Every finding on record at Majestic Care of Fairfield LLC

Based on observations, interviews, record reviews and facility policies and procedures, the facility failed to ensure staff followed infection control policies and procedures. This affected three Residents (#77, #85 and #61) of the three residents reviewed for infection control. The Facility census was 138. Finding include: 1) Record review for Resident #77 revealed the resident was admitted to the facility on [DATE] with diagnoses including shingles, autoimmune hepatitis, end stage renal disease, anemia, hypertension and chronic pain syndrome. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #77 had no cognition impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the physician orders for Resident #77 dated 06/18/26, revealed the resident was ordered valacyclovir HCl (antiviral) 500 milligrams (mg), daily for Shingles until 06/25/26. The resident was ordered to be in contact precautions. Observation on 06/22/26 at 10:55 A.M., revealed Certified Nursing Assistant (CNA) #96 pushing an empty wheelchair while wearing gloves and entered the dialysis center. Shortly thereafter, CNA #96 exited the dialysis center pushing Resident #77 and entered his room. Observation of the signage outside the resident's room indicated Resident #77 was in Contact Precautions. CNA #96 stopped and retrieved gloves from the doorway and entered the resident's room. Once inside the resident's room, CNA # 96 donned gloves and assisted Resident #77 to bed. CNA #97 never donned a gown per the signage instruction on the resident's door. During an interview on 06/22/25 at 10:57 A.M, CNA #96 confirmed Resident #77 was in contact precautions. CAN #97 verified she entered the residents room without donning a gown and gloves as required for staff entering the room. During an interview on 06/22/26 at 11:50 A.M. Infection Preventionist / Licensed Practical Nurse (LPN) #14 confirmed Resident #77 was in contact precautions, and staff should always don gloves and gown prior entering the room of any resident in contact precautions. LPN #14 stated all facility staff were expected to follow all policies and procedures in the Infection Prevention Control Program, the Handwashing-Hand Hygiene policy and the Personal Protective Equipment (PPE) policy. 2) Review of the medical record for Resident #85 revealed an admission date of 05/28/26. Diagnoses included emphysema, heart failure, chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, atrial fibrillation, hypertension, unspecified dementia unspecified severity with other behavioral disturbance, and anxiety disorder. Review of the significant change MDS assessment dated [DATE] revealed Resident #85 had moderately impaired cognition. Observation on 06/22/26 at 4:05 P.M. with CNA #85, revealed a tied up plastic bag on the floor inside Resident #85's room near the door that contained gloves and an incontinence brief. During an interview with CAN #85 at the same time, verified the plastic bag on the floor containing a dirty incontinence brief was not disposed of properly. Interview on 06/25/26 at 1:08 P.M. with the Director of Nursing (DON) revealed the proper procedure was to dispose of the plastic bag in the biohazard room immediately. 3) Record review for Resident #61 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease with late onset, dementia, and gastro-esophageal reflux disease without esophagitis. Review of the MDS assessment dated [DATE], revealed Resident #61 had moderate cognition evidenced by a BIMS score of 10. This resident was assessed to require partial to moderate assistance for all activities of daily living. Observation of medication administration on 06/23/26 at 8:19 A.M. with LPN #25, revealed Resident #61 was in Enhanced Barrier Precautions (EBP) (an infection control measure used to prevent the spread of multidrug-resistant organisms [MDROs]). LPN #25 applied hand sanitizer and donned gloves and administered medications through Resident #61's gastronomy tube (G-tube). LPN #25 did not don a gown. Interview on 06/23/26 at 8:20 A.M., with LPN #61 confirmed Resident #61 was on Enhanced Barrier Precautions for having a G-tube. LPN #25 stated that since she was not performing wound care, she only needed to wear glove for her PPE. Review of the facility policy Infection Prevention & Control Program dated 10/01/25 revealed staff members performing high contact care should wear a gown and gloves for PPE. All staff members were responsible for following all policies and procedures related to the program, hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures, and shall use Personal Protective Equipment (PPE) according to the established facility policy governing the use of PPE. Review of the facility policy titled Waste Disposal, revised 03/05/25, revealed it was the policy of the facility to handle and dispose of infectious waste in a safe and appropriate manner. Review of the facility policy Personal Protective Equipment dated 01/13/26, revealed staff members must wear PPE as appropriate during resident care activities including gloves and gown when the possibility of contact with potentially contaminated surfaces or equipment is anticipated.

Based on observation, policy review and interviews, facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect 134 residents who received food from the kitchen. The facility census was 138.The findings include:Observation of the kitchen on 06/22/26 at 8:45 A.M., with Assistant Food Service Manager (AFSM) #330, revealed the walk-in refrigerator contained wo gallons of milk with an expiration date of 06/21/26. The walk in freezer contained a bag of open pancakes with no open date, a bag of frozen carrots in a bag open to air, a bag of pepperoni open to air and a bag of frozen hamburger patties open to air. There were an open bag of dinner rolls undated and not secured properly as well as four bags of cereal that had been open with no date on the outside of any of the four bags. AFSM #330 verified the findings. Observation of [NAME] Way Unit refrigerator on 06/24/26 at 1:56 P.M. with Licensed practical Nurse (LPN) #40, revealed the refrigerator had spills and food particles throughout the refrigerator unit and needed to be cleaned. Interview at the same time with LPN #40, verified the findings. Observation of [NAME] View Unit refrigerator on 06/24/26 at 2:01 P.M. with LPN #25, revealed three sandwiches that had passed their expiration date, an open container of coated pretzel bites with an open date of 06/20/26 with no name, and an open bottle of salad dressing with no name and an open date of 11/01 (year was undecipherable). Interview at the same time with LPN #25, verified the findings. Observation of Memory Care Unit refrigerator on 06/24/26 at 2:51 P.M. with LPN #22 revealed a Ziploc bag of watermelon with no name and no date. The freezer compartment had a frozen pizza with no name and no date. Interview at the same time with LPN #22, verified the findings. Review of facility policy titled Food Production dated 01/01/26, revealed that all leftover food must be dated, labeled and covered and stored or frozen in refrigerator or freezer for later use. Review of policy titled Food brought in by Family and Visitors dated 12/08/25 revealed families are to notify nursing team when food is brought into the facility. All food brought into the facility must be labeled with a use by date. The nursing care team members with discard perishable food on or before their use by date.

Based on observation, staff interview, and record review the facility failed to ensure medications were stored and labeled properly. This affected seven (#14, #108, #153, #64, #103, #84 and #160) but had the potential to affect all residents. The facility census was 138.1) Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: end stage renal disease, type 1 diabetes, and vascular dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderate cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of physician orders dated 01/28/26 for Resident #14, revealed the resident was ordered to receive insulin lispro subcutaneous solution pen-injector. Orders dated 04/16/26 revealed an order for insulin glargine solution (Lantus). Record review for Resident #108 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, hypertensive heart disease, and peripheral vascular disease.Review of the MDS assessment dated [DATE], revealed Resident #108 had intact cognition evidenced by a BIMS score of 15. Review of physician orders for Resident #108 dated 05/09/26, revealed an order for insulin lispro 100 unit/mL solution pen-injector. Record review for Resident #153 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, morbid obesity, and major depressive disorder. Review of the MDS assessment dated [DATE], revealed Resident #153 had intact cognition evidenced by a BIMS score of 15. Review of physician orders for Resident #153 dated 06/18/26, revealed an order for Toujeo SoloStar subcutaneous solution pen-injector (insulin glargine). Record review for Resident #64 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, major depressive disorder, and mild intermittent asthma. Review of the MDS assessment dated [DATE], revealed Resident #54 had intact cognition evidenced by a BIMS) score of 15. Review of physician orders for Resident #64 dated 02/20/23, revealed an order for Lantus Solostar solution pen-injector. Orders dated 02/20/23, revealed the resident was ordered Humalog solution (insulin lispro). Record review for Resident #103 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, irritable bowel syndrome with constipation, and hyperlipidemia.Review of the MDS assessment dated [DATE], revealed this resident had intact cognition evidenced by a BIMS score of 14. Review of physician orders dated 06/06/25 for Resident #103, revealed an order for Novolog FlexPen solution pen-injector. Record review for Resident #84 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, end stage renal, and chronic ischemic heart disease.Review of the MDS assessment dated [DATE], revealed this resident had intact cognition evidenced by a BIMS score of 15. Review of physician orders for Resident #84 dated 05/21/26, revealed an order for Novolog FlexPen solution pen-injector Record review for Resident #160 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: chronic respiratory failure, type 2 diabetes, and hyperkalemia. Review of the MDS assessment dated [DATE] revealed Resident #160 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Review of physician orders for Resident #160 dated 06/22/26m revealed an order for insulin glargine solution pen-injector. Observation of the 400-1 hall medication cart on 06/24/26 at 2:49 P.M with the Director of Nursing (DON) revealed Resident #14 insulin glargine solution (Lantus) was open and without an open date and insulin lispro subcutaneous solution pen-injector was open and without an open date. The DON verified the findings at the time of the observation. Observation of the 300-hall medication cart on 06/24/26 at 2:55 P.M with the DON, revealed Resident #153's Toujeo Solostar subcutaneous solution pen-injector was open and without an open date. Resident #64's Lantus Solostar solution pen-injector was open and without an open date and Humalog solution was open and without an open date. Resident #103's Novolog FlexPen solution pen-injector was open and without an expiration date. Resident #84's Novolog FlexPen solution pen-injector was open and without an open date. The DON verified the findings at the time of the observation.Observation of the 900-hall medication cart on 06/24/26 at 3:30 P.M of the 900-hall with the DON, revealed Resident #160's insulin glargine solution pen-injector was open and without an open date. The DON verified the findings at the time of the observation. 2) Observation of the 200-hall medication room on 06/24/26 at 3:09 P.M. with the DON, of revealed in the medication fridge there was an open vial of tuberculin (TB) without an open date. The DON verified the findings at the time of the observation.Observation of the 900-hall medication room on 06/24/26 at 3:25 P.M with the DON, revealed the medication fridge there was an open vial of TB without an open date. The DON verified the findings at the time of the observation.Review of the facility policy titled, Medication Administration dated on 10/30/2018 revealed multi-dose vials that have been opened should be dated when opened and discarded within 28 days.

Based on Observation, medical record review, staff and resident interviews and review of the facility policy. The facility failed to ensure residents followed safe smoking practices which included smoking in their rooms. This affected one (#01) out of the three Residents (#01, #05, and #45) reviewed for smoking. The facility census was 138. Findings include: Review of the medical record for Resident #01 revealed an admission date to the facility 04/09/26. Diagnoses included lung disease, pneumonia and anxiety. Review of the Minimum Data Set (MDS) assessment dated revealed Resident #01 was cognitively intact. Review of the smoking Plan of Care for Resident #01, revealed the resident could smoke unsupervised. Review of the most recent smoking assessment dated [DATE], revealed Resident #01 smoked safely. He remains alert and aware while smoking, does not endanger self or others while smoking, does not burn furniture, clothing, skin, self or others, turns oxygen off prior to lighting cigarette and smokes only in designated areas. Observations of Resident #01 on 06/22/26 at 4:25 P.M. by two surveyors, revealed the resident was in her room sitting on the side of the bed talking on the phone with a lit cigarette. The resident was asked to extinguish the cigarette, and a nurse was called to the room. During an interview with Resident #01 on 06/22/26 at 4:30 P.M., alongside Licensed Practical Nurse (LPN) # 117, revealed the resident reported no remembrance of lighting a cigarette and stated she must have done it out of habit. During an interview LPN #117 at the same time, verified she smelled the smoke and saw the haze as she walked into the residents room. Review of the facility smoking policy titled, Smoking Policy, July 2017, revealed the facility shall establish and maintain safe resident smoking practices. Smoking was only permitted in designated resident smoking areas, which are located outside. Any smoking-related privileges, restrictions, and concerns (for example, the need for close monitoring) will be noted in the care plan. If a resident was found to be smoking in non-designated area, a care conference would be held, and a discharge may be initiated due to the safety risk associated. This is a recite to the complaint survey dated 06/10/26.

