the resident's cognition was impaired. The resident discharged from the facility on 08/17/19. Review of a nursing progress note, dated 08/01/19 at 11:00 P.M., revealed the resident slid out of his wheelchair onto his bottom. The resident suffered a small abrasion on his back. There was no evidence the resident's family was notified of the fall. Interview on 09/19/19 at 1:10 P.M., the DON revealed staff were supposed to notify the resident's physician and family/responsible party of any change in condition unless the resident was alert and oriented and did not wish them to do so. The DON confirmed the resident's family was not notified the resident's fall on 08/01/19. Review of facility policy titled, Family Involvement, most recent revision date 04/15/19, revealed the facility was to provide information to the family to keep them informed of the resident's status including their progress and changes. This deficiency substantiates Complaint Number OH 695.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents were given an opportunity to formulate advanced directives on admission. The facility further failed to ensure resident's advanced directive wishes were consistent throughout the medical record. This affected two residents (#249 and #55) of 21 residents reviewed for advanced directives. The facility census was 95. Findings include: 1. Medical record review revealed Resident #249 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's electronic health record (EHR) revealed the resident's advanced directive wish was to be a Do Not Resuscitate Comfort Care (DNR-CC), which meant no resuscitative actions to maintain life would be attempted. The EHR further revealed staff were directed to see the resident's living will for instructions. Further review of the resident's EHR revealed no documented evidence the resident requested to be a DNR-CC nor was a living will found for the resident. Interview on 09/18/19 at 8:53 [NAME]M., with Registered Nurse (RN) #180 confirmed Resident #249's EHR revealed the resident's advanced directive whish was to be a DNR-CC and staff were directed to see the resident's living will for instructions. RN #180 searched the resident's EHR and paper chart, and was unable to find evidence the resident requested to be a DNR-CC nor could she find a living will for the resident. RN #180 confirmed there was no evidence the resident was given an opportunity to formulate an advanced directive. 2. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE]. On 11/15/18 a Do Not Resuscitate (DNR) form was signed, however the admission form continued to identify Resident #55 was a full code. Interview with Registered Nurse (RN)#177 on 09/18/19 at 8:18 [NAME]M. confirmed Resident #55's admission record incorrectly identified Resident #55 was a full code and was not updated on 11/15/18 when Resident #55's code status changed.

Based on medical record review and staff interviews, the facility failed to ensure written notification of the facilities bed hold policy was provided to the resident and representative, at the time of transfer. This affected two residents (#75 and #94) of two reviewed for hospitalization s. The facility census was 95. Findings include: 1. Review of Resident #75's medical record identified admission to the facility occurred on 04/19/19 and he was paying privately for services at the facility. The record identified on 07/21/19 and 08/05/19 Resident #75 required hospitalization s. Further review of the medical record identified a lack of written notification of the bed hold policy to Resident #75 and his representative, at the time of transfer/discharge. Interview with Business office Manager (BOM) #128 on 09/18/19 at 10:50 [NAME]M. confirmed she had no written notification of the bed hold policy being provided to Resident #75 or his representative. 2. Review of Resident #94's medical record identified admission to the facility occurred on 07/28/19, with medical [DIAGNOSES REDACTED]. The record identified on 08/10/19 Resident #94 was transferred from the facility to the hospital and stayed there until 08/16/19, then returned to the facility. The record identified Resident #94 was utilizing and insurance benefit and would need to pay privately to hold his bed in the event of a transfer or discharge. The record lacked evidence the facility provided the bed hold policy and procedure to Resident #94's representative at the time of transfer on 08/10/19. Interview with the facility Administrator on 09/19/19 at 2:49 P.M. confirmed the facility did not provide a bed hold notification for Resident #94.

Based on medical record review, observations, staff interview, resident interview, and facility policy review, the facility failed to ensure two residents (#13 and #75) of three reviewed for pressure ulcers had treatments and services to promote healing and prevent new ulcers from development. The facility identified nine residents with pressure ulcers. The facility census was 95. Findings include: 1. Review of Resident #75's medical record identified admission to the facility occurred on 04/19/19 with medical [DIAGNOSES REDACTED]. The readmission assessment dated [DATE] revealed Resident #75 was cognitively intact. Review of the wound clinic notes dated 09/13/19 revealed Resident #75 returned from the appointment with new physician orders [REDACTED]. with ABD (thick dressing) and paper tape, change BID (twice a day). Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed on 09/13/19 when Resident #75's dressing was ordered to be completed twice a day, the staff inadvertently transcribed the order for once a day. The TAR identified on 9/14/19 and 09/15/19 the dressing was documented as being completed once a day. The TAR confirmed the dressing was not completed at all on 09/16/19, and was only scheduled for once a day on 09/17/19. Observation of Resident #75's wound dressing change on 09/17/19 at 11:21 [NAME]M., with Registered Nurse (RN) #19 and State tested Nursing Assistant (STNA) #116 revealed RN #19 removed Resident #75's old dressing which was dated 09/15/19, confirmed by RN #19 and STNA #116. Resident #75 revealed the dressing was not changed on 09/16/19, because two nurses called off and no one had time to do it. RN #19 then cleaned the wound with normal saline and applied [MEDICATION NAME] cream (over the counter-moisture barrier cream) to the peri wound. RN #19 then applied the wet to dry Dakins solution dressing, applied paper tape. Interview with RN #19 on 09/17/19 at 11:45 [NAME]M. confirmed he did not use the cream that was ordered by the wound clinic on 09/13/19, which was a mixture of [MEDICATION NAME] (a prescription anti-fungal cream). Interview with RN/Unit manager #77 on 09/17/19 at 2:11 P.M. confirmed prescription wound cream ([MEDICATION NAME]/[MEDICATION NAME] cream) was located in the treatment cart. RN #77 removed the cream from the box and confirmed the cream was sealed and had never been used since arriving at the facility from the pharmacy on 09/14/19. RN #77 confirmed nursing staff were documenting applying it. The RN further confirmed Resident #75's wound orders were not transcribed correctly from the wound clinic visit of 09/13/19, resulting in Resident #75's dressing only being completed once on 09/14/19, 09/15/19, and not completed at all on 09/16/19. 