Every finding on record at Locust Ridge Healthcare LLC

Based on medical record review, staff interview, and facility policy review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued and the resident had benefits days remaining. This affected one (Resident #34) of three residents reviewed for beneficiary notices. The facility census was 59 residents. Findings include:Review of the medical record for Resident #34 revealed an admission date of 10/04/25 with diagnosis of metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 03/11/26 revealed the resident had intact cognition. Review of the SNF Beneficiary Notification Review for Resident #34 revealed the resident's Medicare Part A skilled services started on 02/11/26 and the last covered day of Part A service was 03/11/26. Per the SNF Beneficiary Notification Review, the facility initiated the discharge from Medicare Part A services when benefits days were not exhausted, and the resident was not issued a SNF ABN. During an interview on 05/13/2026 at 12:28 PM, the Social Services Director (SSD) stated the SNF ABN was issued hours prior to the last covered day. The SSD reviewed her files and confirmed a SNF ABN was not issued to Resident #34 or the resident's representative. The SSD stated she thought the SNF ABN was only to be issued if one skilled service remained, and if all skilled services were being cut then only the Notice of Medicare Non-Coverage (NOMNC) would be issued. During an interview on 05/13/2026 at 3:00 PM, the Administrator stated a resident should always receive a SNF ABN and NOMNC when Medicare Part A services were discontinued and the resident still had benefits days remaining. Review of the facility policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated 03/28/23 revealed the facility would issue SNF ABN notices for the following triggering events: a. Initiation - In the situation in which the direct of admissions or benefits coordinator believes Medicare will not pay for extended care items or services that a physician has ordered, a SNF ABN is issued to the beneficiary before those non-covered extended care items or services are furnished to the beneficiary. b. Reduction - In the situation in which the facility proposed to reduce a beneficiary's extended care items or services because it expects that Medicare will not pay for a subset of extended care items or services, or for any items or services at the current level and/or frequency of care that a physician has ordered, the SNF ABN is issued to the beneficiary before items or services to the beneficiary are reduced. c. Termination - In the situation in which the facility proposed to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving services.

Based on medical record review, observation, staff interview, review of manufacturer information, and facility policy review, the facility failed to ensure the medication error rate was five percent (%) or less. The facility had three medication errors of 28 opportunities which resulted in a medication error rate of 10.71 percent (%.) This affected two (Residents #21 and #22) of three residents observed for medication administration. The facility census was 59 residents. Findings include:1.Review of the medical record for Resident #21 revealed an admission date of 02/13/26 with a diagnosis of diabetes mellitus type two. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 02/18/26 revealed the resident had moderate cognitive impairment and received insulin injections seven of the last seven days of the assessment period. Review of the physician's orders for Resident #21 revealed an order dated 05/11/26 for Novolog insulin 10 units per subcutaneous pen-injector before meals. Observation of medication administration for Resident #21 on 05/13/26 at 8:24 A.M. per Licensed Practical Nurse (LPN) #2 revealed the nurse administered 10 units of Novolog insulin to the resident but did not prime the pen prior to the injection. LPN #2 administered the insulin after Resident #21 had consumed approximately 50 % of his breakfast meal at the time of administration. Interview on 05/13/26 at 10:10 A.M. with LPN #2 confirmed she did not prime the pen prior to insulin administration for Resident #21. LPN #2 stated Resident #21's insulin was ordered to be administered prior to meals, but the resident had already consumed 50% of the breakfast meal when she administered the dose of insulin. Review of the manufacturer information for the Novolog FlexPen dated 2009 revealed the nurse should do an air shot to prime the needle prior to each administration using the following steps: dial two units, hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle, press the push button on the syringe as far as it will go until a drop of insulin appears. 2. Review of the medical record for Resident #22 revealed an admission date of 05/01/22 with a diagnosis of type two diabetes mellitus. Review of the physician's orders for Resident #22 revealed an order dated 06/04/24, for insulin glargine 35 units per subcutaneous pen injection twice per day and an order dated 03/20/26 for insulin lispro 20 units per subcutaneous injection before meals and an order dated 03/20/26 for insulin lispro 12 units per subcutaneous injection if the resident's blood glucose level was between 251 milligrams per deciliter (mg/dL) and 300 mg/dL. Review of the MDS assessment for Resident #22 dated 04/27/26 revealed the resident had intact cognition and received insulin injections seven of the last seven days of the assessment period.Observation of medication administration for Resident #22 on 05/12/26 at 8:27 A.M. per LPN #1 revealed the nures administered 35 units of insulin glargine and 32 units of insulin lispro but did not prime the pens prior to the injections. LPN #1 administered the insulin after Resident #22 had consumed approximately 90% of his breakfast meal at the time of administration. Interview on 05/13/26 at 2:06 P.M. with LPN #1 confirmed she could not remember if she had primed the pen prior to insulin administration for Resident #22. LPN #1 stated Resident #22's insulin was ordered to be administered prior to meals, but the resident had already consumed 90% of the breakfast meal when she administered the dose of insulin. Review of the manufacturer information for insulin lispro revised 05/02/25 revealed the insulin pen must be primed before each injection to make sure the pen is ready to dose. Performing the priming step is important to confirm that insulin comes out when you push the injection button and to remove air that may collect in the insulin cartridge during normal use. If you do not prime, you may get too much or too little insulin. Interview on 05/14/26 at 8:29 A.M. with the Director of Nursing (DON) confirmed she expected insulin to be administered as ordered without errors, and each insulin pen should be primed with two units of insulin prior to dialing the prescribed dosage of insulin to administer to the resident to ensure the resident received the prescribed dosage. Review of the facility policy titled Administering Medications dated 02/14/24 revealed medications are administered in a safe and timely manner, and as prescribed. The policy specified medications, including insulin and any oral or subcutaneous hypoglycemic, are administered in accordance with prescriber orders, including any required time frame.