Based on medical record review, observation and staff interview, facility failed to establish a mood and behavior care plan for residents who demonstrated varying moods and behaviors This affected one (#110) of the three residents reviewed for behaviors in the Memory Care Unit (MCU) The facility census was 138Findings include: Review of Resident #110's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, irritable bowel syndrome, spinal stenosis, and depression. Review of resident's Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #110 to be severely cognitively impaired, dependent for all activities of daily living and on hospice services. Review of the nurse's progress notes dated 05/01/26, revealed Resident #110 was sent out to the hospital and was admitted to the psychiatric unit. Resident #110 returned to facility on 05/18/26. During an interview on 06/24/26 at 3:47 P.M., Resident #110's representative stated the resident had been living at the home of one of her daughters prior to being admitted to the Assisted Living (AL) Community. Resident #110's representative stated the resident was only in the AL less than a week when it became clear she was not placed correctly and was sent to the hospital. The resident returned to AL on new medications but had all the same behaviors. Resident #110's representative stated the resident was moved to the nursing home where they took the resident off all psychotropic medications. Resident #110's representative stated the resident continued to have behaviors when staff provided care and the resident was found in another resident's room where there had been an altercation as both residents had physical injuries. Resident #110's representative stated the resident's behaviors increased and asked for the resident to be sent to the hospital. Resident #110's representative stated the resident seemed to be doing better but then declined functionally throughout the hospital stay and was returned to the facility on [DATE]. Resident #110's representative stated the resident gets physically aggressive at times. During an interview on 06/24/26 at 4:00 P.M., Registered Nurse (RN) #107 stated she cared for Resident #110 frequently and stated after her hospital stay in May 2026, the resident was not as combative. RN #107 stated the resident has now resumed her agitation the resident will hit, scratch and bite to try to express her displeasure. RN #107 stated the family comes in daily and the resident can get aggressive with them if they try to feed her or provide hands on care. RN #107 stated Hospice comes in twice a week to assist the resident with showers, and it takes three staff to be able to give her a shower. During an interview on 06/25/26 at 9:37 A.M., the Director of Nursing (DON) confirmed Resident #107 did not have a current care plan addressing her mood and behaviors. The DON acknowledged Resident #110 has been aggressive with staff and has been more challenging over the past few weeks. The DON acknowledged there should be a care plan instructing staff how deal with resident's mood and behavior.

Based on observation, record review and staff interview, facility failed to treat residents with dignity and respect. This affected two Residents (#39 and #106) of the three residents (#39, #106 and #110) reviewed for resident rights. Facility census was 138.Findings include:1) Medical record review for Residents #39 was admitted to facility on 09/11/24 with diagnosis including vascular dementia with psychotic mood disturbance, chronic pulmonary obstructive disease and osteoarthritis. Review or Minimum Data Set (MDS) dated [DATE], revealed Resident #39 to be cognitively impaired. Resident required moderate assistance with toileting and bathing. Observations of the Memory Care Unit (MCU) on 06/22/26 at 2:04 P.M., revealed Resident #39 was knocking on nurse's station office door requesting assistance to the bathroom. One staff person who was not visible, stated to the resident just go to your room and go to the bathroom. Resident #39 again said she needed to go to the bathroom and another voice in the nurse's station, told the resident to go to her room and use the bathroom. Resident #39 began walking away from office still requesting assistance to the bathroom. Licensed Practical Nurse (LPN) #21 came from down the hallway and assisted Resident #39 to the bathroom. Registered Nurse (RN)/Unit Manager #118 came out of the nurse's station and stated Resident #106 usually knows to go to her room and go to the bathroom. Review of [NAME] Care Dementia Care Program Training dated 06/05/24, revealed staff were to assess resident's psychosocial needs, validate their feelings, and treat them with dignity and respect when dealing with resident issues. During an interview on 05/25/26 at 1:36 P.M., The Administrator stated the staff should have gotten up and addressed the resident's needs. 2) Review of medical record revealed Resident #106 was admitted to facility on 06/27/24 with diagnoses including vascular dementia, asthma, schizophrenia, heart disease and dysphagia. Review of the most recent MDS assessment revealed Resident #106 was severely cognitively impaired and has a legal guardian who makes all healthcare decisions. Observations of the MCU on 06/22/26, 06/23/26 and 06/24/26 revealed Resident #106 to be ambulatory and roaming through the unit. At times she was sitting at tables coloring or writing and then resuming her wandering. The resident would interact with other residents at times as well as interact with staff. Observation of the MCU on 06/23/26 at 3:38 P.M., revealed Resident #106 was walking through the main dining area and approached a red door which she found to be open. Resident #106 went into the room and was in there a few moments. When she came back out of the room, LPN #28 saw her coming out and from across the room, yelled no, no you can't be in that room. LPN #28 started walking toward the resident and continued to express her displeasure in a full voice and stating the resident steals stuff when she is the room by herself. Resident stated she just wanted to play Bingo. LPN #28 responded to the resident that she could not play by herself and she needed to go down the hall and watch TV with everyone else. During an interview on 06/23/26 at 4:43 P.M. the Administrator stated that scolding a cognitively impaired resident was not appropriate in dealing with someone with dementia. The Administrator stated all staff on the MCU go through specialized training and should be aware of the proper way to redirect a resident. During an interview on 06/25/26 at 10:35 A.M., the DON stated scolding a resident was not the proper way to intervene in a situation such as the one she found involving Resident #106 on 06/23/26.This deficiency represents non-compliance investigated under Complaint Numbers 2700629 and 2576942.

Based on medical record review, resident interview, staff interview, and facility policy review the facility failed to ensure residents followed safe smoking practices which included smoking in their rooms. This affected two Residents (#111 and #112) out of three Residents (#105, #111, and #112) reviewed for smoking. The facility identified the following seventeen Residents (#04, #06, #10, #14, #15, #24, #27, #33, #38, #43, #47, #53, #62, #63, #77, #85, #105) as smokers. The facility census was 145.Findings include: 1) Review of the medical record for Resident #111 revealed he was admitted to the facility on [DATE]. His diagnoses included emphysema, chronic angina, chronic kidney disease, anemia, hyperlipidemia, obstructive sleep apnea, fatty liver, major depressive disorder, edema, anxiety disorder, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 was cognitively intact. The assessment did not indicate the resident utilized oxygen. Review of the active care plans for Resident #111 revealed there was documentation related to the resident smoking or any behavior related to not following the smoking policy. Resident #111 was care planned for the use of oxygen as needed. Review of the Safe Smoking Review dated 05/19/26 at 12:54 P.M. revealed Resident #111 was marked as having short term memory issues and the resident was assessed to smoke safely. Resident #111verbalized understanding of the smoking policy. Review of the nurse's progress note for Resident #111 dated 05/19/26 at 9:26 A.M. and written as a late entry on 05/20/26 at 9:29 A.M. by Assistant Director of Nursing (ADON) #103, revealed the resident was talked to about smoking in his room. The resident stated he bought the cigarettes after his appointment yesterday. The resident was informed he had the right to smoke but it must be in a designated smoking area and he must be supervised. The resident voiced understanding and stated he would not smoke in his room. The power-of-attorney (POA) was notified of the incident. Review of the nurse's progress notes for Resident #111 dated 05/19/26 at 12:42 P.M. and authored by LPN #101 revealed staff entered the resident's room and found him in bed smoking a cigarette. LPN #101 educated Resident #111 on safe smoking and the facility policy. Review of the nurse's progress notes for Resident #111 dated 05/19/26 at 11:27 P.M., and authored by Registered Nurse (RN) #104, revealed Resident #111 was escorted to and from the smoking area by an unknown certified nurse aide (CNA) and assisted back to his room. Review of the nurse's progress notes for Resident #111 dated 05/20/26 at 7:17 P.M. and authored by LPN#100, revealed during medication administration pass staff, identified the smell of smoke coming from Resident #100's rooms. Entered the resident's room and observed him lying in bed on his left side smoking a cigarette. The resident was educated on the importance of not smoking in his room and while the use of oxygen equipment was in use. During an interview on 06/10/26 at 2:28 P.M., ADON #103 stated Resident #111 was observed smoking in his room and the staff were able to redirect Resident #111. ADON #103 stated the resident had cognitive impairment, and he forgot that he does not smoke. ADON #103 stated Resident #111 obtained his cigarettes when he was out on an appointment. ADON #103 stated the staff took his lighter and cigarettes on a separate occasion when he was smoking in his room. ADON #103 stated the resident was not actively care planned to be a smoker because the resident did not want to smoke. ADON #103 stated it was the Administrator's discretion for what steps would be taken when a Resident does not follow the smoking policy. During an interview on 06/10/26 at 10:35 A.M., Resident #111 reported he was discovered smoking in his room by the nursing staff. Resident #111 stated he purchased the cigarettes at a gas station. During an interview on 06/10/26 at 3:50 P.M., LPN #100 stated she had concerns related to Resident #111 smoking in his room. LPN #100 stated the notes were confusing on how many times Resident #111 was found to be smoking in his room. LPN #100 stated she knew of three separate times in a 24-hour period. LPN #100 stated three different nurses found him smoking in his room. LPN #100 stated she did not know why Resident #111 wasn't on smoking list because she has observed other staff assist Resident #111 to smoke. 2) Review of the medical record for Resident #112 revealed she was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, congestive heart failure, diabetes mellitus, COPD, asthma, depression, and GERD. Review of the new admission MDS assessment for Resident #112 dated 05/21/26, revealed Resident #112 was at the facility for rehabilitation following an acute hospital stay. Review of the care plan for Resident #112 dated 05/21/26 revealed the resident required assistance from staff with activities of daily living (ADL) related to impaired mobility. The care plan was revised on 06/08/26 to indicate the resident was as a smoker and the resident exhibited behavior of smoking in her room with goals of Resident #112 complying with the facility smoking policy. Review of the nurse's progress notes for Resident #112 dated 05/29/26 at 2:10 P.M. and authored RN#104 revealed Resident #112 was found smoking in her room. Resident #112 was educated on safe smoking and the facility policy. Review of the nurse's progress notes for Resident #112 dated 06/06/26 at 2:30 P.M. and authored by LPN # 100, revealed Resident #112 had filled up her denture cup with water and used it as an ash tray in her room. Resident #112 was educated on safe smoking and why it was unsafe to smoke in the room. During an interview on 06/10/26 at 2:28 P.M., ADON #103 verified Resident #112 was found smoking in her room on a few different occasions. ADON #103 stated the resident worried about her spouse and she would forget where she was at. ADON #103 confirmed Residents #111 and #112 were not listed as smokers because neither one of them smoke. ADON#103 stated Residents #111 and #112 chose not to smoke at the facility. During an interview on 06/10/26 at 2:36 P.M., the Administrator stated if a resident was found smoking in his/her room or not following the facility smoking policy, it was up him to decide how to handle the situation. The Administrator stated he had no additional details regarding Resident #111 and #112 being observed smoking in their rooms. During an interview on 06/10/26 at 3:50 P.M., LPN #100 stated she found Resident #112 on 06/06/26 smoking in her room sitting in her recliner. LPN #100 stated the resident filled up her denture cup with water and used it as an ash tray. Review of the list of smokers provided by the facility on 06/10/26, revealed Residents #111 and #112 were not listed. Review of the facility smoking policy titled, Smoking Policy, July 2017, revealed the facility shall establish and maintain safe resident smoking practices. Smoking was only permitted in designated resident smoking areas, which are located outside. Any smoking-related privileges, restrictions, and concerns (for example, the need for close monitoring) will be noted in the care plan. If a resident was found to be smoking in non-designated area, a care conference would be held, and a discharge may be initiated due to the safety risk associated. This deficiency represents non-compliance investigated under Complaint Number 3038703.