2. Medical record review revealed Resident #13 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. Staff were able to use soft boots as needed. Observations on 09/17/19 at 1:18 P.M. and on 09/18/19 at 8:44 [NAME]M. and 2:32 P.M., revealed Resident #13 laying in bed with her heels on the mattress. No soft boots were observed. Interview on 09/18/19 at 8:45 [NAME]M., with State tested Nursing Assistant (STNA) #70 confirmed Resident #13 was lying in her bed with her heels on the mattress. Further interview at 2:36 P.M., Registered Nurse (RN) #180 confirmed the resident was lying in her bed with her heels on the mattress. Review of a facility policy titled, Wound Care (pressure injury), most recent revision date 04/05/19, revealed treating and/or preventing pressure injury involved relieving pressure, restoring circulation, promoting adequate nutrition and resolving and/or managing related disorders. Staff were to provide care measures such as risk factor management, use of topical treatments, wound cleaning, debridement and use of dressings to support wound healing.

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure interventions to prevent injury from falls were in place. The facility further failed to ensure resident's call light system was in resident's reach while in their room. This affected one resident (#13) of three reviewed for falls. The facility census was 95. Findings include: Medical record review revealed Resident #13 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nursing progress note dated 09/06/19 at 8:05 P.M. revealed Resident #13 fell from her wheelchair and was found sitting on the floor. Interventions included to use a matt on the floor, next to the resident's bed, due to the resident's impulsiveness and confusion. Observations on 09/16/19 at 4:25 P.M. revealed Resident #13 was in her bed. The resident's fall matt was observed to be propped up against a cupboard on the opposite side of the room. Observations on 09/17/19 at 1:18 P.M. revealed Resident #13 was lying in her bed. Her call light system was observed to be not in her reach and lying on a chair. The resident's fall matt was observed to be propped up against a cupboard on the opposite side of the room. Interview on 09/17/19 at 1:23 P.M., with State tested Nursing Assistant (STNA) #116 verified Resident #13's call light was not within the resident's reach and her fall matt was not in place. Observation on 09/18/19 at 8:44 [NAME]M. revealed Resident #13 was again lying in bed her bed. Her call light system was noted to be lying on the floor under her bed. Interview on 09/18/19 at 8:45 [NAME]M., with STNA #70 confirmed Resident #13's call light was lying on the floor, under the bed, and not within the resident's reach. Review of a facility policy titled, Fall Management, most recent revision date 04/15/19, revealed staff were to promote patient safety and reduce patient falls by proactively identifying patient's fall indicators. Staff were to ensure resident's environment remained as free of accident hazards as possible and received adequate supervision and assistive devices to prevent accidents. This deficiency substantiates Complaint Number OH 695.

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure an catheter securement device was used to prevent possible injury from the use of an indwelling urinary catheter. This affected one resident (#249) of two reviewed for urinary catheters. The facility census was 95. Findings include: Medical record review revealed Resident #249 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. Observation of catheter care on 09/18/19 at 11:30 [NAME]M. for Resident #249, with State tested Nursing Assistant (STNA) #9, revealed there was no catheter securement device (a device designed to securely hold the catheter in place to prevent urine back-flow and urethral trauma caused due to catheter movement or dislodgement) in use for the resident's catheter. The STNA revealed staff were supposed to use a strap style anchoring device for safety to keep the catheter tubing from getting caught on resident's pants or briefs and to prevent the tubing from being pulled out. STNA #9 confirmed there was not a catheter securement device in use for Resident #249's catheter. Review of a facility policy titled, How to Care for Your Foley Catheter, dated 2019, revealed catheter care included to keep the catheter tube secure.

Based on medical record review, observation, and staff interviews, the facility failed to provide a resident with nutritional interventions as ordered for a significant weight loss. This affected one resident (#75) of two reviewed for nutrition. The facility identified three residents with significant weight loss in the census of 95. Findings include: Review of Resident #75's medical record identified admission to the facility occurred on 04/19/19 with medical [DIAGNOSES REDACTED]. The record identified Resident #75's admission weight was 161 pounds (lb) on 04/26/19. Resident #75 was hospitalized from [DATE] through 08/26/19 and was noted with a weight of 139 lb upon readmission. Resident #75's weight on 08/26/19 was 143 lb and on 09/04/19 was 142.5 lb, which evidenced a significant weight loss of 11.8%, since admission. Review of nutritional progress note dated 09/09/19 at 11:31 [NAME]M. revealed Resident #75 had had a weight change of 15.4% loss in the past 90 days. The note revealed the dietician recommend Magic Cup (frozen high calorie supplement) at meals to prevent further loss. Review of Resident #75's physician order [REDACTED]. Review of a nutrition progress note dated 09/16/19 at 3:24 P.M. revealed Resident #75 had a coccyx wound, needed additional protein, and was receiving 15 grams of protein from Magic cups ordered three times a day, with meals. Observation of Resident #75 on 09/18/19 at 8:23 [NAME]M. revealed State tested Nursing Assistants (STNAs) #70 and #125 were passing meal trays which included Resident #75's tray. The breakfast tray was observed without the Magic Cup. STNA #75 revealed Magic Cups came from the kitchen and she did not think Resident #75 was ordered them. STNA #125 revealed Resident #75 did not get them in the morning and she only remembered him getting them at lunch.