Based on resident and staff interview and record review, the facility failed to ensure residents had access to funds on weekends and evenings. This had the potential to affect 34 residents (#1, #2, #3, #4, #5, #7, #10, #11, #13, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #27, #28, #29, #31, #32, #37, #39, #40, #41, #42, #46, #49, #50, #51, and #52) who had funds with the facility. The facility census was 55. Findings include: Record review of Resident #4 revealed an admitted [DATE] with pertinent diagnosis of: schizoaffective disorder bipolar type, anemia, major depressive disorder, post traumatic stress disorder, seizures, hypertension, seizures, and hypertension. Interview with Resident #4 on 01/28/24 at 12:30 P.M. revealed she is unable to get funds on the weekends. Interview with Business Office Manager (BOM) #25 on 01/31/24 at 9:50 A.M. revealed someone has the keys to the office on the weekends. There is no sign that you can get money on the weekends and we do not advertise that. Interview with State tested Nurse Aide (STNA) #10 on 01/31/24 at 12:25 P.M. revealed they was not sure how to get funds if the family does not provide, and the BOM is not here. Interview with Registered Nurse (RN) #12 on 01/31/24 at 12:27 P.M. reveled they was not for sure how to get money on the weekends or evenings. Interview with STNA #14 on 01/31/24 at 12:32 P.M. revealed they was not sure how a resident would get funds if the BOM was not here, and they would ask the nurse on duty. Interview with RN #20 on 01/31/24 at 12:35 P.M. revealed they had a resident asked for funds after hours, and RN #20 told them no one is here to get money.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interview, record review, website review, and document review, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous Intravenous (IV) fluid medications to residents. This affected three (Residents #42, #43, and #46) of three reviewed for pharmacy services. The facility identified 36 (Residents #9, #10, #11, #15, #18, #20, #21, #23, #25, #26, #27, #28, #33, #34, #39, #41, #42, #43, #46, #48, #51, #52, #53, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71 ) who received IV fluids through the company. The facility census was 56. Findings include: 1. Record review of Resident #42 revealed an admitted [DATE] with pertinent diagnoses of congestive heart failure, chronic pain syndrome, type one diabetes mellitus with diabetic neuropathy, xerosis cutis, chronic venous hypertension, localized edema, mild intellectual disabilities, anxiety disorder, cellulitis of left lower limb, cognitive communication deficit, morbid obesity, anemia, atherosclerotic heart disease of native coronary, cardiac arrhythmia, heart failure, hyperlipidemia, hypertension, presence of prosthetic heart valve, and peripheral venous insufficiency. Review of the 07/21/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Review of a physician order dated 03/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 milliliters (ml) 0.9% normal saline at 1000 ml per (/) hour (hr) additive formula: ascorbic acid 5 gram (gm) b complex - b5 250 milligrams (mg), b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. Review of a physician order dated 04/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 2. Record review of Resident #43 revealed an admitted [DATE] with pertinent diagnoses of: parapelegia, radiculopathy cervical and thoracic region, muscle wasting and atrophy, colostomy status, morbid obesity, nutritional deficiency, xerosis cutis, neurogenic bladder, acute ischemic heart disease, type two diabetes mellitus, pressure ulcer of sacral region, atrial fibrillation, spinalfusion thoracic and lumbar region, hyperlipidemia, sleep apnea, hypertension, calculus of kidney, and retention of urine. Review of the 07/20/23 quarterly MDS assessment revealed the resident was totally dependent for transfers and required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Review of physician orders dated 03/13/23, 04/11/23, 05/15/23, 06/22/23, 07/20/23, and 08/29/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 3. Record review of Resident #46 revealed an admitted [DATE] with pertinent diagnoses of: chronic obstructive pulmonary disease, [NAME] disorder, severe protein calorie malnutrition, chronic kidney disease, history of covid-19, chronic respiratory failure with hypoxia, dysphagia, benign neoplasm of cerebral meninges, hyperglycemia, gastro-esophagael reflux disease, arthropathy, history of falling, hyperlipidemia, hypertension, myoneural disorder, iron deficiency anemia, congestive heart failure, edema, vitamin D deficiency, long term opiate use, chronic pain, major depressive disorder, hypertensive heart and chronic kidney disease, and insomnia. Review of the 10/26/23 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a wheelchair to aid in mobility. The Resident was dependent for toileting, chair to chair transfer, and tub or shower transfer. The resident was always incontinent of bowel and bladder. Review of physician orders dated 03/13/23 and 04/13/23 revealed an order for infection infusion protocol-for Agency #700 IV therapy infusion-one time- 0.9% normal saline at 1000 ml/hr (total additive volume, 22 ml) additive formula: ascorbic acid 5 gm b complex - b5, 250 mg zinc, 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, glutathione 600 mg. Review of the Ohio State Pharmacy Board website revealed Agency #700 does not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 12/05/23 at 2:20 P.M. revealed she found out from their corporate company the facility was going to utilize services from Agency #700 to try to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. Facility nurses got with the facility Physician and the Physician wrote an order for Agency #700's IV bags. Agency #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September and Regional Nurse #300 was not sure why the corporate office stopped services, and reported services were on a trial basis. Interview with Regional Nurse #300 on 12/05/23 at 2:20 P.M. verified Agency #700 did not have an Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and that the facility was unaware of that at the time of IV administrations from March 2023 to September 2023. As a result of the incident, the facility took the following corrective actions to correct the deficient practice by 11/29/23: On 09/22/23, Agency #700 cessation was effective. On 11/20/23, education was provided to the governing body, [NAME] President of Operations #305, and Director of Operations #310 to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. Starting on 11/22/23 monitoring of ongoing compliance would take place. The facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly times three months. Audits will be taken to the QAPI review. On 11/29/23, residents who received Agency #700's IV fluids were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/29/23, all contracts that involve providing medications were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 12/08/23 at 11:16 A.M. an interview with [NAME] President of Operations #305 confirmed education in regards to proper pharmacy licensure for companies administering medications was provided. Review of Residents #42, #43, and #46 revealed assessments were completed as indicated in the plan of correction. This deficiency represents non-compliance investigated under Complaint Number OH00146750.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interview, record review, and website review, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous Intravenous (IV) fluid medications. This affected three (Residents #42, #43, and #46) of three reviewed for pharmacy services. The facility identified 36 (Residents #9, #10, #11, #15, #18, #20, #21, #23, #25, #26, #27, #28, #33, #34, #39, #41, #42, #43, #46, #48, #51, #52, #53, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71 ) who received IV fluids through the company. The facility census was 56. Findings include: 1. Record review of Resident #42 revealed an admitted [DATE] with pertinent diagnoses of congestive heart failure, chronic pain syndrome, type one diabetes mellitus with diabetic neuropathy, xerosis cutis, chronic venous hypertension, localized edema, mild intellectual disabilities, anxiety disorder, cellulitis of left lower limb, cognitive communication deficit, morbid obesity, anemia, atherosclerotic heart disease of native coronary, cardiac arrhythmia, heart failure, hyperlipidemia, hypertension, presence of prosthetic heart valve, and peripheral venous insufficiency. Review of the 07/21/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Review of a physician order dated 03/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 milliliters (ml) 0.9% normal saline at 1000 ml per (/) hour (hr) additive formula: ascorbic acid 5 gram (gm) b complex - b5 250 milligrams (mg), b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. Review of a physician order dated 04/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 2. Record review of Resident #43 revealed an admitted [DATE] with pertinent diagnoses of: parapelegia, radiculopathy cervical and thoracic region, muscle wasting and atrophy, colostomy status, morbid obesity, nutritional deficiency, xerosis cutis, neurogenic bladder, acute ischemic heart disease, type two diabetes mellitus, pressure ulcer of sacral region, atrial fibrillation, spinalfusion thoracic and lumbar region, hyperlipidemia, sleep apnea, hypertension, calculus of kidney, and retention of urine. Review of the 07/20/23 quarterly MDS assessment revealed the resident was totally dependent for transfers and required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Review of physician orders dated 03/13/23, 04/11/23, 05/15/23, 06/22/23, 07/20/23, and 08/29/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 3. Record review of Resident #46 revealed an admitted [DATE] with pertinent diagnoses of: chronic obstructive pulmonary disease, [NAME] disorder, severe protein calorie malnutrition, chronic kidney disease, history of covid-19, chronic respiratory failure with hypoxia, dysphagia, benign neoplasm of cerebral meninges, hyperglycemia, gastro-esophagael reflux disease, arthropathy, history of falling, hyperlipidemia, hypertension, myoneural disorder, iron deficiency anemia, congestive heart failure, edema, vitamin D deficiency, long term opiate use, chronic pain, major depressive disorder, hypertensive heart and chronic kidney disease, and insomnia. Review of the 10/26/23 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a wheelchair to aid in mobility. The Resident was dependent for toileting, chair to chair transfer, and tub or shower transfer. The resident was always incontinent of bowel and