Based on observation and staff interview, the facility failed to have a Licensed Social Worker to provide services to the residents. This had the potential to affect all of the residents in the facility. The facility census was 135 residents. Findings include: Observation on 03/11/25 at 3:30 P.M. revealed Social Work Consultant (SWC) #432 was working in the facility and providing services to residents. There was a sign on the office door which read Social Services. Further observation revealed there was no information posted in the office regarding SWC #432 license to practice as a social worker. Interview on 03/11/25 at 3:35 P.M. with the Administrator confirmed the facility did not have a Licensed Social Worker (LSW) employed with the facility. The Administrator confirmed the facility had a social services designee and an outside consultant, SWC #432, who came in two to three times per week and was available full time if needed. Interview on 03/12/25 at 1:15 P.M. with SWC #432 confirmed she had a bachelor's degree but was not an LSW. Interview on 03/12/25 at 2:20 P.M. with the Administrator confirmed he mistakenly thought SWC #432 was an LSW, but he had asked for a copy of her social work license on 03/12/25 and learned she did not have one. The Administrator confirmed there was no LSW providing services to the residents in the facility. This deficiency represents noncompliance investigated under Complaint Number OH00163464 and OH00163460.

Based on medical record review, review of letter from Administrator, review of email correspondence from the local health department, policy reviews, review of water temperature audits, review of Environmental Assessment of Water Systems report, review of the third -party consultant action plan, review of infection control logs, review of contract with a Water Management Consultant Company and staff interviews, the facility failed to implement a water management program to prevent Legionella in the water system and report a case of Legionella to the local authorities. This affected one (#10) of three residents reviewed for Legionella and had the potential to affect all 149 residents residing at the facility. The facility census was 149. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Resident #10 was discharged to the hospital on 08/15/24 and returned to the facility on [DATE]. His diagnoses included: morbid obesity, essential hypertension, Legionnaires disease, cellulitis of lower limb, anemia, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed he was cognitively intact. Further review of the MDS assessment revealed Resident #10 was dependent on staff for medication administration, toileting, personal hygiene, and he required assistance from staff with eating, and oral hygiene. Review of the Resident #10's hospital progress notes, dated 08/15/24, verified Resident #10 had a positive urine test for Legionella. Further review of the hospital progress notes confirmed the facility was notified of the illness on 08/19/24 at 8:05 A.M. Review of the nursing progress notes for August 2024 for Resident #10 revealed no indication of the Legionnaires disease diagnoses including family or physician notification. Review of the electronic communication from the Public Health Department, dated 08/26/24 at 2:09 P.M., revealed the public health department emailed the facility management team including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Infection Control Prevention (ICP) Nurse #165 to notify and discuss a confirmed case of Legionella at the facility. Review of the electronic communication between the DON and the laboratory (lab) confirmed the Legionella test for Resident #10, dated 08/28/24 at 12:01 P.M., verified the lab ran a rapid test to determine the presence of Legionella on Resident #10 and the results were positive. Interview on 08/29/24 at 12:47 P.M., with the Assistant Director of Nursing (ADON) #200 revealed the facility was notified from [NAME] County Health Department via email communication dated 08/26/24 of Resident #10's diagnoses of Legionella. ADON #200 confirmed on 08/26/24 when the facility was notified, the facility immediately stopped utilizing the water and utilized bottled water for care, drinking, and bed baths. The ADON #200 stated the facility was not aware of the diagnoses until she received the email from the health department. ADON #200 stated the facility was not notified of Resident #10's diagnoses from the hospital even at discharge from the hospital to admission to the nursing facility. ADON #200 confirmed nothing was written in Resident #10's medical chart relates to the Legionella diagnoses because the facility was not notified of the diagnoses from the hospital. ADON #200 confirmed Resident #10 received treatment for the Legionella Diagnoses in the hospital, however, she stated Resident #10 has many comorbidities that the same antibiotics could have been used to treat Legionella. Interview on 08/29/24 at 1:37 P.M., with the Administrator, Director of Nursing (DON), and ADON revealed ADON #200 stated she has a separate file that has the documentation of Resident #10's diagnoses and confirmed it is not located in his medical chart. The Administrator, DON, and ADON #200 continued to confirm the diagnoses was not made available to the facility until the local health department contacted the facility via email on 08/26/24. The DON stated the facility would not have been made aware of the diagnosis because Resident #10 received treatment at the hospital for Legionella and he is alert and oriented. The DON insisted the hospital would not have provided the information related to the Legionella diagnoses because they treated it at the hospital. The DON stated there would be no reason to notify Resident #10, his family member, or the physician of the Resident at the facility because treatment was done at the hospital. Interview on 08/29/24 at 1:49 P.M., with the DON and ADON #200 on 08/29/24 at 1:49 P.M. confirmed the facility did not document the new diagnoses of Legionella in Resident #10's medical chart because Resident #10 was aware of what he was tested and treated for. ADON #200 confirmed the Legionella Diagnoses was listed on his hospital paperwork, however, it was not documented as a new diagnosis and the facility wasn't sure if it was an old or new diagnoses. Interview on 08/29/24 at 3:30 P.M., with Infection Control Prevention (ICP) Nurse #165 confirmed the facility failed to notify the Public Health Department or implement the Water Management Plan immediately following notification of Resident #10's new diagnosis of Legionella. ICP #165 stated the facility was aware of Resident #10's new diagnosis of Legionella Disease when the paperwork from the hospital was faxed to the facility on [DATE]. ICP #165 stated any time a resident return from the hospital with an antibiotic he will research the why and list it in the infection control map and binder. ICP #165 verified all of management was aware when Resident #10 returned to the facility with a new diagnosis of Legionella, however, no one was sure what steps the facility should take. ICP #165 confirmed it was not until after the Local Health Department notified the facility on 08/26/24, that the facility acted and corporate sent over the report titled, Environmental Assessment of Water Systems and the facility hired the third-party consultants for an action plan. The ICP #165 stated the facility did not act because the facility felt it did not come from the facility until they were notified by the local health department. Interview on 08/29/24 at 4:45 P.M., with the DON confirmed the facility was aware of Resident #10's new diagnosis on 08/19/24 when the faxed paperwork was given to them by the Admissions Director. Review of the facility infection control log and map of infections confirmed Resident #10 was listed on 08/22/24 with a new diagnosis of Legionella. Review of the facility contract with a Water Management Consultant Company was signed on 08/26/24, by the Administrator and consultant. However, the contract's effective date was listed as 08/28/24. Review of the letter of notification mailed to the resident's family from the Administrator, dated 08/27/24, revealed the facility had worked with the Public Health Department and a third -party consultant company to take the appropriate steps to ensure the safety of the residents. The letter stated water samples had been taken and sent to a Centers for Disease Control and Prevention (CDC) laboratory for testing and sample results are pending. Further review of the family notification letter stated the facility will have the consulting team on sight and in various resident rooms and common areas to complete a water system risk assessment and provide recommendations on 08/27/24. The letter confirmed the facility will apply all appropriate safeguards and recommendations as identified. Review of the facility report titled, Environmental Assessment of Water Systems, hand dated 08/20/24 at 11:20 A.M., completed by ICP#165 revealed the description of the facility was blank on page 3. On page 4 of the assessment, it was determined the facility does have a fountain or water decoration, however the location and description were left blank. Further review of the facility Water System assessment revealed the facility water temperatures ranged from 105 Fahrenheit (F) and 120 F; however, the dates of measurement were left blank on Page 5. Page. 6 of the facility Water System assessment was blank including documentation of the facility thermostatic mixing valve. Page 7 through 13 were left blank and no facility assessment was completed of the Water System. Review of the facility audit titled, Water Temperature Audit, dated April 2024 through present date, revealed water temperatures ranged from 109F to 142 F. No verification of water temperatures January 2024 through April 2024 was provided. Review of the third -party consultant action plan stated the following steps will take place, Step one: Notify the physician, the local health department, and the Ohio Department of Health. Step 2. Notify all residents, family members, responsible parties, and staff and document in the resident's chart. Step 3. Notify the owner of the building. Step 4. Activate the facility's emergency water policy. Step 5. Post signage on all water outlets. Step 6. Post signage at all points of entry into the facility. Step 7. Utilize bag iced and bottles of water. Step 8. Contact the lab and document the result of the discussion. Step 9. Initiate a line listing of the past six months of pneumonia, and review findings with the medical director. Step 10. Begin heightened environmental and clinical monitoring. Step 11. Review the facility Legionella Risk Assessment and correct any short comings. Step 12. Review the facility water management plan. Step 13. Begin discussion with industrial water management to complete remediation. Step 14. Review concerns with other water pathogens. Step 15. Social Services is to complete a wellness relative to the resident's psycho- social wellbeing. Step 16. Formalize revisions to the Water Management program and notify residents of the changes. Step 17. Post remediation sampling every two weeks for three months. If no Legionella is produced during the second three-month period, then the testing can be reduced to quarterly. Step 18. If the environmental sampling is produces positive Legionella results, isolates should be typed and saved. Step 19. Continue heightened physical environment and clinical monitoring. Review of the undated policy titled, Legionella Surveillance and Detection, indicated the facility included Legionella as part of the infection surveillance activities. The clinical staff will be trained on how to identify signs and symptoms and notify the physician immediately if Legionnaire's disease is suspected. Further review of the policy confirmed if Legionella is detected in one or more residents, then the Infection Preventionist will activate the surveillance for Legionnaire's Disease, notify the local health department, notify the Administrator and Director of Nursing, and an investigation into the possible source of contamination will be initiated. Review of the policy titled, Legionella Water Management Program, dated July 2017, indicated the facility has a water management program overseen by the water management team. The team consisted of the Administrator, the Infection Preventionist, the Medical Director (or designee), the Director of Maintenance, and the Director of Environmental Services. The purpose of the water management teams is to reduce the risk of Legionnaires disease. Further review of the policy revealed the facility water management program is based on the Centers for Disease Control and Prevention (CDC) and the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHARE) recommendations. The facility water program consists of a detailed diagram and description of the water system, the identification of areas in the water system that could permit Legionella or other bacteria to grow, the identification of situations that can lead to Legionella growth, specific measures used to control the introduction or spread of the disease, and how often the water management team will meet. This deficiency represents noncompliance investigated under complaint numbers OH00157504, OH00157484, OH00157442, OH00157404, and OH00157265.

Based on medical record review, review of facility posted signage, review of letter from Administrator, and staff interviews, the facility failed to administer the facility to ensure residents, families, and appropriate authorities were timely notified regarding a Legionella infection and potential water contamination in the facility. This had the potential to affect all residents. The facility census was 149. Findings include: Review of Resident #10's medical record revealed an admitted [DATE]. Resident #10 was discharged to the hospital on 08/15/24 and returned to the facility on [DATE]. His diagnoses included: morbid obesity, essential hypertension, Legionnaires disease, cellulitis of lower limb, anemia, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed he was cognitively intact. Further review of the MDS assessment revealed Resident #10 was dependent on staff for medication administration, toileting, personal hygiene, and he required assistance from staff with eating, and oral hygiene. Review of the Resident #10's hospital progress notes, dated 08/15/24, verified Resident #10 had a positive urine test for Legionella. Further review of the hospital progress notes confirmed the facility was notified of the illness on 08/19/24 at 8:05 A.M. Review of the posted document titled, Re: Emergency Water Plan is in effect until further notice dated 08/26/24, revealed Due to an unforeseen issue with the facilities water system, all water sources in the Skilled Nursing Facility were not to be used until further notice. Staff, residents, and visitors were instructed to use bottled water and ice provided from the nurse's stations. Review of the letter of notification mailed to the resident's family from the Administrator, dated 08/27/24, revealed the facility had worked with the Public Health Department and a third -party consultant company to take the appropriate steps to ensure the safety of the residents. The letter stated water samples had been taken and sent to a Centers for Disease Control and Prevention (CDC) laboratory for testing and sample results are pending. Further review of the family notification letter stated the facility will have the consulting team on sight and in various resident rooms and common areas to complete a water system risk assessment and provide recommendations on 08/27/24. The letter confirmed the facility will apply all appropriate safeguards and recommendations as identified. Interview on 08/29/24 at 3:30 P.M., with Infection Control Prevention Nurse #165 confirmed the facility failed to notify the Public Health Department or implement the Water Management Plan immediately following notification of Resident #10's new diagnosis of Legionella. Interview on 08/29/24 at 4:45 P.M., with the Director of Nursing (DON) confirmed the facility was aware of Resident #10's new diagnosis of Legionella on 08/19/24, when the faxed paperwork was given to them by the Admissions Director. Interview on 09/09/24 at 9:00 A.M., with the Assistant Director of Nursing (ADON) #200 verified the facility did not begin notifying residents and families about the Legionella infection or potentially contaminated water until 08/26/24. This deficiency represents noncompliance investigated under Complaint Number OH00157404.