Based on medical record review, review of hospital discharge records, and staff interview, the facility failed to ensure a resident received ordered medications. This affected one resident (#94) of six reviewed for medications. The facility census was 95. Findings include: Review of Resident #94's medical record identified admission to the facility occurred on 07/28/19, with [DIAGNOSES REDACTED]. Review of Resident #94's hospital discharge instructions dated 08/16/19 identified Resident #94 returned to the facility at 10:20 P.M. The instructions included a medication order for [MEDICATION NAME] inhalation solution for Nebulizer four times a day. Review of Resident #94's Medication Administration Record [REDACTED].M., 6:00 [NAME]M. and 12:00 P.M. dose. Interview with Licensed Practical Nurse (LPN) #165 on 09/19/19 at 2:00 P.M. confirmed she worked the day shift on 08/17/19 and had to obtain Resident #94's medications from the facility Pyxis system when she arrived. LPN #165 confirmed there was no evidence Resident #94 received his [MEDICATION NAME] Nebulizer medications as ordered by the physician on 08/17/19. This deficiency substantiated complaint OH 6695.

Based on medical record review and staff interview, the facility failed to ensure residents advanced directives were placed in the resident's electronic health record. This affected two (#74 and #244) of two residents reviewed for advanced directives. The facility census was 97. Findings include: 1. Medical record review revealed Resident #74 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED].#74 was to be a do not resuscitate, comfort care (DNRCC), which meant he/she wished for comfort care measures only with no cardiopulmonary resuscitation (CPR) performed. Review of the resident's electronic health record revealed no advanced directive for Resident #74. 2. Medical record review revealed Resident #244 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED].#244 was to be a do not resuscitate, comfort care arrest (DNR CCA), he/she wished to have all medically necessary services provided, until a point of [MEDICAL CONDITION], or [MEDICAL CONDITION]. Review of the resident's electronic health record revealed no advanced directive for Resident #244. Interview on [DATE], at 3:44 P.M., the Director of Nursing (DON) revealed all resident's advanced directive whishes were to be placed in both the residents paper chart, as well as the electronic health record on admission. The DON verified Resident #244 and Resident #74 did not have an advanced directive in their electronic health record.

Based on medical record review, resident interview, staff interview, and policy review the facility failed to provide written notification prior to two room changes. This affected one (#48) of four residents reviewed for choices. The facility census was 97. Findings include: Medical record review for Resident #48 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #48 was cognitively intact. Review of a nursing progress note dated 07/11/18 at 11:59 A.M., revealed Resident #48 agreed to move to another room later the same afternoon. Review of a nursing progress note dated 07/29/18 at 3:45 P.M., revealed Resident #48 would move temporarily to a private room for isolation. Resident #48 verbalized understanding. Interview on 07/30/18 at 12:03 P.M., with Resident #48 revealed she was not provided written notification prior to two room changes. Further interview with Resident #48 revealed the facility also did not provide her enough notice before informing her she needed to move to a different room. Interview on 07/31/18 at 4:22 P.M., with the Director of Social Services #220 verified Resident #48 was not provided written notification of two room changes. Review of the Resident Room Relocation, policy last revised 06/17/08, revealed no guidelines requiring written notification prior to room changes.