bladder. Review of physician orders dated 03/13/23 and 04/13/23 revealed an order for infection infusion protocol-for Agency #700 IV therapy infusion-one time- 0.9% normal saline at 1000 ml/hr (total additive volume, 22 ml) additive formula: ascorbic acid 5 gm b complex - b5, 250 mg zinc, 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, glutathione 600 mg. Review of the Ohio State Pharmacy Board website revealed Agency #700 does not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 12/05/23 at 2:20 P.M. revealed she found out from their corporate company the facility was going to utilize services from Agency #700 to try to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. Facility nurses got with the facility Physician and the Physician wrote an order for Agency #700's IV bags. Agency #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September and Regional Nurse #300 was not sure why the corporate office stopped services, and reported services were on a trial basis. Interview with Regional Nurse #300 on 12/05/23 at 2:20 P.M. verified Agency #700 did not have an Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and that the facility was unaware of that at the time of IV administrations from March 2023 to September 2023. As a result of the incident, the facility took the following corrective actions to correct the deficient practice by 11/29/23: On 09/22/23, Agency #700 cessation was effective. On 11/20/23, education was provided to the governing body, [NAME] President of Operations #305, and Director of Operations #310 to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. Starting on 11/22/23 monitoring of ongoing compliance would take place. The facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly times three months. Audits will be taken to the QAPI review. On 11/29/23, residents who received Agency #700's IV fluids were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/29/23, all contracts that involve providing medications were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 12/08/23 at 11:16 A.M. an interview with [NAME] President of Operations #305 confirmed education in regards to proper pharmacy licensure for companies administering medications was provided. Review of Residents #42, #43, and #46 revealed assessments were completed as indicated in the plan of correction. This deficiency represents non-compliance investigated under Complaint Number OH00146750.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interview, record review, and website review, the governing body of the facility failed to appropriately manage the facility when they allowed an outside company, who was not licensed in Ohio by the State Pharmacy Board, to administer dangerous Intravenous (IV) fluid medications to residents. This affected three (Residents #42, #43, and #46) of three reviewed for pharmacy services. The facility identified 36 (Residents #9, #10, #11, #15, #18, #20, #21, #23, #25, #26, #27, #28, #33, #34, #39, #41, #42, #43, #46, #48, #51, #52, #53, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71 ) who received IV fluids through the company. The facility census was 56. Findings include: 1. Record review of Resident #42 revealed an admitted [DATE] with pertinent diagnoses of congestive heart failure, chronic pain syndrome, type one diabetes mellitus with diabetic neuropathy, xerosis cutis, chronic venous hypertension, localized edema, mild intellectual disabilities, anxiety disorder, cellulitis of left lower limb, cognitive communication deficit, morbid obesity, anemia, atherosclerotic heart disease of native coronary, cardiac arrhythmia, heart failure, hyperlipidemia, hypertension, presence of prosthetic heart valve, and peripheral venous insufficiency. Review of the 07/21/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfer, walk in room, walk in corridor, dressing, toilet use, personal hygiene. Review of a physician order dated 03/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 milliliters (ml) 0.9% normal saline at 1000 ml per (/) hour (hr) additive formula: ascorbic acid 5 gram (gm) b complex - b5 250 milligrams (mg), b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. Review of a physician order dated 04/13/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 2. Record review of Resident #43 revealed an admitted [DATE] with pertinent diagnoses of: parapelegia, radiculopathy cervical and thoracic region, muscle wasting and atrophy, colostomy status, morbid obesity, nutritional deficiency, xerosis cutis, neurogenic bladder, acute ischemic heart disease, type two diabetes mellitus, pressure ulcer of sacral region, atrial fibrillation, spinalfusion thoracic and lumbar region, hyperlipidemia, sleep apnea, hypertension, calculus of kidney, and retention of urine. Review of the 07/20/23 quarterly MDS assessment revealed the resident was totally dependent for transfers and required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Review of physician orders dated 03/13/23, 04/11/23, 05/15/23, 06/22/23, 07/20/23, and 08/29/23 revealed infection and derma infusion protocol-for Agency #700 IV therapy infusion-one time 1000 ml 0.9% normal saline at 1000 ml/hr additive formula: ascorbic acid 5 gm b complex - b5 250 mg, b7 biotin, 20 mg zinc 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, and glutathione 600 mg. 3. Record review of Resident #46 revealed an admitted [DATE] with pertinent diagnoses of: chronic obstructive pulmonary disease, [NAME] disorder, severe protein calorie malnutrition, chronic kidney disease, history of covid-19, chronic respiratory failure with hypoxia, dysphagia, benign neoplasm of cerebral meninges, hyperglycemia, gastro-esophagael reflux disease, arthropathy, history of falling, hyperlipidemia, hypertension, myoneural disorder, iron deficiency anemia, congestive heart failure, edema, vitamin D deficiency, long term opiate use, chronic pain, major depressive disorder, hypertensive heart and chronic kidney disease, and insomnia. Review of the 10/26/23 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a wheelchair to aid in mobility. The Resident was dependent for toileting, chair to chair transfer, and tub or shower transfer. The resident was always incontinent of bowel and bladder. Review of physician orders dated 03/13/23 and 04/13/23 revealed an order for infection infusion protocol-for Agency #700 IV therapy infusion-one time- 0.9% normal saline at 1000 ml/hr (total additive volume, 22 ml) additive formula: ascorbic acid 5 gm b complex - b5, 250 mg zinc, 10 mg amino blend, glutamine 150 mg, arginine 500 mg, ornithine 150 mg, lysine 250 mg, citrulline 250 mg, glutathione 600 mg. Review of the Ohio State Pharmacy Board website revealed Agency #700 does not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 12/05/23 at 2:20 P.M. revealed she found out from their corporate company the facility was going to utilize services from Agency #700 to try to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. Facility nurses got with the facility Physician and the Physician wrote an order for Agency #700's IV bags. Agency #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September and Regional Nurse #300 was not sure why the corporate office stopped services, and reported services were on a trial basis. Interview with Regional Nurse #300 on 12/05/23 at 2:20 P.M. verified Agency #700 did not have an Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and that the facility was unaware of that at the time of IV administrations from March 2023 to September 2023. As a result of the incident, the facility took the following corrective actions to correct the deficient practice by 11/29/23: On 09/22/23, Agency #700 cessation was effective. On 11/20/23, education was provided to the governing body, [NAME] President of Operations #305, and Director of Operations #310 to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. Starting on 11/22/23 monitoring of ongoing compliance would take place. The facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly times three months. Audits will be taken to the QAPI review. On 11/29/23, residents who received Agency #700's IV fluids were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/29/23, all contracts that involve providing medications were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 12/08/23 at 11:16 A.M. an interview with [NAME] President of Operations #305 confirmed education in regards to proper pharmacy licensure for companies administering medications was provided. Review of Residents #42, #43, and #46 revealed assessments were completed as indicated in the plan of correction. This deficiency represents non-compliance investigated under Complaint Number OH00146750.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to follow infection control procedures when a staff member failed to wash or sanitize their hands after changing gloves during a dressing change for Resident #42. This affected one (Resident #42) of three residents reviewed for wound care. The facility census was 56. Findings include: Record review of Resident #42 revealed an admitted [DATE] with pertinent diagnoses of congestive heart failure, chronic pain syndrome, type one diabetes mellitus with diabetic neuropathy, xerosis cutis, chronic venous hypertension, localized edema, mild intellectual disabilities, anxiety disorder, cellulitis of left lower limb, cognitive communication deficit, morbid obesity, anemia, atherosclerotic heart disease of native coronary, cardiac arrhythmia, heart failure, hyperlipidemia, hypertension, presence of prosthetic heart valve, and peripheral venous insufficiency. Review of the 07/21/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene. Review of a physician order dated 07/06/23 revealed to cleanse area on abdominal mid [NAME] with normal saline, pat dry, apply calcium alginate inside of wound, and cover with clean dry dressing. Observation of Registered Nurse (RN) #10 completing the wound dressing change for Resident #42 on 12/05/23 at 11:20 A.M. revealed the nurse gathered the supplies and washed her hands and put on clean gloves. RN #10 opened gauze and used wound cleanser saline on the wound to the abdominal area. RN #10 removed her soiled gloves and put on clean gloves, RN #10 did not wash or sanitize her hands after removing the soiled gloves. RN #10 cut the calcium alginate and placed it in the wound and then placed the abdominal pad over the wound. Interview with RN #10 on 11:35 A.M. verified she did not wash her hands or use hand sanitizer after removing her gloves when she completed cleaning the wound. Review of a 08/01/19 facility handwashing/hand hygiene policy revealed to use an alcohol based hand rub of at least 62% alcohol or alternatively soap and water after removing gloves.