Based on observations and staff interviews, the facility failed to provide a sanitary and comfortable environment for the residents, staff and public. This had the potential to affect the residents residing on the memory care unit, 200 and 300 halls. Census was 149. Findings include: Observations on 09/04/24 and 09/05/24, revealed discolored ceiling tiles and dark discoloration near sprinkler and sensor located in the ceiling in the 300 hallway. Interview on 09/05/24 at 6:35 A.M., with Licensed Practical Nurse (LPN) #175 verified the discolored ceiling tiles. Observations on 09/04/24 and 09/05/24, revealed discolored ceiling observed near the light fixture and fire sensor outside room [ROOM NUMBER]. Interview on 09/05/24 at 7:02 A.M., with LPN #175 verified the discolored ceiling tiles. Observations on 09/04/24 and 09/05/24, revealed dark discoloration surrounding orange colored growth on ceiling tiles in the hallway outside of the 200 hall nurses' station and discoloration on multiple ceiling tiles and covering for ceiling light fixture outside of the 200A nurses station. Interview on 09/05/24 at 7:00 A.M., with LPN #175 verified the discolored ceiling tiles. Interview on 09/05/24 at 7:02 A.M., with LPN #172 revealed the dark stains on ceiling tiles near 200 hall nurses' station are common due to water leaks from ceiling. LPN #172 stated the facility place containers on the floor under the leaks to catch the water. Observations on 09/04/24 and 09/05/24, revealed discolored ceiling tiles near rooms [ROOM NUMBERS]. Interview on 09/05/24 at 7:05 A.M., with LPN #175 verified the discolored ceiling tiles. Observations on 09/04/24 and 9/05/24, revealed discolored ceiling tiles and a bowed-out ceiling tile with brown stain in the memory unit dining area. Wet floor sign located below the bowed ceiling tile. Interview on 09/05/24 at 7:26 A.M., with LPN #193 verified the discolored ceiling tiles. Interview on 09/05/24 at 10:40 A.M., with LPN #180 revealed there is a hole in the ceiling of memory unit nurses' station and mold on the ceiling because the ceiling leaks frequently. LPN #180 stated a bucket is placed on the floor when leaks occur. This deficiency represents noncompliance investigated under Complaint Number OH00156369.

Based on staff interview and review of resident fund account documents, the facility failed to ensure timely conveyance of resident funds following discharge. This affected one (#3) of three residents reviewed for funds post discharge. The facility census was 144. Findings include: Review of Resident #3's medical record revealed an admitted [DATE]. Resident #3 passed away, in the facility, on [DATE]. Diagnoses included multiple sclerosis, pulmonary disease and chronic pain syndrome. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a two-person assist for Activities of Daily (ADL). Review of resident fund documents revealed on [DATE], Resident #03 had an account balance of $150.97. On the same date, the Social Security Administration (SSA) made a deposit of $1160.00 into the resident's account, for a total account balance of $1310.97. Further review revealed on [DATE] the account was closed and the total of $1310.97 was debited from the account, with the payee noted to be Resident #3 himself. Also, on [DATE], the SSA withdrew its payment of $1160.00 back from the resident's account, leaving a negative balance of $1159.77 (minus $0.23 in interest from [DATE]). Interview on [DATE] at 11:50 A.M. with the Administrator revealed after Resident #3's death on [DATE], the SSA deposited the [DATE] payment into the resident's account. The SSA rescinded the payment and debited $1160.00 from Resident #3's account, leaving a negative balance. The Administrator verified there was no evidence on [DATE] of a check being paid to the estate of Resident #3 for the $1310.97, as was indicated on the account statement. The Administrator confirmed once the SSA rescinded the [DATE] payment of $1160.00, Resident #3's account balance should have been $150.97 and payment should have been sent to resident's estate within 30 days of his passing. The Administrator verified there was no evidence Resident #3's remaining account balance was sent to the resident's estate. This deficiency represents non-compliance investigated under Complaint Number OH00153805.

Based on medical record review, review of a facility Self-Reported Incident (SRI), review of a local police report, staff interview, review of the county on-line court docket and review of facility policy, the facility failed ensure residents were free from misappropriation. This affected one resident (#1) of five residents reviewed for misappropriation. The facility census was 144. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. The resident discharged on [DATE]. Diagnoses included hemiplegia, chronic respiratory failure, muscle weakness and dystonia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Review of the facility SRI #240101, initiated 10/12/23 and completed on 10/17/24, revealed on 10/12/23, the facility was notified by Resident #1 and her family that the resident was missing a check from her checkbook. Per the SRI, all staff and like residents were interviewed regarding the incident and the local law enforcement was conducting an investigation into the incident. The SRI did not indicated a name for the Specified Perpetrator (SP). On 10/17/23, the facility determined there was no conclusive evidence of misappropriation and the allegation was unsubstantiated. Review of the facility's investigation revealed all staff who cared for Resident #1 during the time of the incident were interviewed and all denied any knowledge of the incident. The resident's roommate was interviewed and denied any knowledge of the misappropriation. Per the investigation all staff were re-educated on the misappropriation policy. Review of the police investigation narrative report, dated 10/19/23, revealed between 10/06/23 at 6:00 P.M. and 10/12/23 at 8:00 A.M., Resident #1 stated an unknown person took one of her checks from her checkbook, filled the check out for $325.00 and cashed it. Resident #1 discovered this after she received a copy of the canceled check from her bank. On 10/17/23 at 10:00 A.M., Police Detective (PD) #520 responded to the bank and spoke with an unknown clerk. PD #520 was informed SP #500 deposited the check into her own account. PD #520 attempted to contact SP #500, via telephone and at her home, but was unsuccessful. PD #520 contacted the facility and spoke with a manager to see if the facility knew SP #500. Per the report, the unknown manager told him SP #500 worked at the facility cleaning rooms. SP #500 was not working at the time PD #520 called. PD #520 asked to be notified the next time SP #500 worked and was told by the manager this would have to be looked up. PD #520 told the manager SP #500 was only a suspect and no charges had been filed at that time. Further review of the report revealed on 10/19/23 at 5:00 P.M., PD #520 received a voicemail from an unknown supervisor at the facility to advise him SP #500 had been suspended from work until the investigation was completed. Review of the facility's addendum to SRI #240101, dated 05/31/24, revealed the local police determined a facility contracted worker, SP #500, cashed Resident #1's check and charges were filed against the former employee. Interview on 06/03/24 at 3:00 P.M. with the Director of Nursing (DON) revealed SP #500 was identified to the DON after charges had been filed, on or around 04/26/24. The DON stated SP #500 had been a contracted housekeeper at the facility and had not worked since the stolen check was cashed on 10/06/23. The DON stated the resident and her family reported the suspected misappropriation to the facility on [DATE] and stated Resident #1 did not report who the staff member was who stole the check. The DON stated all staff who worked in the facility during the time of the missing check were interviewed but confirmed SP #500 was not interviewed because the facility did not know her identify during their investigation. The DON stated to prevent any further misappropriation, all residents were provided lockboxes and all staff were educated on the misappropriation policy. Interview on 06/24/24 at 9:30 A.M. with the Administrator revealed he was unaware of PD #520 speaking with anyone at the facility and identifying SP #500 as a suspect in the misappropriation involving Resident #1 during the course of the facility's investigation from 10/12/23 through 10/17/23. As a result, the facility unsubstantiated the allegation of misappropriation. The Administrator could not recall the actual date he was notified of SP #500 being a suspect, but stated it was after the facility had closed their investigation on 10/17/23. The Administrator stated when he did speak with the police, it was reported SP #500 was wanted for questioning and had not been formally charged. The Administrator confirmed SP #500 stole a check from Resident #1 and cashed it in the amount of $325.00. The Administrator stated the bank reimbursed Resident #1 the funds that were withdrawn from her bank account. While the facility re-educated staff on the facility's abuse police and offered lockboxes to residents for their belongings, the Administrator confirmed the facility implemented no further action to ensure residents were free from misappropriation, such as conducting audits and involving the facility's Quality Assurance and Performance Improvement (QAPI) committee to ensure on-going compliance. Interview on 06/24/24 at 11:30 A.M. with Assistant Director of Nursing (ADON) #250 revealed she was interviewed during the SRI investigation and confirmed staff were re-educated on the facility's misappropriation policy. ADON #250 stated the identity of SP #500 was not known during the facility's investigation into the incident. ADON #250 stated once the police reported to the facility the identity of SP #500, which was sometime after 10/17/23, SP #500 was considered suspended and her employing agency was notified she was not to return to the facility. ADON #250 could not recall the actual date SP #500 was suspended, but stated it was after the facility was made aware of her identity. Review of the [NAME] County, Ohio on-line court docket confirmed, on 06/06/24, SP #500 pleaded guilty to petty theft, amended from a felony charge of theft from an elderly person or disabled adult. Review of the facility policy titled Abuse Prevention, revised March 2021, revealed residents had the right to be free from abuse, including misappropriation of resident's property. Further review revealed misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. This deficiency represents non-compliance investigated under Master Complaint Number OH00154308.