Based on record review and interview, the facility failed to ensure adequate assistance was provided as assessed per the plan of care to prevent falls for one (Resident #52) of two residents reviewed for falls. This resulted in actual harm when Resident #52 sustained a fall with fracture to the left medial malleolus (ankle) while being transferred with only one staff member instead of the assessed needed two person assistance with transfers. The facility census was 89. Findings include: Record review revealed Resident #52 was originally admitted to the facility on [DATE] from the hospital after sustaining a fall at home resulting in a right ankle fracture. After receiving therapy, Resident #52 was transferred to the hospital on [DATE] for an elective surgical revision and repair of her total right knee replacement. On 01/06/16, Resident #52 was readmitted to the facility with the following [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS) five day assessment dated [DATE] revealed Resident #52 was assessed to be alert and oriented to person, place and time and able to make her needs known. Resident #52's functional status was assessed as requiring extensive assistance of two plus staff members for physical assistance with transfers which includes moving between surfaces including to and from the bed, chair, wheelchair and standing position, and also had limited range of motion on the right side of her lower extremities. Review of the facility form titled: Fall Risk Evaluation dated 01/06/16 revealed Resident #52's was assessed to have difficulty with mobility and balance indicating the following: ambulates with problems and with devices (gait is unsteady, slow, lurching) and an evaluation of her balance while standing, sitting and during transitions revealed she was not able to attempt without physical help. The total fall risk score was 18 indicating a high risk for falls. Review of the Resident #52's current Interdisciplinary Care Plan revealed the following: Problem-at risk for physical injury from falls related to: fall risk score of 20; history of falls with injury and medications. With a goal to minimize risk of fall related to injury through target date of 04/15/16. One of the approaches was to provide assistance with transfers as needed. Review of the Resident #52's nursing documentation revealed on 02/04/16 at 2:00 P.M. Resident #52 was alert and oriented to person, place and time and required extensive assistance for ADL's, two person assistance for transfers, bed mobility two person assist. On 02/05/16 at 2:00 P.M., Resident #52 was alert and oriented to person, place and time, two person assist for transfers. Medicated with an as needed pain medication for complaint of right leg pain level six out of 10, and pain scale decreased to level two out of 10 after thirty minutes. On 02/08/16 at 2:00 P.M., Resident #52 was alert and oriented to person, place and time. Required extensive assistance for ADL's, two person assistance for transfers, and two person assistance for bed mobility. On 02/22/16 at 2:00 P.M., Resident #52 was alert and oriented to person, place and time. The documentation revealed the resident was medicated at 7:00 A.M. and again at 1:30 P.M. for complaint of leg pain level at a four out of 10. On 02/23/16 at 2:00 P.M., Resident #52 was alert and oriented to person, place and time. Resident #52 was medicated at 11:30 A.M. for complaint of discomfort. During transfer from bed to wheelchair, Resident #52 lost footing and rolled the left ankle, transferred back to wheelchair with two staff, complained of left ankle pain level six out of 10. Staff notified the nurse practitioner and new orders were received. Review of the facility forms titled: PT Daily Treatment Note revealed the following physical therapist notes: On 02/15/16 at 2:35 P.M., Resident #52 elevates with moderate assistance of two persons and stands for 30-60 second intervals with caregiver assist with flexed posture. She refuses to attempt ambulation this date secondary to complaint of right ankle pain and left knee pain Resident #52 yells out I can't walk! I can't move that leg. Educated on need to be able to elevate, transfer and ambulate without assistance in order to return home. On 02/17/16 at 3:15 P.M., Resident #52 declined all standing and ambulation this date secondary to complaint of right ankle pain. On 02/19/16 at 3:29 P.M., Resident #52 attempted standing and ambulation this date but complained of severe right ankle pain. Resident #52 elevates with moderate assistance of two persons and will only stand for five seconds before insisting she sit back down secondary to pain. Educated her on need to ambulate and she agrees and understands. However, again upon standing Resident #52 complains of ankle pain and insists on sitting down. Further review of PT daily treatment notes revealed on 02/22/16 at 2:11 P.M., Resident #52 attempted standing this date. She complained of severe right ankle pain even before attempting to stand. Upon first standing attempt, she was able to achieve approximately half stand position before screaming out stating, No! No! I have to sit Resident #52 agreed to attempt standing again and was able to almost make it to full stand prior to screaming out and sitting down. She refuses to attempt standing again this date. Review of the electronic charting progress notes revealed on 02/22/16 at 10:07 P.M. Resident #52 was alert and oriented to person, place and time and able to make her needs known. Complained of bilateral lower extremity pain and medicated with relief. On 02/23/16 at 9:47 P.M., per report, Resident #52 rolled on her left ankle during transfer with an x- ray ordered, and transferred to the emergency room . Review of the hospital documentation dated 02/23/16 revealed the chief complain included ankle pain, traumatic. [DIAGNOSES REDACTED]. Triage documentation included a chief complaint quote per Emergency Medical Services (EMS) which revealed the nursing home says she has a fractured ankle, states her knee gave out, and she fell on to her left ankle this morning. X-rays were done where she currently resides. Review of the hospital documentation titled Emergency Department Discharge Instructions dated 02/23/16 revealed a [DIAGNOSES REDACTED]. Review of the facility form titled: Incident Follow-Up and Recommendation Form dated: 02/23/16 revealed the summary of investigative facts included Resident #52 was transferring from the wheelchair to bed with a state tested nursing assistant (STNA), her knee buckled and she lost her footing, she squatted down and staff was able to get her back into the chair without lowering her to the ground. Recommendations/Actions Taken: Resident #52 was to be a two person hoyer lift transfer, x-ray of the left ankle related to pain, send to emergency room related to superficial positive fracture and a follow-up appointment with the orthopedic doctor for a positive left medial malleolus (ankle) fracture. On 03/15/16 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON) along with the administrator being present. A review of Resident #52's record was conducted with the DON revealing that Resident #52 sustained a fall resulting in a fracture to her left ankle on 02/23/16 after being transferred with the assistance of only one person, STNA #1. It was verified that Resident #52 was assessed per the MDS as requiring extensive assistance of two plus staff members for transfers and was care planned for two person extensive assistance with transfers. The DON also verified that Resident #52 was receiving physical therapy and had not been reevaluated to only need one person assistance with transfers. On 03/16/16 at 5:25 P.M. an interview was conducted with Resident #52 verifying that only one staff member, STNA #1 was present and assisted her with transferring from the bed to the wheelchair when her knee buckled and she collapsed on her left foot resulting in a fractured left ankle. Review of the facility's incident management policy (revised November 2008) revealed the intent was the facility would identify residents at risk for incidents and adequately plan care and implement procedures designed to reduce the incident risk and minimize the potential for occurrences. The policy revealed that each resident would receive adequate assistance and oversight as defined in an individualized plan of care that reduces the risk for incidents.