Based on observation, review of menu spread sheets and recipes, review of policy and staff interviews, the facility failed to ensure menu spreadsheet and recipes for portion sizes were followed. This affected 46 of 46 residents who received meals from the kitchen. The facility census was 46. Findings include: Review of the facility's menu spreadsheet dated 05/26/21 revealed the portion size for scrambled eggs to be three ounces. Review of the scrambled eggs recipe dated 05/26/21 revealed staff should count out the number of portions needed, place in the food processor and process until the characteristics were achieved. Milk should be added a little at a time to achieve the desired characteristic. Observation of the kitchen on 05/26/21 at 6:50 A.M., revealed Dietary Manager #48 to be making pureed scrambled eggs by placing two ounces of scrambled eggs each for two residents with a four ounces of scrambled eggs total into the food processor. Dietary Manager #28 then turned the food processor on and added two ounces of water to thin the scrambled eggs. After pureeing the scrambled eggs, Dietary Manager #48 divided the pureed eggs in half and put them into two divided plates. Interview with Dietary Manager #48 on 05/26/21 at 6:50 A.M. verified Dietary Manager #48 pureed two servings of scrambled eggs using four ounces of scrambled eggs and two ounces of water. Observation of tray line on 05/26/21 at 7:15 A.M., revealed Dietary Manager #48 to give all regular diets and mechanical soft diets two ounces of scrambled eggs. Interview with Dietary Manager #48 on 05/26/21 at 7:15 A.M., verified she provided all regular diets and mechanical soft diets two ounces of scrambled eggs. Dietary Manager #48 also verified the menu spreadsheet reported the portion size for scrambled eggs was three ounces. Interview with Dietary Technician 05/26/21 at 3:47 P.M., revealed scrambled eggs should be pureed or thinned using milk. Review of the facility's list of residents by diet types dated 05/24/21 revealed the facility had no residents that required no food by mouth (NPO). All residents received meals from the kitchen. Review of the policy titled Kitchen Weights, and Measures, dated April 2007, revealed food service staff will be trained in proper use of cooking and serving measurements to maintain portion control.