Based on medical record review, review of a facility Self-Reported Incident (SRI), review of the facility investigation, review of a local police report, staff interview, review of the county on-line court docket and review of facility policy, the facility failed to ensure an accurate and thorough investigation of misappropriation was completed. Furthermore, the facility failed to implement corrective actions to monitor and/or prevent further instances of resident misappropriation. This affected one resident (#1) of five residents reviewed for misappropriation. The facility census was 144. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. The resident discharged on [DATE]. Diagnoses included hemiplegia, chronic respiratory failure, muscle weakness and dystonia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Review of the facility SRI #240101, initiated 10/12/23 and completed on 10/17/24, revealed on 10/12/23, the facility was notified by Resident #1 and her family that the resident was missing a check from her checkbook. Per the SRI, all staff and like residents were interviewed regarding the incident and the local law enforcement was conducting an investigation into the incident. The SRI did not indicated a name for the Specified Perpetrator (SP). On 10/17/23, the facility determined there was no conclusive evidence of misappropriation and the allegation was unsubstantiated. Review of the facility's investigation revealed all staff who cared for Resident #1 during the time of the incident were interviewed and all denied any knowledge of the incident. The resident's roommate was interviewed and denied any knowledge of the misappropriation. Per the investigation, all staff were re-educated on the misappropriation policy. Review of the police investigation narrative report, dated 10/19/23, revealed between 10/06/23 at 6:00 P.M. and 10/12/23 at 8:00 A.M., Resident #1 stated an unknown person took one of her checks from her checkbook, filled the check out for $325.00 and cashed it. Resident #1 discovered this after she received a copy of the canceled check from her bank. On 10/17/23 at 10:00 A.M., Police Detective (PD) #520 responded to the bank and spoke with an unknown clerk. PD #520 was informed SP #500 deposited the check into her own account. PD #520 attempted to contact SP #500, via telephone and at her home, but was unsuccessful. PD #520 contacted the facility and spoke with a manager to see if the facility knew SP #500. Per the report, the unknown manager told him SP #500 worked at the facility cleaning rooms. SP #500 was not working at the time PD #520 called. PD #520 asked to be notified the next time SP #500 worked and was told by the manager this would have to be looked up. PD #520 told the manager SP #500 was only a suspect and no charges had been filed at that time. Further review of the report revealed on 10/19/23 at 5:00 P.M., PD #520 received a voicemail from an unknown supervisor at the facility to advise him SP #500 had been suspended from work until the investigation was completed. Review of the facility's addendum to SRI #240101, dated 05/31/24, revealed the local police determined a facility contracted worker, SP #500, cashed Resident #1's check and charges were filed against the former employee. Interview on 06/03/24 at 3:00 P.M. with the Director of Nursing (DON) revealed SP #500 was identified to the DON after charges had been filed, on or around 04/26/24. The DON stated SP #500 had been a contracted housekeeper at the facility and had not worked since the stolen check was cashed on 10/06/23. The DON stated the resident and her family reported the suspected misappropriation to the facility on [DATE] and stated Resident #1 did not report who the staff member was who stole the check. The DON stated all staff who worked in the facility during the time of the missing check were interviewed but confirmed SP #500 was not interviewed because the facility did not know her identify during their investigation. The DON stated to prevent any further misappropriation, all residents were provided lockboxes and all staff were educated on the misappropriation policy. Interview on 06/24/24 at 9:30 A.M. with the Administrator revealed he was unaware of PD #520 speaking with anyone at the facility and identifying SP #500 as a suspect in the misappropriation involving Resident #1 during the course of the facility's investigation from 10/12/23 through 10/17/23. As a result, the facility unsubstantiated the allegation of misappropriation. The Administrator could not recall the actual date he was notified of SP #500 being a suspect, but stated it was after the facility had closed their investigation on 10/17/23. The Administrator stated when he did speak with the police, it was reported SP #500 was wanted for questioning and had not been formally charged. The facility investigation was not updated to reflect SP #500 had been identified as a suspect in the misappropriation of Resident #1's funds. The Administrator confirmed no further action related to the investigation was taken once additional information was received, such as reopening the SRI once SP #500's identify was known, notifying the Ohio Department of Health (ODH) of SP #500's identity or substantiating the allegation of misappropriation. Additionally, the Administrator confirmed the facility did not conduct any audits or involve the facility's Quality Assurance and Performance Improvement (QAPI) committee to ensure on-going compliance. Interview on 06/24/24 at 11:30 A.M. with Assistant Director of Nursing (ADON) #250 revealed she was interviewed during the SRI investigation and confirmed staff were re-educated on the facility's misappropriation policy. ADON #250 stated the identity of SP #500 was not known during the facility's investigation into the incident. ADON #250 stated once the police reported to the facility the identity of SP #500, which was sometime after 10/17/23, SP #500 was considered suspended and her employing agency was notified she was not to return to the facility. ADON #250 could not recall the actual date SP #500 was suspended, but stated it was after the facility was made aware of her identity. Review of the [NAME] County, Ohio on-line court docket confirmed on 06/06/24 SP #500 pleaded guilty to petty theft, amended from a felony charge of theft from an elderly person or disabled adult. Review of the facility policy titled Abuse Prevention, revised March 2021, revealed misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Further review revealed the facility had procedures in place to ensure a timely and thorough investigation of allegations of abuse, the reporting and filing of accurate documents relative to incidents of abuse, an on-going review and analysis of incidents of abuse, and implementation of changes to prevent future occurrences of abuse. This deficiency represents non-compliance investigated under Master Complaint Number OH00154308.

Based on record review, staff and resident interview, review of facility's Self-Reported Incidents (SRIs) and review of facility policy, the facility failed to ensure care and services were provided by staff members. This affected one (#51) resident out of three residents reviewed for accidents hazards. The facility census was 155. Findings include: Review of the medical record for Resident #51 revealed the resident was admitted to the facility on [DATE]. His diagnoses included anoxic brain damage, hyperlipidemia, dysphagia, anxiety disorder, gastro esophageal reflux disease (GERD), insomnia, mood disorder, major depressive disorder, and aphasia. Review of a nurse's progress notes dated 01/12/23 for Resident #51, revealed the staff spoke with Resident#51's father and the resident's roommate (Resident #57) about Resident #57 providing Resident #51 with fluids. Notes indicated Resident #51's father instructed Resident #57 to still give the resident fluids and stated Resident #57 could provide the fluids if he gave the permission. The nurse received an order to encourage fluids every 2 hours per staff and father was aware. The facility documented education to Resident #51's father and Resident #57 which was not effective. Review of the physician orders dated 04/13/23 for Resident #51, revealed the resident was ordered regular diet, dysphagia puree texture, with nectar thickened liquids consistency, related to anoxic brain damage. Orders also revealed for Resident #51 to be encouraged to drink 240 milliliters (mls) of nectar thickened liquid three times a day between meals. Review of a nurse's progress note dated 05/04/23 for Resident #51, revealed the facility documented they spoke to Resident #51's mother regarding Resident #57 assisting Resident #51 with his thickened liquids and the mother indicated she would get back to the facility staff about this issue. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #51, revealed the resident had impaired cognition. Resident #51 was totally dependent on staff for activities of daily living (ADLs). Review the care plan dated 11/20/23 for Resident #51, revealed the resident had potential altered nutritional status related to dysphagia, and was at nutritional risk related to mechanically altered diet, anoxic brain damage, paraplegia, aphasia, need for thickened liquids, totally dependent on staff at meals, needed adaptive equipment at meals, and needed extra drinks to meet fluid needs. and. Interventions included document fluid/food intakes, provide an altered fluid consistency as ordered, no water pitcher at bedside and a mechanically altered diet as ordered. The care plan did not mention Resident #57 was assisting with mixing and providing Resident #51 with thickened liquids. Review of an untitled facility document dated 01/17/24 and authored by Assistant Director of Nursing (ADON) #301, revealed she educated Resident #57 on thickening liquids for Resident #51 and Resident #57 returned the demonstration which was done at the request of Resident #51's Power of Attorney. Resident #57 was able to thicken fluids as required and Resident #57 was aware that the facility did not encourage this. Resident #57 was also educated on the risk and sign symptoms of choking if thickened fluids were not thickened properly. Review of a facility's SRI (tracking number 243523) created on 01/19/24 at 7:45 P.M. revealed the staff observed Resident #57 in Resident #51's room and created the SRI for an allegation of abuse. During the interviews, Resident #57 stated he was in Resident #51's room feeding the resident a magic cup. The facility indicated this was a normal act since Resident #51's family encouraged Resident #57 to engage with their son and the SRI for abuse was unsubstantiated. Interview with State tested Nurse Aide (STNA) #304 on 03/06/24 at 10:04 A.M., revealed Resident #57 would mix up Resident #51's thickened liquids in Resident #51's room then serve the liquids to the resident. STNA #304 stated she was told by management that Resident #57 had been approved and care planned to provide the thickened liquids to Resident #51. STNA #304 indicated she never saw the careplan for Resident #51 and only went off of what the management team told her. STNA #304 stated she did not think it was safe for Resident # 57 to mix and provide thickened liquids to Resident #51 Interview with STNA #305 on 03/06/24 at 10:06 A.M., revealed Resident #57 goes into Resident #51's room and mixes up his thickened liquids then administers it to Resident #51. STNA #305 stated she did not think it was safe for Resident #57 to mix up and provide Resident #51 with thickened liquids. Observation of Resident #51's room at the same time with STNA #305, revealed a large tub of thickener and a cup of what appeared to be a very thin liquids at the bedside. Interview with Resident #57 on 03/06/24 at 10:46 A.M., revealed he regularly provided Resident #51 with thickened liquids that he mixed. Resident #57 stated Resident #51's family and the facility were aware of this and were ok with it. Resident #57 stated the nursing staff provided him with education and training on how to mix and provide Resident #51 with the thickened liquids. Resident #57 stated he is aware that different types of liquids require a different mixture of the thickener. Resident #57 stated he was also provided with education on what steps to take if Resident #51 were to choke while Resident #57 provided Resident #51 with the fluids. Interview with the Assisted Director of Nursing (ADON) #301 on 03/06/24 at 12:07 P.M. verified Resident #57 provided thickened liquids to Resident #51. ADON #301 reported she provided education and completed a skills competency on 01/17/24 with Resident #57 so he could mix and provide thickened liquids to Resident #51 properly. ADON #301 stated Resident #51's family encouraged Resident #57 to provide Resident #51 with additional liquids between meals when the staff were not available so Resident #51 could stay hydrated. ADON #301 stated she felt Resident # 57 was going to provide Resident #51 with the thickened liquids despite the facility being against it and therefore felt Resident #57 should provide the liquids to Resident #51 in a safe manner. Interview with Registered Dietician (RD) #300 and ADON #301 on 03/06/24 at 12:07 P.M. confirmed Resident #51 was ordered to receive a puree diet with nectar thickened liquids. ADON #301 confirmed the facility did not have any documentation of the physician being aware or having an active care plan in place related to Resident #57 providing thickened liquids to Resident #51. Observation of Resident #51's room with RD #300 on 03/06/24 at 12:10 P.M. revealed a large container of thickener on the table next to Resident #51's bed. RD #300 stated the thickener must have been brought in by the family. Interview with ADON #300 on 03/06/24 at 3:27 P.M. indicated the facility had no risk agreement on file for Resident #57 providing thickened liquids to Resident #51. ADON #300 indicated she had a complaint from Resident #51's father about the resident not receiving showers when she learned of Resident #57 mixing and given Resident #51 thickened liquids. Interview with Director of Nursing (DON) on 03/06/24 at 3:35 P.M., revealed the facility was aware of Resident #57 mixing and providing thickened liquids to Resident #51. The DON stated the facility only educated Resident #57 on 01/17/24 in the event Resident #57 provided thickened liquids to Resident #51 without staff's knowledge. The DON stated this was recently discovered while investigating a complaint from the resident's father about showers not being done. When the DON was questioned about the notes of Resident #57 providing the thickened liquids dating back to January 2023, the DON indicated she was not aware of that since she was not employed then. Review of the facility policy titled, Thickened Liquids, dated October 2018, revealed liquids that require consistency medication will either be purchased pre-thickened and/or be thickened with commercial thickener by Nutrition and Dining Services Care Team Staff or community Speech Therapists. The policy stated thickened liquids will be available in nourishment pantries for offering of liquids at times of resident request as well as medication pass. This deficiency represents non-compliance investigated under Master Complaint Number OH00151172.

Based on review of Board of Executives of Long-Term Services and Support (BELTSS) documentation, review of the Enhanced Information Dissemination and Collection (EIDC), interview with a BELTSS Representative, and staff interview, the facility governing body failed to appoint an administrator, licensed in the State of Ohio who was responsible for the management of the facility. This had the potential to affect all 150 residents residing in the facility. Findings include: On [DATE], review of the State Agency EIDC System revealed Administrator #400 was listed as the facility current and primary Administrator with an effective date of [DATE]. On [DATE], review of the BELTSS system revealed Administrator #400's license was inactive. Interview with BELTSS Representative #100 on [DATE] at 10:44 A.M. indicated their website (https://prod.beltss.age.ohio.gov/) for licensure verification was up to date and had no system issues. BELTSS #100 representative verified the Administrator was not active and the license expired on [DATE]. Interview on [DATE] at 12:54 P.M., Administrator #400 verified he was the Administrator of record for the facility. Administrator #400 stated he was unaware his license was not active.