Based on staff interview, medical record review, review of policies relating to abuse, and self-reported incident review, the facility failed to prevent abuse from facility staff members towards two (#149 and #34) out of three residents reviewed for occurrences of abuse. Actual harm occurred when Resident #149 suffered bruises to her upper body after staff continued to shower the resident when she became physically aggressive during a shower, having requested not to receive a shower. Additionally, a staff member used verbal intimidation towards Resident #149 and threw water into the face of Resident #149 following the shower. Actual harm occurred for Resident #34 when she suffered a swollen and bruised right fourth finger after staff grabbed the shower head back from the resident during bathing. The facility census was 99. Findings Include: 1. Review of medical record for Resident #149 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. The 30 day minimum data set (MDS) assessment dated [DATE] revealed Resident #149 had some cognitive impairment. Interview with the Administrator on 12/17/14 at 12:00 P.M. revealed on the evening of 06/07/14, around 9:30 PM., Resident #149 had been incontinent of urine. State tested Nursing Assistant (STNA) #21 took the resident to the shower to wash her up. Resident #149 became combative in the shower room stating to several staff members she did not want a shower. During the course of the shower the resident was hitting out at the staff members and sustained bruising on her upper body. The Administrator stated the former unit manager reported the incident to him on 06/08/14 and a self-reported incident, tracking number , was completed. The Administrator provided a copy of the facility's investigation for review. Review of the facility's investigation revealed a telephone interview was conducted by Registered Nurse (RN) #5 and Licensed Practical Nurse (LPN) #13 with STNA #21 on 06/08/14, no time of interview noted. STNA #21 indicated Resident #149 was soaked with urine so the aide decided to take her to the shower room instead of the bathroom to wash her up. When they got to the shower Resident #149 was "acting crazy" and started yelling and hitting STNA #21. Resident #149 told her she was allergic to the water and then told RN #6 she was allergic to the facility's soap. STNA #22 was also in the room and the three of them transferred Resident #149 from the wheelchair to the shower chair. STNA #21 washed Resident #149's body while STNA #22 washed the resident's hair. When the shower was completed Resident #149 was placed back in her wheelchair and returned to bed. Upon putting the resident to bed, Resident #149 threw a cup of water at STNA #21, but the STNA stated she never threw any water back at the resident. She said she cleaned up the cup, threw it away and left the room without returning. The documented interview was not signed by STNA #21 verifying the accuracy of the interview. Review of the document during an interview with the Director of Nursing (DON) on 12/18/14 at 12:17 P.M. confirmed STNA #21 had not signed the form indicating she verified the accuracy of the interview. A written statement was obtained from STNA #22 on 06/08/14 regarding Resident #149's shower. STNA #22 indicated as she was walking by the shower room she could hear yelling from the inside and heard STNA #21 telling Resident #149 "If you don't stop hitting me I will have to call the police." STNA #22 said when she entered the shower room she could smell urine on Resident #149. STNA #21 said Resident #149 was soaked in urine all the way up to her hair. STNA #22 said she helped to undress Resident #149 and the resident continued to yell at the aides. RN #6 then entered the shower room and helped transfer Resident #149 to the shower chair. STNA #22 said she held Resident #149's hands down because every time she let them go the resident attempted to hit STNA #21. Once the shower was completed, STNA #22 helped STNA #21 get Resident #149 back into her wheelchair then returned to her own assignment. A written statement from RN #6 dated 06/07/14 indicated he heard Resident #149 yelling in the shower room and entered to see what was going on. Resident #149 was flailing her arms and saying she was allergic to the soap. RN #6 helped transfer her to the shower chair, left the room, and informed Resident #149's nurse of the resident's status. A written statement was obtained from RN #7, Resident #149's primary nurse, on 06/08/14. RN #7 noted around 9:00 P.M. to 10:00 P.M. she saw STNA #21 pushing Resident #149's wheelchair toward the shower room. Resident #149 was telling STNA #21 she did not want a shower because she was allergic to the facility's soap. RN #7 said she was in another resident's room and heard Resident #149 yelling for help numerous times. RN #7 went into the shower room and saw STNA #21, STNA #22, and RN #6 with Resident #149. RN #7 asked the staff if everything was alright then returned to distributing medications. RN #7 observed STNA #21 returning Resident #149 to her room. RN #7 then heard Resident #149 yelling for help numerous times. RN #7 went to Resident #149's room and STNA #21 told her the resident had thrown a glass of water at her. Resident #149 said she had thrown the water at STNA #21, but then STNA #21 had filled the glass back up and threw it in the resident's face. STNA #21 denied throwing any water on the resident. RN #7 then told STNA #21 they needed to dry Resident #149 off because there was water all over the resident's face, the front of her gown, and the bed linen. STNA #21 got a clean gown from the resident's closet but Resident #149 said she wanted her sweat pants and a top instead. STNA #21 told Resident #149 she could stay there naked and left the room. Resident #149 told RN #7 she did not want to take a shower but STNA #21 forced her to and was rough with her during the shower. Resident #149 said she was hitting STNA #21 because she was being rough with her and forced her to take a shower. The resident said the staff were grabbing her, pulling her hair, and twisting her legs. She stated they covered her eyes with a washcloth and pushed it over her eyes. RN #7 indicated throughout the rest of the shift Resident #149 told her the same story three to four times. RN #7 indicated she spoke with RN #6 about what she should do but did not indicate what RN #6 advised. RN #7 spoke privately with STNA #22 who said nothing abusive had happened to the resident. RN #7 also spoke privately with STNA #21 who said Resident #149 was fine with taking a shower until they entered the shower room and then she began refusing the shower. STNA #21 indicated the resident had broken her necklace, scratched her, kicked her and