Based on observation, record review, policy review and staff interviews, the facility failed to dispose of expired food out of active circulation. This had the potential to affect 46 of 46 residents who receive food from the kitchen. The facility census was 46. Findings include: Observation of the kitchen on [DATE] at 6:50 A.M., revealed there to be four loafs of expired white bread dated [DATE], four loaf of expired wheat bread dated [DATE] and eight loaf of expired wheat bread dated [DATE] in the facility's dry storage. Further observation of the kitchen revealed there to be an opened gallon of expired milk in the reach in refrigerator dated [DATE]. Interview with Dietary Manager #48, at the time of the observation, verified there were four loafs of expired white bread dated [DATE], four loaf of expired wheat bread dated [DATE], eight loaf of expired wheat bread dated [DATE] in the facility's dry storage and an opened gallon of expired milk in the reach in refrigerator dated [DATE]. Review of the facility's list of residents by diet types dated [DATE] revealed the facility had no residents that required no food by mouth (NPO). All residents in the facility receives food from the kitchen. Review of the policy titled Food Receiving and Storage, dated [DATE], revealed foods shall be received and stored in a manner that complies with safe food handling practices.

Based on observation and staff interview, the facility failed to ensure handrails were maintain in a safe manner to allow residents to utilize them. This had the potential to affect all 25 of 25 residents on the Station 1 hall. The facility census was 46. Findings include: Observation of the Station 1 Hall on 05/27/21 at 8:40 A.M., revealed on the south side of the hall was an unpainted section of the wall, roughly about three feet from the floor, was missing a wooden handrail. This strip of unpainted wall was observed to have a broken piece of railing remaining with two nails sticking from the wall where the railing had been. Interview with the Administrator on 05/27/21 at 8:50 A.M., verified the hand railing was missing from the wall, and there were nails sticking out from the wall where the railing had been at one point in time. Observation of Station 1 Hall on 05/27/21 at 10:30 A.M., revealed the broken railing had been removed as well as the nails that had been sticking out of the wall.

Based on medical record review, staff interview, and policy review the facility failed to ensure the physician signed a resident's formulated advanced directive. This had the potential to affect one resident (#7) of two residents reviewed for advanced directives. The facility census was 46. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with bed mobility, dressing, toileting, eating and personal hygiene. Review of the code status form revealed Resident #7's guardian requested the resident was a do not resuscitate comfort care (DNRCC) on 04/20/20. Further review of the form revealed the form had not been signed by a physician. Review of the advanced directives care plan dated 01/18/21 revealed Resident #7 was listed as a DNRCC. Interview with Social Services Director (SSD) #59 on 05/26/21 at 9:12 A.M. verified Resident #7's DNRCC code status form dated 04/20/20 was not signed by the physician in the paper chart. SSD #59 also verified Resident #7's code status was listed as a DNRCC in the electronic record. Review of the facility policy titled Advanced Directives dated December 2016 revealed the Director of Nursing (DON) or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician will not be required to write orders for which he or she has an ethical or conscientious objection.

Based on medical record review, staff interview, and policy review the facility failed to provide a resident with transfer or discharge notices. The facility also failed to send a copy of the transfer or discharge notices to the Ombudsman for a resident who discharged to the hospital. This affected one resident (#18) of two residents reviewed for hospitalization s. The facility census was 46. Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required supervision with bed mobility, dressing, toileting, eating and personal hygiene. Review of the progress note dated 11/28/20 at 8:49 A.M. revealed Resident #18 was sent to the emergency room . A progress note dated 12/02/20 at 1:30 P.M., revealed the resident returned to the facility. A progress note dated 12/26/20 at 12:16 P.M., revealed the resident was transferred and admitted to the hospital. A progress note dated 12/29/20 dated 11:49 P.M., revealed the resident returned to the facility. Review of the notices of transfer or discharge revealed there was no transfer or discharge notice provided to Resident #18 on 11/28/20 or 12/26/20 when Resident #18 was sent to the hospital. Further review of Resident #18's transfer and discharge notices revealed there was no documentation that the Ombudsman was notified or was sent a copy of Resident #18's transfer or discharge notice for his 11/28/20 and 12/26/20 hospitalization . Interview with the Administrator on 05/26/21 at 11:02 A.M. verified Resident #18 was not given a discharge or transfer notice and the Ombudsman was not notified of Resident #18's discharges to the hospital on 11/28/20 or 12/26/20. Review of the facility policy Transfer or Discharge Notice undated revealed the resident or the resident's representative will be notified of the reason for the transfer or discharge in writing and a copy of the notice will be sent to the office of the state long term care ombudsman.