Based on observation, staff interview, resident interview, review of resident council meeting minutes, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but two (#27 and #93) residents who did not receive food from the facility's kitchen. The facility census was 150. Findings include: Observation of the kitchen on 02/01/24 at 8:20 A.M. revealed a test tray went out on the 2B unit cart. All trays were retrieved from the meal cart on 07/03/23 at 8:34 A.M. The scrambled eggs, served on a Styrofoam plate and covered with an insulated lid, were 110 degrees Fahrenheit and cold to taste. Interview on 02/01/24 at 8:35 A.M., Account Manager (AM) #315 verified the scrambled eggs were cold and not palatable. AM #315 further stated the facility's dishwasher had been out since 12/22/23 and the facility often had to serve on disposable dinner ware. Interview on 02/01/24 at 10:11 A.M. Resident #69 stated the food was usually served cold. Interview on 02/01/24 at 10:21 A.M., Resident #52 stated the food was often served cold. Interview on 02/01/24 at 10:28 A.M., Resident #75 stated the food is always served cold. Interview on 02/01/24 at 10:44 A.M., Resident #17 stated the food was only sometimes hot enough and further stated the eggs were not hot that morning. Interview on 02/01/24 at 10:45 A.M., Resident #22 stated the food was not hot enough and always luke warm. Review of the resident council meeting minutes dated 12/20/23 revealed the residents stated the food was cold on trays. Review of the resident council meeting minutes dated 01/25/24 revealed the residents stated food can be cold on trays. Review of the facility policy titled, Food: Quality and Palatability, dated 02/2023, revealed food was to be served palatable, attractive, and served at a safe and appetizing temperature. This deficiency represents non-compliance investigated under Complaint Number OH00150427.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, staff interview, and interview with contracted entity provider representative, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30, #47, #50, #54, and #59) for total of 59 residents. The facility census was 153. Findings include: 1) Review of the medical record for Resident #03 revealed the resident was admitted on [DATE], Diagnosis included anemia, coronary artery disease hypertension, hyperlipidemia, hip fracture, dementia, Parkinson's disease, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 10/13/23 for Resident #03, revealed the resident had intact cognition. Review of the Care Plan for Resident #03 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/09/23, 07/07/23, 08/02/23 and 09/06/23 for Resident #03, revealed the resident was ordered to receive cognition infusion protocol - DRIPT IV (entity who provides hydration and vitamin nutrient therapy) intravenously (IV) one-time monthly 500 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 250 mLs an hour (hr.) (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 100 mgs, vitamin C (ascorbic acid) 5 grams (gms), Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) one daily for cognition via IV for cognition and infusion of micronutrient hydration therapy. Review of Medication Administration Records (MARs) revealed Resident #03 received the physician ordered nutrition IV infusions on 05/08/23, 06/09/23, 07/07/23, 08/02/23, and 09/06/23. Interview with Resident #03 on 12/04/23 at 11:10 A.M. revealed no concerns related to the IV services received from DRIPT IV. 2) Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease (GERD), diabetes hyperlipidemia, anxiety, depression, and asthma, Review of the MDS assessment dated [DATE] for Resident #26, revealed the resident had intact cognition. Review of the care plan for Resident #26 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 07/02/23. 08/02/23 and 09/06/23 for Resident #26 , revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #26 revealed the resident received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. 3) Review of medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included non-traumatic brain dysfunction, anemia hypertension, peripheral vascular disease (PVD), GERD, diabetes, hyperlipidemia, Alzheimer's disease, dementia, and asthma. Review of the MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Review of the Care Plan for Resident #36 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 06/09/23 and 09/06/23 for Resident #36 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #36, revealed the resident received the physician ordered infusions on 06/09/23 and 09/06/23. Interview with Resident #36 on 12/04/23 at 11:22 A.M. revealed no concerns related to the IV services received from DRIPT-IV. 4) Review of medical records for Resident #23 revealed an admitted [DATE]. Diagnoses included coronary artery disease, hear failure, hypertension, Peripheral vascular disease, anxiety, asthma, hyperlipidemia, and Alzheimer's disease, Review of the MDS assessment dated [DATE] for Resident #23, revealed the resident had severely impaired cognition. Review of the physician's ordered dated 07/07/23, 08/02/23 and 09/06/23 for Resident #23 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of MARs revealed Resident #23 received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. Interview with the Administrator and the Director of Nursing (DON) on 12/04/23 revealed they were unaware that the ancillary provider (DRIPT IV) did not possess a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio when they provided IV services to the facility. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Regional Clinical Director (RCD) #600 on 12/05/23 at 2:15 P.M. revealed on 11/14/23 the Administrator from their sister facility ([NAME] of Middletown) notified them that DRIPT IV was no longer servicing the Ohio market and there was no additional information provided as to the reasoning. RCD #600 reported that all of the residents were assessed and any changes in conditions were discussed on a daily basis and there were no issues noted. Registered Nurse #110 with the interdisciplinary team (IDT) was assigned to do the resident record reviews. RCD #600 reported their Corporate Chief Executive Officer (CEO) # 115 educated the Administrators, Regional Nurses, and Regional Administrators of the requirement to verify the TDDD for all vendors. RCD #600 reported medication education occurred on 11/09/23 that was related to a similar situation to the findings of another complaint survey, and the training was appropriate for both the previous complaint and the current investigation. RCD #600 stated that the clinical documentation for all residents who received DRIPT therapy was reviewed for any negative outcomes or undesirable results. Attempts to interview Medical Director (MD) #100 on 12/07/23 and 12/12/23 were unsuccessful. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview with the facilities General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and rehospitalization . General Counsel #406 stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio, they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. General Counsel #406 stated she was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/19/23 after the facility implemented the following corrective actions: On 09/06/23 was the last utilization of services from DRIPT IV. On 09/22/23, the contract with DRIPT IV cessation was effective. On 11/14/23, the facility was notified that DRIPT IV solution vendor company who serviced the facility did not have a TDD licensure required in Ohio to dispense drugs. The Corporate attorney and Corporate Director of Procurement were notified by the RCD #600 On 11/15/23, all current residents who received DRIPT IV services were audited by RN #110 for change of condition related to receiving IVs from DRIPT IV and no issues were found. On 11/15/23, the governing body policy was revised and adopted by the Quality Assurance Performance Improvement (QAPI) committee during their meeting. On 11/15/23, the QAPI Committee was educated on the governing body policy by Corporate. On 11/15/23, the QAPI Committee will review any new contracts via the QAPI committee to ensure licensure is validated and compliant with the governing policy. The QAPI committee will meet monthly as needed. On 11/15/23, the Administrator and/or the DON will be responsible for monitoring on going compliance. On 11/19/23, all licensed nurses were educated on the medication administration and medication documentation by RN #100 Review of four Residents (#01, #09, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148166.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and interview the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30, #47, #50, #54, and #59) for total of 59 residents. The facility census was 153. Findings include: 1) Review of the medical record for Resident #03 revealed the resident was admitted on [DATE], Diagnosis included anemia, coronary artery disease hypertension, hyperlipidemia, hip fracture, dementia, Parkinson's disease, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 10/13/23 for Resident #03, revealed the resident had intact cognition. Review of the Care Plan for Resident #03 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/09/23, 07/07/23, 08/02/23 and 09/06/23 for Resident #03, revealed the resident was ordered to receive cognition infusion protocol - DRIPT IV (entity who provides hydration and vitamin nutrient therapy) intravenously (IV) one-time monthly 500 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 250 mLs an hour (hr.) (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 100 mgs, vitamin C (ascorbic acid) 5 grams (gms), Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) one daily for cognition via IV for cognition and infusion of micronutrient hydration therapy. Review of Medication Administration Records (MARs) revealed Resident #03 received the physician ordered nutrition IV infusions on 05/08/23, 06/09/23, 07/07/23, 08/02/23, and 09/06/23. Interview with Resident #03 on 12/04/23 at 11:10 A.M. revealed no concerns related to the IV services received from DRIPT IV. 2) Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease (GERD), diabetes hyperlipidemia, anxiety, depression, and asthma, Review of the MDS assessment dated [DATE] for Resident #26, revealed the resident had intact cognition. Review of the care plan for Resident #26 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 07/02/23. 08/02/23 and 09/06/23 for Resident #26 , revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #26 revealed the resident received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. 3) Review of medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included non-traumatic brain dysfunction, anemia hypertension, peripheral vascular disease (PVD), GERD, diabetes, hyperlipidemia, Alzheimer's disease, dementia, and asthma. Review of the MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Review of the Care Plan for Resident #36 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 06/09/23 and 09/06/23 for Resident #36 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #36, revealed the resident received the physician ordered infusions on 06/09/23 and 09/06/23. Interview with Resident #36 on 12/04/23 at 11:22 A.M. revealed no concerns related to the IV services received from DRIPT-IV. 4) Review of medical records for Resident #23 revealed an admitted [DATE]. Diagnoses included coronary artery disease, hear failure, hypertension, Peripheral vascular disease, anxiety, asthma, hyperlipidemia, and Alzheimer's disease, Review of the MDS assessment dated [DATE] for Resident #23, revealed the resident had severely impaired cognition. Review of the physician's ordered dated 07/07/23, 08/02/23 and 09/06/23 for Resident #23 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of MARs revealed Resident #23 received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. Interview with the Administrator and the Director of Nursing (DON) on 12/04/23 revealed they were unaware that the ancillary provider (DRIPT IV) did not possess a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio when they provided IV services to the facility. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Regional Clinical Director (RCD) #600 on 12/05/23 at 2:15 P.M. revealed on 11/14/23 the Administrator from their sister facility ([NAME] of Middletown) notified them that DRIPT IV was no longer servicing the Ohio market and there was no additional information provided as to the reasoning. RCD #600 reported that all of the residents were assessed and any changes in conditions were discussed on a daily basis and there were no issues noted. Registered Nurse #110 with the interdisciplinary team (IDT) was assigned to do the resident record reviews. RCD #600 reported their Corporate Chief Executive Officer (CEO) # 115 educated the Administrators, Regional Nurses, and Regional Administrators of the requirement to verify the TDDD for all vendors. RCD #600 reported medication education occurred on 11/09/23 that was related to a similar situation to the findings of another complaint survey, and the training was appropriate for both the previous complaint and the current investigation. RCD #600 stated that the clinical documentation for all residents who received DRIPT therapy was reviewed for any negative outcomes or undesirable results. Attempts to interview Medical Director (MD) #100 on 12/07/23 and 12/12/23 were unsuccessful. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview with the facilities General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and rehospitalization . General Counsel #406 stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio, they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. General Counsel #406 stated she was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/19/23 after the facility implemented the following corrective actions: On 09/06/23 was the last utilization of services from DRIPT IV. On 09/22/23, the contract with DRIPT IV cessation was effective. On 11/14/23, the facility was notified that DRIPT IV solution vendor company who serviced the facility did not have a TDD licensure required in Ohio to dispense drugs. The Corporate attorney and Corporate Director of Procurement were notified by the RCD #600 On 11/15/23, all current residents who received DRIPT IV services were audited by RN #110 for change of condition related to receiving IVs from DRIPT IV and no issues were found. On 11/15/23, the governing body policy was revised and adopted by the Quality Assurance Performance Improvement (QAPI) committee during their meeting. On 11/15/23, the QAPI Committee was educated on the governing body policy by Corporate. On 11/15/23, the QAPI Committee will review any new contracts via the QAPI committee to ensure licensure is validated and compliant with the governing policy. The QAPI committee will meet monthly as needed. On 11/15/23, the Administrator and/or the DON will be responsible for monitoring on going compliance. On 11/19/23, all licensed nurses were educated on the medication administration and medication documentation by RN #100 Review of four Residents (#01, #09, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148166.