bit STNA #22. RN #7 continued to reassess Resident #149 throughout the rest of the shift. The resident was alert and oriented throughout the shift and told other staff the same thing she had told RN #7. RN #7 noted Resident #149 requested pain medication twice during the night as her" body was sore from fighting." At the end of her shift RN #7 noticed new bruising on the resident's arms and back so she notified the unit manager at that time. Interview with the Administrator and DON on 12/17/14 at 12:00 P.M. confirmed the incident was not reported until almost eight hours later. When questioned if STNA #21 had been removed from duty after the shower, the Administrator stated STNA #21's shift was over and she clocked out shortly after completing the shower. The Administrator confirmed STNA #21 was not removed from duty by either RN #6 or RN #7. An interview was conducted with the Administrator on 12/17/14 at 12:00 P.M. who confirmed STNA #21 was terminated after the shower incident, as during the course of the investigation they felt there was enough evidence to substantiate STNA #21 had thrown water at Resident #149. A second interview was conducted with the Administrator on 12/18/14 at 11:30 A.M. which confirmed the facility had not reported the substantiated allegation of abuse by STNA #21 to the state nurse aide registry. The Administrator also confirmed a discipline had not been issued at the time to RN #7, but she would be receiving one for failure to report an allegation of abuse the next time she was scheduled to work. No disciplinary action had been provided to RN #6. Review of the nurses' notes from 06/07/14 through 06/09/14 revealed no documentation regarding either the physician or the family being notified of Resident #149's bruises nor was there documentation by RN #7 regarding the new bruising that developed over the course of her shift. This was confirmed during an interview with the DON on 12/18/14 at 12:17 P.M. 2. Review of medical record for Resident #34 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. The annual minimum data assessment completed on 09/21/14 indicated the resident had moderate cognitive impairment. Review of facility investigation revealed on 11/25/14 Licensed Practical Nurse (LPN) #10 reported to the DON Resident #34's right ring finger was swollen and bruised. The injury had occurred the previous day during the resident's shower. The DON interviewed Resident #34 who stated the injury occurred during her shower the day before. The resident indicated she did not remember all the details but remembered STNA #20 had been upset and rough with her during the shower. During the course of the DON's investigation STNA #20 was interviewed about the shower. STNA #20 indicated Resident #34 was not happy about taking a shower but did agree to go. During the course of the shower Resident #34 became upset and grabbed the shower head from STNA #20. STNA #20 grabbed the shower head back. The investigation indicated this was what caused Resident #34's injury to her right ring finger. The DON interviewed LPN #11 regarding the shower incident. LPN #11 said she had been looking for STNA #20 and found her in the shower room with Resident #34 and indicated there were "issues" but Resident #34 had no complaints. Later in the shift STNA #20 informed LPN #11 that Resident #34 was complaining of pain and swelling to the right ring finger. An interview was conducted with the Administrator on 12/17/14 at 12:10 P.M. The Administrator confirmed there were no written statements from the staff involved in Resident #34's investigation, only the DON's handwritten notes of the interviews conducted. The Administrator also confirmed LPN #11 should have reported the incident immediately to the unit manager, DON, or himself. LPN #11 has since been disciplined for not reporting an allegation of abuse. During interview with LPN #11 and the DON on 12/18/14 at 12:17 P.M., LPN #11 stated later in the day on 11/24/14, the staff informed her Resident #34 was complaining of pain to her right ring finger and by the afternoon had developed bruising. LPN #11 said the injury seemed to be fine as the resident can become agitated and has a history of paranoia. LPN #11 confirmed she had not documented in the medical record about the resident not wanting a shower and had documented nothing regarding the injury or Resident #34's complaints of pain. LPN #11 said if the STNAs tell her a resident does not wish to take a shower then not to give them one. Resident #34 had her shower around 7:00 A.M. and the nurse realized around 8:00 A.M. there was a problem with the resident's finger. LPN #11 stated she removed STNA #20 from Resident #34's assignment but did not remove her from the building or notify anyone in administration about the incident. The DON said she notified the resident's physician and family on 11/25/14 and began the investigation. The DON confirmed there were no statements from the staff involved, just her notes, and she had not documented anything regarding notifying the physician, the orders given by the physician, or that the family was notified regarding the incident. Review of Resident #34's medical record revealed no documentation in the chart for 11/24/14 regarding the shower incident or injury. The only documentation regarding the injury was documented by Unit Manager (UM) #12 on 11/25/14 at 1:00 P.M., which indicated the right ring finger was swollen. The lack of documentation was confirmed during interview with the DON and LPN #11 on 12/18/14 at 12:17 P.M. Review of the DON's investigation for self-reported incident tracking number confirmed there were no signed documents by any staff regarding what they had seen, just the DON's report of what she wrote down from their interviews. The notes from the investigation revealed both LPN #11 and STNA #20 received disciplines from this incident, and the facility began educating staff regarding dementia, respecting residents' choices, and how to handle an agitated resident. Review of the facility policy titled "Protection of Residents: Reducing the Threat of Abuse and Neglect," revised on 07/2011, revealed all alleged or suspected violations involving mistreatment, abuse, neglect, and injuries of unknown origin will be promptly reported to the Administrator and/or the DON. The facility's policy also indicated any employee accused of abuse will immediately be removed from duty and placed on suspension pending an investigation of the incident. The policy also indicated a list of questions to be asked during interviews and upon completion of the interview the staff member answering the questions was to review the report for accuracy then sign and date it indicating the accuracy of the facts reported.