Based on medical record review and staff interview the facility failed to provide written bed hold notices to a resident that discharged to the hospital. This affected one resident (#18) of two residents reviewed for hospitalization s. The facility census was 46. Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required supervision with bed mobility, dressing, toileting, eating and personal hygiene. Review of the progress note dated 11/28/20 at 8:49 A.M. revealed Resident #18 was sent to the emergency room . A progress note dated 12/02/20 at 1:30 P.M., revealed the resident returned to the facility. A progress note dated 12/26/20 at 12:16 P.M., revealed the resident was transferred and admitted to the hospital. A progress note dated 12/29/20 dated 11:49 P.M., revealed the resident returned to the facility. Review of the bed hold notices revealed there was no bed hold notices provided to Resident #18 or Resident #18's responsible party on 11/28/20 or 12/26/20 when Resident #18 was sent to the hospital. Interview with the Administrator on 05/26/21 at 11:02 A.M. verified Resident #18 or Resident #18's responsible party was not given a written bed hold notice when he discharged to the hospital on 11/28/20 or 12/26/20. Review of the facility policy titled Holding Bed Space dated December 2006 revealed the facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of the bed hold policy.

Based on medical record review and staff interviews, the facility failed to notify the state mental health authority when a resident with a mental illness had a change of condition and was admitted to hospice. This affected one (#18) of two residents reviewed for significant change Pre-Admission Screening and Resident Review (PASARR). The facility census was 46. Findings include: Review of Resident #18's medical record revealed an admitted [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's quarterly Minimum Data Sets assessment dated [DATE] revealed resident to be severely cognitively impaired and required supervision with bed mobility, dressing, toileting, eating and personal hygiene. Review of Resident #18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's hospice paperwork dated 02/11/21 revealed Resident #18 was admitted to hospice services on 02/11/21. Review of Resident #18's PASARR dated 11/26/19 revealed resident had serious indications of mental illness. Further review of Resident #18's PASARR revealed Resident #18 did not have a significant change PASARR or notification to the state mental health authority when the resident was admitted to hospice services on 02/11/21. Interview with Social Services Director (SSD) #59 on 05/26/21 at 9:06 A.M., verified Resident #18 did not have a significant change PASARR completed or notification to the state mental health authority of Resident #18's significant change in condition when he was admitted to hospice on 02/11/21.

Based on medical record review, policy review and staff interview, the facility failed to ensure resident's medical record accurately reflected the resident's code status. This had the potential to affect one (#18) of two residents reviewed for advanced directives. The census was 46. Findings include: Review of Resident #18's medical record revealed and admitted [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's quarterly Minimum Data Sets assessment dated [DATE] revealed resident to be severely cognitively impaired and required supervision with bed mobility, dressing, toileting, eating and personal hygiene. Review of Resident #18's electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's face sheet dated 05/25/21 revealed Resident #18's code status to be a DNRCC. Review of Resident #18's paper chart revealed Resident #18 had the code status form dated and signed by the physician on 12/29/20 indicating Resident #18's code status to be a do not resuscitate comfort care arrest (DNRCCA). Interview with Social Services Director (SSD) #59 on 05/26/21 at 9:15 A.M., verified Resident #18's code status listed as a DNRCC in the electronic orders and face sheet did not match Resident #18's most recent code status form indicating Resident #18's code status was a DNRCCA in the paper chart. Review of the facility's undated policy titled Charting and Documentation revealed documentation in the medical record will be accurate.

Based on observation, resident and staff interviews, the facility failed to provide a safe and comfortable environment by not properly repairing a damaged wall in a resident room. This affected one (#148) of five residents reviewed on the Station 1 hall. The facility census was 46. Findings include: Observation of Resident #148's room on 05/27/21 at 8:40 A.M., revealed there was an unpainted strip of wall approximately three feet above the floor that had numerous holes in the wall along the entire back wall of the room opposite the door to the room. This room also had a broken railing directly above the headboard of the resident's bed that was hanging loosely from the wall. Interview with Resident #148 on 05/27/21 at 8:50 A.M., revealed her room was like this when she moved into it. Resident stated it definitely needed fixed. Interview with the Administrator on 05/27/21 at 8:50 A.M., verified the room of Resident #148 needed repaired and verified a strip of unpainted wall with approximately six holes visible in the wall along the entire back of the room. Administrator also verified the broken railing above the resident's headboard.

Based on medical record review, staff interview, policy review, and review of the self-reported incidents, the facility failed to report an allegation of sexual abuse. This affected one Resident (#100) of three reviewed for abuse. The facility census was 49 Findings include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged home on[DATE]. [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident had behaviors directed towards others and her mood was not assessed. Review of the nurse progress notes dated 2/2/2021 at 5:45 P.M. revealed Resident #100 arrived to the facility via Emergency (EMT) transport from the hospital. The resident was alert and oriented upon arrival. The resident was greeted and oriented to surroundings and call light. The resident was given fluids and food upon arriving, and a phone to contact family. The resident was assessed upon arriving and denied any complaints of pain or distress at that time. The admission nurse's note had no mention of alleged abuse. Interview on 03/22/21 at 9:42 A.M., the State tested Nursing Assistant (STNA) #38 revealed Resident #100 was very confused and disoriented as to why she was in the facility and not at home. The resident was upset the emergency transport squad brought her to the facility. The resident was also upset and alleged one of the two young boys who brought her, had felt her up. Telephone interview on 03/22/21 at 9:53 A.M., the STNA #33 revealed Resident #100 kept talking about a man had put his hand down her gown. The resident did not say when it happened. She further revealed it had to be the emergency squad men as there were no other men near her until her laboratory tests the following morning. Telephone interview 03/30/21 at 9:47 A.M., the Director of Nursing (DON) revealed the staff had reported bazaar things Resident # 100 had said that they did not take the allegation of sexual abuse serious and it had not been reported. Review of the self-reported incidents dated from 02/02/21 through 03/22/21 revealed the alleged incident had not been reported until 03/22/21. Review of the facility policy titled Abuse Investigation and Reporting dated 07/2017 revealed All alleged violations involving abuse will be reported immediately.