837 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four of four Residents (#27, #89, #85, and #30) reviewed for medications administered by a contracted ancillary provider. This affected four (#03, #26, #23 and #36) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected 40 additional current Residents (#01, #02, #09, #10, #11, #12, #13, #16,, #17, #18, #19, #20, #22, #28, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #43, #44, #45, #46, #48, #49, #51, #52, #53, #55, #56, #57, #58, #60, #61, and #62) and 15 discharged Residents (#04, #05, #06, #08, #14, #15, #21, #25, #27, #29, #30, #47, #50, #54, and #59) for total of 59 residents. The facility census was 153. Findings include: 1) Review of the medical record for Resident #03 revealed the resident was admitted on [DATE], Diagnosis included anemia, coronary artery disease hypertension, hyperlipidemia, hip fracture, dementia, Parkinson's disease, anxiety, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 10/13/23 for Resident #03, revealed the resident had intact cognition. Review of the Care Plan for Resident #03 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/09/23, 07/07/23, 08/02/23 and 09/06/23 for Resident #03, revealed the resident was ordered to receive cognition infusion protocol - DRIPT IV (entity who provides hydration and vitamin nutrient therapy) intravenously (IV) one-time monthly 500 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 250 mLs an hour (hr.) (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 100 mgs, vitamin C (ascorbic acid) 5 grams (gms), Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) one daily for cognition via IV for cognition and infusion of micronutrient hydration therapy. Review of Medication Administration Records (MARs) revealed Resident #03 received the physician ordered nutrition IV infusions on 05/08/23, 06/09/23, 07/07/23, 08/02/23, and 09/06/23. Interview with Resident #03 on 12/04/23 at 11:10 A.M. revealed no concerns related to the IV services received from DRIPT IV. 2) Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease (GERD), diabetes hyperlipidemia, anxiety, depression, and asthma, Review of the MDS assessment dated [DATE] for Resident #26, revealed the resident had intact cognition. Review of the care plan for Resident #26 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 07/02/23. 08/02/23 and 09/06/23 for Resident #26 , revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #26 revealed the resident received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. 3) Review of medical record for Resident #36 revealed the resident was admitted on [DATE]. Diagnoses included non-traumatic brain dysfunction, anemia hypertension, peripheral vascular disease (PVD), GERD, diabetes, hyperlipidemia, Alzheimer's disease, dementia, and asthma. Review of the MDS assessment dated [DATE] for Resident #36 revealed the resident had intact cognition. Review of the Care Plan for Resident #36 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 06/09/23 and 09/06/23 for Resident #36 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of the MARs for Resident #36, revealed the resident received the physician ordered infusions on 06/09/23 and 09/06/23. Interview with Resident #36 on 12/04/23 at 11:22 A.M. revealed no concerns related to the IV services received from DRIPT-IV. 4) Review of medical records for Resident #23 revealed an admitted [DATE]. Diagnoses included coronary artery disease, hear failure, hypertension, Peripheral vascular disease, anxiety, asthma, hyperlipidemia, and Alzheimer's disease, Review of the MDS assessment dated [DATE] for Resident #23, revealed the resident had severely impaired cognition. Review of the physician's ordered dated 07/07/23, 08/02/23 and 09/06/23 for Resident #23 revealed the resident was ordered to receive Derma infusion protocol for DRIPT IV nurse via IV one-time monthly 500 mLs of 0.9 % NS at rate of 250 mLs an hr. (total additive volume of 30.4 mLs) Additive formula: Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 100 mgs, vitamin C (ascorbic acid) 5 gms, Vitamin B5 (Dexpanthenol) 250 mgs, Vitamin B6 (Pyridoxine) 4 mgs, Vitamin B12 (Methylcobalamin) 2 mgs, Vitamin B7 (Biotin) 20 mg, Magnesium Chloride 900 mgs, Calcium Chloride 200 mgs, Gluconate 200 mg, Zinc 10 mgs and Amino blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mg Taurine 100 mgs, and Glycine 100 mg) every month for micronutrient hydration therapy. Review of MARs revealed Resident #23 received the physician ordered infusions on 07/07/23, 08/02/23, and 09/06/23. Interview with the Administrator and the Director of Nursing (DON) on 12/04/23 revealed they were unaware that the ancillary provider (DRIPT IV) did not possess a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio when they provided IV services to the facility. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Regional Clinical Director (RCD) #600 on 12/05/23 at 2:15 P.M. revealed on 11/14/23 the Administrator from their sister facility ([NAME] of Middletown) notified them that DRIPT IV was no longer servicing the Ohio market and there was no additional information provided as to the reasoning. RCD #600 reported that all of the residents were assessed and any changes in conditions were discussed on a daily basis and there were no issues noted. Registered Nurse #110 with the interdisciplinary team (IDT) was assigned to do the resident record reviews. RCD #600 reported their Corporate Chief Executive Officer (CEO) # 115 educated the Administrators, Regional Nurses, and Regional Administrators of the requirement to verify the TDDD for all vendors. RCD #600 reported medication education occurred on 11/09/23 that was related to a similar situation to the findings of another complaint survey, and the training was appropriate for both the previous complaint and the current investigation. RCD #600 stated that the clinical documentation for all residents who received DRIPT therapy was reviewed for any negative outcomes or undesirable results. Attempts to interview Medical Director (MD) #100 on 12/07/23 and 12/12/23 were unsuccessful. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Interview with the facilities General Counsel #406 stated studies had shown hydration therapy improved and reduced risk of dehydration and rehospitalization . General Counsel #406 stated she learned of this licensing concern on 11/14/23 and had contacted the General Counsel for the ancillary provider who reported when they started the process in Ohio, they had been told they did not require TDDD license for Ohio. They reported they were initially told by the Board of Pharmacy they did not require an Ohio license, there were a ton of exemptions. They reported they applied for the license. General Counsel #406 stated the provider did not explain concerns with licensure when they announced they were no longer providing services. It was explained as a decrease in services related to rate freezes. General Counsel #406 stated she was not involved with the initial vetting process and could not provide specific information as to the steps involved in the approval. The corporation had started a compliance investigation on this with a compliance officer specific to this incident. General Counsel #406 revealed the contract had been signed on 12/09/22 by their Chief Financial Officer (CFO). The General Counsel at that time would have gone through a legal review with a multi-layered vetting process before it was presented to the CFO. She was in the process of investigating everything involved in the process and was still gathering information. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/19/23 after the facility implemented the following corrective actions: On 09/06/23 was the last utilization of services from DRIPT IV. On 09/22/23, the contract with DRIPT IV cessation was effective. On 11/14/23, the facility was notified that DRIPT IV solution vendor company who serviced the facility did not have a TDD licensure required in Ohio to dispense drugs. The Corporate attorney and Corporate Director of Procurement were notified by the RCD #600 On 11/15/23, all current residents who received DRIPT IV services were audited by RN #110 for change of condition related to receiving IVs from DRIPT IV and no issues were found. On 11/15/23, the governing body policy was revised and adopted by the Quality Assurance Performance Improvement (QAPI) committee during their meeting. On 11/15/23, the QAPI Committee was educated on the governing body policy by Corporate. On 11/15/23, the QAPI Committee will review any new contracts via the QAPI committee to ensure licensure is validated and compliant with the governing policy. The QAPI committee will meet monthly as needed. On 11/15/23, the Administrator and/or the DON will be responsible for monitoring on going compliance. On 11/19/23, all licensed nurses were educated on the medication administration and medication documentation by RN #100 Review of four Residents (#01, #09, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148166.

Based on medical record review, staff interview, review of the facility's fall investigation, review of the hospital notes, and review of the facility policy, the facility failed to ensure a resident was safely transferred using a mechanical lift (Hoyer) and failed to accurately identify the root cause of the incident. This resulted in Actual Harm when Resident #163 fell from a Hoyer lift during a transfer sustaining a left communicated, nondisplaced humeral head fracture, and an acute nondisplaced C3 (neck) fracture. This affected one (Resident #163) of three residents reviewed for accidents. The facility census was 162. Findings include: Review of the medical record revealed Resident #163 was readmitted to the facility on [DATE]. Diagnoses included status post hospitalization for a left non-displaced humeral head (arm) and a C3 (spine) fracture, chronic obstructive pulmonary disease, end stage renal disease, dependent on renal dialysis, heart failure, osteoarthritis, and anxiety disorder. Review of the quarterly Minimum data set (MDS) assessment dated [DATE] revealed Resident #163 had no cognitive impairment and required extensive assistance of two persons with bed mobility and transfers. Review of the care plan dated 03/11/22 revealed Resident #163 had an activities of daily living self-care performance deficit related to activity intolerance and weakness. Interventions included to utilize a Hoyer lift (patient mechanical lift) with all transfers. Review of the nursing progress notes revealed on 12/09/22 at 1:50 P.M. Licensed Practical Nurse (LPN) #144 documented Resident #163 fell at 1:00 P.M. during a staff transfer utilizing the Hoyer lift. Resident #163 complained of left shoulder pain, mid to lower back pain, coccyx pain, and right hip pain. Resident #163 stated he hit his head. There was no visible injury noted to his cranium. There was a small skin tear with approximated edges noted to his left elbow and first aid was applied. Nurse Practitioner (NP) #145 was notified and ordered Resident #163 to be sent to the emergency room (ER) to be evaluated and treated. Review of the facility's fall investigation report dated 12/09/22 at 1:00 P.M., completed by LPN #119, revealed Resident #163 had a witnessed fall from the Hoyer lift while being transferred from his bed to the dialysis chair, by State tested Nursing Assistant (STNA) #109 and LPN #119. The report revealed Resident #163 sustained a laceration to his left elbow and complained of left shoulder pain. A dressing was applied to Resident #163's left elbow and Resident #163 was sent to the hospital for evaluation and treatment. Review of the facility's root cause of the fall investigation dated 12/09/22 revealed staff did not use the correct Hoyer pad for the Hoyer lift used in the transfer of Resident #163. Review of the written statement provided by LPN # 119 dated 12/09/22 at 1:00 P.M., revealed STNA #109 and LPN #119 went into Resident #163's room to get him ready for dialysis. They put the Hoyer pad under Resident #163 and attached the straps to the Hoyer lift. As they lifted him up over the bed, there were no issues at this time, then STNA #109 moved the Hoyer lift to bring Resident #163 out of the bed towards the chair and one of the straps slipped. Resident #163 lunged forward causing him to fall forward out of the Hoyer pad. Resident #163 hit his shoulder on the bed then landed on the floor on the side of his bed. Resident #163 complained of pain to his left shoulder and a skin tear was noted to his left elbow. Review of the written statement provided by STNA #109 dated 12/09/22 at 1:00 P.M. revealed LPN #119 and STNA #109 were getting Resident #163 up for dialysis. They strapped Resident #163 to the Hoyer lift and when STNA #109 was lifting Resident #163 up off the bed everything was fine. Then STNA #109 was pulling the Hoyer lift back to get Resident #163 in the chair, and before she even got Resident #163 away from the bed, the strap came loose. STNA #109 witnessed Resident #163 lunge forward causing him to fall. Review of the hospital encounter report dated 12/10/22, revealed Resident #163 resided in a long-term-care facility. Resident #163 stated he was being lifted with a Hoyer lift to get him onto the dialysis stretcher to take him for dialysis when the strap broke, and he fell . Resident #163 fell on to the bed then onto the floor. Resident #163 hit his head and injured his left arm and leg. Resident #163 was brought to the ER by Emergency Medical Services (EMS). Work-up in the ER revealed a left communicated, nondisplaced humeral head fracture and an acute nondisplaced C3 fracture. Resident #163 was treated with nonsurgical interventions with a sling/immobilizer to his left arm and a cervical collar to his neck. Resident #163 was discharged back to the facility on [DATE]. Subsequent review of the fall investigation dated 12/10/22 revealed the facility completed another root cause analysis and revealed the Hoyer pad sling attachment became detached startling Resident #163 causing him to lunge forward and fall from the Hoyer sling. On 12/21/22 at 11:30 A.M., during an interview with Assistant Director of Nursing (ADON) #111, revealed she completed the fall investigation on 12/09/22 without the assistance of the Director of Nursing (DON) who had resigned prior to the incident. ADON #111 stated the Hoyer lift used to transfer Resident #163 was one of the two new Hoyer lifts in the facility (Lumex LF1090 Bariatric Patient Lift), and she assumed the Hoyer pads for the other Hoyers (Reliance) were not compatible with the New Lumex Hoyer. With the information she gathered, ADON #111 determined the root cause was the wrong Hoyer pad was used with the Hoyer lift. ADON #111 stated after Resident #163's incident on 12/09/22, all residents requiring a Hoyer lift for transfers were measured according to the Hoyer Lift manufacture guidelines to ensure the proper size Hoyer pad was used with the specified Hoyer lift and found no issues. ADON #111 stated Resident #163 was at the hospital, and she was not able to obtain his measurements to confirm if the correct Hoyer pad was used. ADON #111 discovered when Resident #163 returned from the hospital on 12/14/22, she measured Resident #163 and found the correct Hoyer pad was used during the transfer on 12/09/22. On 12/21/22 at 1:53 P.M., during an interview with LPN #119 revealed on 12/09/22 at approximately 1:00 P.M., she was assisting STNA #109 to transfer Resident #163 from his bed to the dialysis chair to take him to his scheduled dialysis session. LPN #119 stated Resident #163 was in the Hoyer lift elevated above the bed and she was guiding Resident #163 toward the dialysis chair when the bottom left strap of the Hoyer pad slipped off. Resident #163 lunged forward and fell from the Hoyer lift hitting his left arm on the bed and landing on his knees on the floor. LPN #119 stated the only part of the resident's body to come in contact with the floor was both of his knees. LPN #119 stated Resident #163 sustained a laceration to his left elbow. LPN #119 stated NP #145 was notified and ordered Resident #163 to be sent to the ER for evaluation. On 12/22/22 at 1:20 P.M., a follow up telephone interview was conducted with LPN #119 and revealed she did not observe the Hoyer strap detach from the lift and that she assumed it detached because after the fall all the straps were intact except the lower left strap located near the resident's left leg. LPN #119 explained the new Hoyer lift that was being used during the transfer does not have latches like the older Hoyer lifts that prevent the Hoyer pad straps from slipping off the Hoyer lift hooks. LPN #119 stated all the Hoyer straps were attached prior to transferring the resident. On 12/21/22 at 2:11 P.M., during an interview with STNA #109 revealed on 12/09/22 at approximately 1:00 P.M., she was assisting LPN #119 with transferring Resident #163 from his bed to the dialysis chair. STNA #109 stated she was standing behind Resident #163 and guided the Hoyer lift to the dialysis chair and all Hoyer straps were attached to the Hoyer lift. STNA #109 stated while Resident #163 was suspended above the bed when the Hoyer strap detached, Resident #163 lunged forward hitting his left arm on the bed and landing on the floor on both of his knees. STNA #109 stated she did not observe the Hoyer strap detach but assumed it did because after the fall she saw the left bottom strap was not attached to the Hoyer lift. On 12/22/22 at 11:40 A.M., during an interview with Regional Director of Healthcare Services (RDHS) #146 revealed after reviewing additional information obtained on 12/21/22 and 12/22/22, review of the manufacture guidelines and staff interviews, the investigation found the facility was using the correct Hoyer sling pad with the Hoyer. RDHS #146 stated the sling was not observed detaching from the lift by nurse or STNA during Resident #163's transfer on 12/09/22 but noticed it was detached after the transfer/fall. RDHS #146 stated the new Hoyer lift does not have metal latches as the older ones that prevent the strap from detaching. RDHS #146 stated when the strap slipped and became detached, it startled Resident #163 causing him to lunge forward falling out of the sling. Review of the facility's policy titled Using a Mechanical Lifting Machine, revised 07/2017, revealed the steps in the procedure included before the resident is lifted, double check the security of the sling attachment; Examine all hooks, clips, or fasteners; and check the stability of the straps. This deficiency represents non-compliance investigated under Complaint Number OH00138530 and OH00137998.