Based on surveyor observation, record review, review of facility policy and resident, family, staff, pharmacist and physician interview, it was determined the facility failed to ensure one resident reviewed for pain management received treatment to control his pain. This resulted in actual harm for Resident #248 who was five days status [REDACTED]. This affected one (#248) of three residents reviewed for pain management of a total of 41 residents currently on a pain management program. Findings include: Review of Resident #248's medical record revealed the resident was admitted to the facility the evening of 04/12/11. [DIAGNOSES REDACTED]. Review of the "Initial Data Collection Tool/Nursing Service" document revealed only that the resident had previously had a history of [REDACTED]. A separate "Pain Assessment" document completed at 7:00 P.M. on 04/12/11 noted Resident #248 currently denied having pain, but did note that the resident was at risk for pain. The "Interim Plan of Care" dated 04/12/11 indicated the resident was at risk for pain related to his surgical procedure with the goal that the resident would state that his pain was at a tolerable level. Interventions included educating the resident/family on pain management and to monitor pain intensity following medication or treatment. At 9:15 A.M. on 04/13/11, Resident #248 was observed being pushed toward the therapy department in a wheelchair by therapy personnel, accompanied by his wife. Licensed Practical Nurse (LPN) #12 asked the resident if he would like some pain medication before going to therapy and the therapist stated, "That would probably be a good idea." The resident verified that he was having pain and could use the medication, but when informed that his ordered pain pills had not yet arrived from the pharmacy but that he could take Tylenol, he declined the offer and went on to therapy. When questioned by the surveyor, LPN #12 stated she had faxed the pharmacy this morning for permission to pull the ordered medication from the contingency supply, but had not yet received authorization. At 3:25 P.M. on 04/13/11, interview with LPN #12 revealed Resident #248 had not yet been medicated for pain because authorization had not yet been received from the pharmacy. At 3:45 P.M. on 04/13/11, an interview was conducted with Resident #248. When asked how he was feeling, he stated he was pretty sore since therapy. He was also noted to have a few spots of bright red drainage on the front of his gown. When questioned if he had received any pain medication yet, he stated he had just spoken with the nurse and "she doesn't know when it's going to come through. I don't know why there'd be any kind of mix-up but she said the pharmacy was saying something about allergies [REDACTED]. that. I have to have something to take the edge off so I can at least sleep." The resident's wife then stated, "I'm upset with the hospital - they should not have sent him without medication." The resident was observed yawning and drumming his fingers on the armrest of the chair during the interview. He was also noted to have a frequent cough which he stated was contributing to his discomfort. The interview was interrupted by the visit from his attending physician at 3:50 P.M. on 04/13/11. The resident was noted to have several short coughing spells during the examination and the physician commented after assessing his lungs that he had noted wheezing bilaterally. At 4:15 P.M. on 04/13/11, an interview was conducted with the attending physician. The physician stated he had been in the previous night (at the hospital) prior to the resident's arrival to the facility and verified orders and provided the Drug Enforcement Agency (DEA) required written documentation for the narcotic pain reliever ([MEDICATION NAME]). He stated there was also a valid prescription in the record for the [MEDICATION NAME] that had been sent by the hospital on discharge. When asked if he had been notified that the facility had not yet received the medication or authorization to pull the ordered pain medication from the contingency supply and therefore his patient had not received pain medication since admission the evening before, he stated he was not aware. When questioned by the surveyor if this was acceptable to him, he stated, "No, that is not acceptable." The physician added that not only had the discharging facility sent a legitimate and acceptable prescription for the medication, he had also filled out the facility form to meet the DEA's new interpretive rules. He stated he would be speaking with facility staff to ensure his resident received the ordered pain medication. On 04/13/11 at 4:20 P.M., the interview with Resident #248 was continued. When questioned to rate his pain on a scale of 1-10 with 10 being the worst pain, the resident replied that his pain level had been a "7" during the night. When asked what his pain level had been the previous morning prior to therapy, he replied it was a "5." When asked what the pain level was after therapy, he stated, "7-8." When asked what his pain level was at the current time, he stated it was a "7" because of the coughing. His wife then interjected, "you won't get a 10 out of him." When asked what was the highest that she had heard him complained of, she said "7." When the resident was then asked to think back to his surgery and rate his pain at that time, he replied that it was a "7" following surgery. Further interview on 04/14/11 at 7:45 A.M. with Resident #248 and his wife revealed he had finally received pain medication "around 6:30 or 7:00 the evening before." The resident then stated, "And I slept like a baby. I feel so much better today." The wife then added, "And his blood sugar was down. I think all the stress on his body from the pain was making his sugar go up." During an additional interview conducted at 11:32 A.M. at 04/14/11, the resident was questioned if other than yesterday morning when he was asked if he needed any pain medication before therapy, if anyone had talked to him about his pain level, he stated "No - you're the only one who asked." When asked if anyone had checked on him or asked him about his pain during his first night, he stated that he and his wife had inquired about him receiving pain medication but were told that it takes awhile to get the medication from the pharmacy. On 04/14/11 at 11:50 A.M., an interview was conducted with Licensed Physical Therapist #44. The therapist was questioned about the role that pain control