Based on observations and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. This affected seven rooms (room [ROOM NUMBER], #13, #15, #20, #23, #26 and activity rooms) of 38 resident rooms in the facility. The facility census was 41. Findings include: 1. Observation on 02/19/19 at 10:35 A.M., of room [ROOM NUMBER] revealed a brown water stain in the corner of the room, a cracked window pane, dried and broken caulking around the window, and a sheet thumb tacked to the wall as a curtain. The bedsheet/curtain was tied in a knot at the bottom, allowing a view into the room from the courtyard. The resident was visible from room windows across the courtyard. Interview on 02/19/19 with Maintenance Director (MD) #184 and Regional Clinical Consultant (RCC) #169 verified the leak in the ceiling, the cracked window, and the sheet for a curtain. Both verified the resident was visible from the courtyard and the windows across the courtyard. 2. Observation on 02/19/19 at 11:00 A.M., revealed a cracked window in room [ROOM NUMBER] and a broken window handle lying on the window sill. 3. Observation on 02/19/19 at 5:00 P.M., revealed sheets as curtains were held in place by thumbtacks in Rooms #20, #23, and #26. In room [ROOM NUMBER], a valance was held above the window by thumbtacks. A towel was thumb tacked over the window in the memory care unit dining room. In room [ROOM NUMBER], the bottom window pane had a large crack in it. Observation on 02/20/19 at 7:10 A.M., revealed a bucket in the corner of the activity room with four inches of water from a drip in the ceiling with a brownish mark noted on the ceiling tiles. Observation on 02/20/19 at 8:00 A.M., revealed MD #184 changing stained ceiling tiles in room [ROOM NUMBER]. Interview on 02/21/19 at 9:30 A.M., with RCC #169 verified the environmental issues of sheets hung as curtains, cracked and broken windows, and leaks from the ceiling in room [ROOM NUMBER] and the activity room.

Based on record review, observations, and staff interviews, the facility failed to accurately assess a resident's status on the Minimum Data Set (MDS) for physical restraints. This affected one resident (#32) of twelve residents reviewed. The facility census was 41. Findings include: Review of the medical record for Resident #32 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident baseline care plan dated 01/27/19 revealed no focus for physical restraints. Review of Resident #32's quarterly MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating significant cognitive impairment with inattention, disorganized thinking, delusions, and verbal and physical behaviors directed at others and self. The resident required extensive one to two person physical assistance with most activities of daily living (ADLs). The resident was coded for physical restraints. Review of the facility matrix on 02/20/19 revealed Resident #32 was positively identified as having physical restraints. Observation on 02/21/19 at 7:20 A.M., revealed Resident #32 lying in bed sleeping without any physical restraints. Interview on 02/21/19 10:34 A.M., with Licensed Practical Nurse (LPN) #160 revealed Resident #32 had no physical restraints and had never been physically restrained. Interview on 02/21/19 at 1:12 P.M., with the Director of Nursing (DON) revealed she was unaware of any resident requiring physical restraints and verified Resident #32 did not have physical restraints. Interview on 02/21/19 at 1:21 P.M., with Regional Clinical Coordinator (RCC) #169 verified the MDS was coded incorrectly.

Based on medical record review, interview, and review of and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) guidelines, the facility failed to timely develop and implement comprehensive care plans within the required time frame. This affected one resident (Resident #42) of 12 residents reviewed for care plan accuracy and timeliness. The facility census was 41. Findings include: Review of the medical record for Resident #42 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. She was discharged to the community on 12/22/18. Review of the admission MDS 3.0 revealed an assessment reference date of 11/29/18 and was signed as completed on 12/06/18. Care plan signature date was 12/06/18 and review of the care area assessment revealed activities of daily living, incontinence, activities, and falls was to be care planned on 12/06/18. Review of the medical record was silent of any comprehensive care plans. There was a baseline care plan in place upon admitted d 11/29/18 and did not include any interventions for falls, incontinence, or activities. Interview was conducted on 02/21/19 at 12:35 P.M. with Registered Nurse #180 verified there was no comprehensive care plans completed for Resident #42 and that they should have been completed on 12/06/18 and no later than 12/12/18. Review of the MDS 3.0 RAI guidelines revealed care plans must be developed within seven days of completion of the comprehensive assessment.