plays in regard to the effectiveness of therapy. The therapist stated, "For most it is very important. If they're going to make progress you have to control the pain. If it is appropriate and they are due for something, they should be medicated before therapy. If we go to a resident and they're having pain and they're not due for something, we'll ask them if they think they can do a lighter workout or we'll try and adjust our schedule to do their therapy after they've been medicated." On 04/14/11 at 12:20 P.M., an interview was conducted with Pharmacist #8 from the facility's contracted pharmacy. She described the procedure for ordering medications for a new admit which required filling out the admission form and faxing it to the pharmacy from the facility end. The pharmacy technicians were then responsible for keying in the information on the resident and his/her medications. Once the admission process is completed, the pharmacist then reviews the information and checks it against the orders on the admission form (against what the technician put into the system) reviewing it for correct medication, strength, dosage, directions, and interactions. After being reviewed and corrected by the pharmacist, the orders are then sent to the pharmacy to be filled. She stated the pharmacy operates 24 hours/day, so regardless of whether or not it's a late admission, the information is still processed and the order filled. For narcotics orders such as the [MEDICATION NAME], she stated the first thing the nurse needs to do is to see if the resident has come from the discharging facility with a signed prescription or one has been written by the attending physician for the medication. If so, then that can be faxed with the medication orders and the pharmacy will dispense off that prescription. She stated that delivery depends on when the nurse requests it. If they request a drop-ship, it can be as little as 2 hours. If it's a controlled medication (for pain) they can pull it from their starter. Otherwise if not dropped shipped, it comes with their next scheduled delivery. She stated that with the new DEA requirements, the facility must have permission from the pharmacy to obtain those medications from the contingency box because the pharmacy must first have the valid legal prescription on file. She stated the maximum amount of time it should take is an hour to receive authorization after the pharmacy receives the written script. I tell the facilities that if they don't hear from us within an hour they need to call the pharmacy. When questioned how staff know that, she stated that she knew for a fact that the facility's Director of Nursing was aware of that. When she reviewed the prescriptions in Resident #248's medical record, she verified that both prescriptions (the one sent with the resident on transfer and the one filled out by the attending physician) were acceptable documents. She stated that since the new DEA interpretation, it has been an ongoing concern that is being addressed by facilities and the pharmacy alike to ensure that the residents' pain is controlled. She verified that somewhere along the line the "ball got dropped" for Resident #248. During interview with the Medical Director on 04/14/11 at 1:12 P.M., he stated that pain control and the new DEA requirements are addressed in QA (quality assurance) meetings "all the time." We're stressing to the hospitals and discharge planners that we really need to have a complete prescription on transfer. If they come over without a prescription, the pharmacy is allowed, in an emergency, to take a verbal order until they get the signed prescription faxed to them. In that case the physician of record is notified of the situation. As a backup, however, I, as the medical director, have given the facility permission to call me to initiate the procedure if necessary. All the pharmacies, including the facility's contracted pharmacy, have permission to call me at home and have my number. The problem generally seems to be a hold up with the pharmacy. It's usually not the home's problem. He stated it is a top priority for these patients coming straight from surgeries. If they're having pain, their experience is terrible regardless of the customer service provided. Unfortunately this DEA ruling has made it more difficult. Upon sharing the information collected thus far, the Medical Director stated that it was his understanding that there was a concern about a possible allergic reaction and that the pharmacy had faxed over a form, but that when it was faxed back to the pharmacy that it went to a different fax machine that was not accessible to the nurses and was not addressed until the next day. Interview was conducted with the DON (Director of Nursing) on 04/14/11 at 2:45 P.M. The DON stated that after the issue of his patient not receiving the ordered pain medication was brought to her attention by the attending physician, she immediately called the pharmacy to find out what was going on. She stated there were multiple errors that contributed to the problem. She indicated the pharmacy had misspelled the resident's name, so they had no client in their system with orders for what was being requested. Additionally, the pharmacy was mistakenly faxing replies to the business office fax machine (which was closed) rather than the nurses station. She stated once she spoke with someone in "control", that the issue was resolved and they were able to get the medication, but also added that there was no [MEDICATION NAME] left in the contingency box when they went to get some for Resident #248. The DON stated she had already addressed with the pharmacy the need for a larger contingency supply. There was no evidence of anything other than fax communication attempts prior to the telephone call made by the Director of Nursing over the 24 hour period. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 04/13/11, twenty-four hours after admission. Review of the facility's policy entitled, "Pain Management Protocol," revised 03/2007, revealed nursing staff will monitor and document the effectiveness of the pain management program in the resident's medical record, as appropriate for the resident condition. The nurse should also note on the 24 hour report any resident identified as having pain management concerns. The policy further noted the Director of Nursing will monitor effectiveness of pain management programs using the 24 hour report to identify any resident whose pain is not being controlled.