Based on staff interview, observation, record review, and review of facility policy, the facility failed to provide ongoing monitoring, failed to apply treatments as ordered to pressure ulcers, and failed to obtain treatment orders for pressure ulcers for two (#25 and #39) of two residents reviewed for pressure ulcers. This resulted in harm when Resident #25's reddened area at the left great toe bunion developed into an unstageable pressure ulcer with slough and eschar present. The facility identified two residents with pressure ulcers. The facility census was 48. Findings include: 1. Review of the medical record review for Resident # 25 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment, dated 7/24/16, revealed Resident #25 was totally dependent on two plus people for transfer and bed mobility. The Resident was totally dependent of one staff member for locomotion on and off unit, dressing, toilet use, eating, and personal hygiene. Resident #25 was always incontinent of both bowel and bladder. The assessment identified the resident was at risk for developing a pressure ulcer and was coded as currently not having a pressure ulcer. Review of the plan of care revised on 06/20/16 revealed Resident #25 had a potential for pressure ulcer development related to urinary incontinence, diabetes mellitus, and history of pressure ulcers. The goal was for the resident to be free from pressure ulcers. Interventions included treatment as ordered, monitor skin for red/open areas and report to nurse immediately, and weekly skin assessment per nurse. Review of a physician order dated 07/15/16 revealed an ordered for Allevyn pad (a dressing used to cover wounds) to left great toe bunion check every shift and change every three days. Review of a visual skin assessment dated [DATE] and signed by Licensed Practical Nurse (LPN) #12 revealed Resident #25 had redness below her left big toe. Review of a visual skin assessment dated [DATE] and signed by LPN #12 revealed Resident #25 had a fluid filled blister below her left big toe. No measurements were documented. Review of a visual skin assessment dated [DATE] and 08/23/16, and signed by LPN #12, revealed Resident #25 had a red area below her left big toe. No measurements were documented. Review of a visual skin assessment dated [DATE] and signed by LPN #12 revealed Resident #25 had a dark blue pressure like area below her left big toe. No measurements were documented. Review of the Treatment Administration Record (TAR) from 09/01/16 to 09/30/16 revealed the ordered Allevyn pad dressing change every three days to left great toe bunion was only changed on 09/09/16, 09/14/16, 09/22/16, 09/28/16 and 09/30/16. Review of a physician order dated 10/05/16 at 3:45 P.M. revealed an order for [REDACTED]. Review of a progress note dated 10/08/16 revealed Hospice Nurse #80 assessed Resident # 25 in regards to a wound on the medical aspect of the left foot and orders were put in place. Review of a visual skin assessment dated [DATE] revealed Resident #25 had a 2 centimeters (cm) in length by 2 centimeters in width pressure ulcer covered in slough below her left big toe. Interview with Registered Nurse (RN) #15 on 10/11/16 10:06 A.M. revealed Resident #25 had a pressure ulcer to her foot. Interview with LPN #32 on 10/14/16 at 1:55 P.M. verified there was not any weekly skin documentation for Resident #25 from 07/27/16 to 08/15/16 and from 08/24/16 to 09/08/16. LPN #32 verified there was no evidence the pressure ulcer to Resident #25's left big toe was monitored from 09/09/16 when the toe was described as dark blue in color until 10/11/16 when the presence of slough was noted. Observation of Resident #25's wound on 10/17/16 at 11:20 A.M. with LPN #32 revealed a pressure ulcer measuring 3 cms in length by 2.5 cms in width with undetermined depth on the medial aspect of the left foot below the big toe. The pressure ulcer had slough on the outer edges of the wound and eschar in the center of the wound. LPN #32 verified the measurements and verified that it was an unstageable pressure ulcer. An additional interview on 10/17/16 at 3:10 P.M., LPN #32 verified the skin assessments completed for the pressure ulcer to Resident #25's left great toe did not contain any measurements until 10/11/16. LPN #32 also verified the Allevyn pad was not changed as ordered. Review of an undated facility policy titled Wound Policy revealed the treatment will be completed per doctor's order. All areas will be assessed for size, drainage, odor and appearance. Documentation on all areas should be accurate and descriptive. 2. Review of the medical record revealed Resident #39 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had unclear speech, rarely understood others, rarely made herself understood, and was severely impaired for daily decision making skills. She was dependent on one or two staff members for all activities of daily living. She was a risk for developing a pressure ulcer but did not have a current pressure ulcer. Review of the plan of care dated 12/01/15 indicated the resident had the potential for pressure ulcer development. Interventions included administer treatment as ordered. Review of a nurses note dated 09/19/16 at 2:15 P.M. documented the physician was contacted concerning excoriated areas on the resident's buttock. Review of a physician order dated 09/19/16 to apply Magic Butt Cream (a mixture of antifungal cream, an antacid, and a protective cream) to buttock and peri area every shift until clear for excoriation was given. The Magic Butt Cream was not on the Treatment Admission Record (TAR) and not documented as ever being applied. Review of the nurses notes dated 09/22/16 at 2:45 A.M. documented the resident had developed two pressure ulcers. The two new skin areas were noted to right buttock and left buttock. The right buttock area measured 3 centimeter (cm) long by 2 cm width. It was cleansed with antibiotic ointment and [MEDICATION NAME] was applied. The left buttock was not measured but it was cleansed and [MEDICATION NAME] was applied. There was no physician order for [REDACTED].>Review of nurses notes dated 09/24/16 documented Resident #39 had two stage 2 pressure ulcers. The right buttock pressure ulcer was 2 cm by 1.5 cm with 0.1 cm depth. The left buttock pressure ulcer was 1.3 cm by 1.6 cm with 0.1 cm depth. The note documented they were waiting for the Magic Butt Cream order to be signed . Review of Treatment Administration Record for September 2016 and October 2016 revealed there was no treatment administered to the right and left buttock pressure ulcer until 10/05/16. Review of Resident #39's nurses notes dated 10/06/16 at 3:00 P.M. documented the hospice nurse assessed the resident and wrote new orders for treatment to the wounds on the left and right buttocks. The treatment included cleanse the wounds to left and right buttock with normal saline, apply skin prep to periwound, apply [MEDICATION NAME] to wound bed, cover with Allevyn dressing, and change every bath day. Review of Resident #39's Weekly Skin Monitoring on 10/11/16 documented the right and left buttock had a treatment in place and was improving. No measurements or description of the wound was documented. Interview with the Director of Nursing (DON) on 10/14/16 at 11:20 A.M. verified the Magic Butt Cream was ordered but not administered. The DON verified the nurses did not get a physician order for [REDACTED]. Interview with Licensed Practical Nurse (LPN) #32 on 10/17/16 at 8:15 A.M. verified Resident # 39's pressure ulcers ulcers started on 09/22/16.