Based on medical record review, staff interview, review of the facility's fall investigation, and review of the facility policy, the facility failed to ensure a resident received timely radiology services for a fractured left femur. This resulted in Actual Harm when Resident #112, who after experiencing an unwitnessed fall, had a delay of x-ray services and Resident #112 being admitted to the hospital for surgical repair of the fractured left femur. Resident #112 had a physician order for an x-ray and the x-ray was not obtained until two days after the fall. After the x-ray was obtained, the results of an acute, displaced left femoral fracture was not reported to the physician until three days after the fall. Consequently, the resident was admitted to the hospital for surgical repair of a fractured left femur. This affected one (Resident #112) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #112 revealed the resident was readmitted to the facility on [DATE]. Diagnoses included status post hospitalization for surgical repair of fractured left femur, vascular dementia, psychotic disorder with delusions due to physiological condition, osteoarthritis, and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #112 was cognitively impaired, had behaviors of rejecting care and required limited assistance with bed mobility, ambulation, supervision with transfers, and extensive assistance with toilet use and dressing. Review of the care plan, last revised on 04/27/22, revealed Resident #112 was at risk for falls or fall related injury related to impaired mobility, dementia, diagnoses of atrial fibrillation and chronic obstructive pulmonary disease. Interventions included to follow facility fall protocol. Review of the nursing progress notes dated 12/20/22 at 2:32 A.M., revealed Licensed Practical Nurse (LPN) #35 documented Resident #112 was found at her bedside with personal items and trash around her. Resident #112 was without any injuries and stated she just plopped to the floor. Resident #112 was assisted back to bed having no additional needs voiced at this time. Review of the facility's fall investigation report dated 12/20/22 completed by LPN #35, revealed Resident #112 had an unwitnessed fall. The report revealed Resident #112 was found on the floor next to her bed with personal items around her. The physical assessment revealed no injuries. Review of the nursing progress notes dated 12/20/22 at 6:57 A.M., revealed LPN #35 documented Resident #112 complained of pain to her left side. The Nurse Practitioner (NP) was notified and received orders for pain medication and an x-ray of the left hip. Pain medications were administered as directed with Resident #112 reporting relief after pain medication. Review of the nursing progress notes dated 12/21/22 at 9:10 A.M., revealed LPN #35 documented she was reviewing Resident #112's x-ray results. LPN #35 noted x-ray Provider #400 had canceled the x-ray report with no call noted to the facility. LPN #35 ordered the hip x-ray STAT (pushed to top of the queue and performed immediately), related to a resident's fall and complaints of pain. X-ray Provider #400 called with no answer on help-desk line. Review of Resident #112's x-ray results dated 12/21/22 at 3:17 P.M., revealed the conclusion was an acute, displaced left femoral neck fracture. Review of Resident #112's nursing progress notes dated 12/22/22 at 3:43 A.M. revealed LPN #68 documented Resident #112 fell three days ago, and radiology was performed. LPN #68 found radiology report on the fax machine which stated Resident #112 had a left femoral fracture. The physician was notified and ordered to send Resident #112 out to the emergency room (ER). Emergency Medical Services (EMS) was called, and Resident #112 was sent out by stretcher at 4:30 A.M. Further review of Resident #112's medical record revealed the physician order for the x-ray was not entered into the electronic health record (EHR) and not in the treatment administration record (TAR). Review of the hospital encounter report dated 12/22/22 at 3:50 A.M. revealed Resident #112 was diagnosed with a left hip fracture which was surgically repaired on 12/22/22 and the resident was discharged back to the facility on [DATE]. On 01/10/23 at 3:14 P.M., during a telephone interview with LPN #30, revealed she worked the day shift from 7:00 A.M. to 7:00 P.M. on 12/20/22. LPN #30 stated during the morning report at shift change LPN #35 informed her, he had ordered a routine x-ray for Resident #112 who had fallen earlier that morning and was complaining of left side pain. LPN #30 stated all laboratory requisitions were left at the nurse's station for the technician and often the technician will pick up the requisitions and perform the tests without notifying the nurse. LPN #30 stated she noticed the requisition was gone and assumed the technician had taken it and completed the x-ray. LPN #30 stated when the x-ray was done, a copy of the results would be faxed to the facility. LPN #30 stated she did not receive a fax and assumed the results were not available. LPN #30 stated when she returned to work the day shift of 12/21/22, LPN #35 was checking for the results of the x-ray and realized it had not been completed and placed a STAT x-ray for Resident #112. LPN #30 stated she was very busy that day and was not aware the x-ray had been completed and was unaware if the results had been faxed to the facility during her shift, as she had not checked the fax machine. LPN #30 stated when diagnostic tests such as laboratory or x-rays were ordered for a resident, the nurse taking the order will also input the order into the EHR system and the order will display on the resident's TAR to remind the nurses a test has been ordered to follow up and the nurse will document when the test was completed. LPN #30 stated there were no orders for the x-rays for Resident #112 on the resident's TAR. On 01/11/23 at 9:28 A.M., during an interview with LPN #35, revealed he ordered the routine x-ray on the morning of 12/20/22 when he worked night shift and did not return to work until the morning of 12/21/22 and was checking for the results of the x-ray and realized x-ray Provider #400 had canceled the x-ray report without notifying the facility. LPN #35 stated he immediately resubmitted a STAT order for the x-ray. LPN #35 had not been informed by LPN #30, who was Resident #112's assigned nurse, that the x-ray results were back and assumed the results had not been received prior to the end of his shift. LPN #35 stated the nursing procedure to follow when taking orders for medications or diagnostic tests was that the orders were to be entered into the EHR to alert the oncoming nurses a test has been ordered and to follow up and document when the diagnostic test was completed. LPN #35 revealed he did not enter the orders for the x-rays ordered, for Resident #112, on the morning of 12/20/22 and the morning of 12/21/22. On 01/11/23 at 10:08 A.M., during an interview with Regional Director of Clinical Services (RDCS) #146 revealed there were instances when nurses have a change of assignment or cannot complete their shift and that was why it was important for the nurses to enter any orders for diagnostic tests in the EHR so the other nurses were aware the test has been ordered and to follow up and document when the test were completed. On 01/12/23 at 9:00 A.M., during a telephone interview with LPN #68 revealed she had not been informed during shift change report of any pending x-ray results for Resident #112, and there were no orders on the resident's TAR, in the EHR that Resident #112 had orders for an x-ray. LPN #68 stated she discovered the x-ray results on the fax machine the morning of 12/22/22 at approximately 3:43 A.M., and as soon as she saw the results, she notified the physician and called 911 to have the resident sent to the hospital as soon as possible. Review of the facility policy titled, Lab and Diagnostic Test Results, revised November 2018, revealed the test results will be reviewed by nursing staff which would include a nurse will try to determine whether the test was done and to assess a condition change or recent onset of signs and symptoms. This deficiency represents non-compliance investigated under Complaint Number OH00138836.

Based on record review, staff interview, pharmacy staff interview, and policy review, the facility failed to ensure a resident experiencing pain, with a diagnoses of chronic pain syndrome and post fixation of a fracture to her left ankle, had an acute care plan in place with interventions to manage pain and treat pain when displayed. This resulted in actual harm when Resident #196 on 07/22/22 at 5:25 P.M., was assessed by the Certified Nurse Practitioner to be lying in bed, moaning with pain and reported the pain level as a 10 out of 10 (with 10 being the worst). The medical record contained no documentation of nonpharmacological or pharmacological interventions attempted to relieve pain. The medical record contained physician orders for pain medication and no medication was documented given until 07/23/22 at 5:00 A.M. This affected one (#196) of three residents reviewed for pain management. The facility census was 166. Findings included: Review of the closed medical record for Resident #196 revealed an admitted [DATE] and discharged on [DATE]. Resident #196 diagnoses included: fracture of the left lower leg (07/19/22), rheumatoid arthritis, chronic pain syndrome, and polyosteoarthritis. Review of the admission nursing notes dated 07/21/22 at 3:00 P.M., revealed Resident #196 was admitted to the facility from the hospital via stretcher. A nursing assessment was completed. A call was placed to the pharmacy requesting medications be sent stat (immediately). Resident #196 was admitted with a left ankle fracture with a cast in place, and at that time, the resident denied pain/discomfort. The resident was alert and oriented with some confusion. The medical did not contain an acute care plan to address pain management. Review of hospital discharge orders dated 07/21/22 revealed a physician order for Oxycodone 5 milligrams (mg) every eight hours as needed for pain; hydrocodone-acetaminophen tablet 5-325 milligrams (mg) to give one tablet by mouth every six hours as needed for surgical pain from 07/18/22 until 07/21/2022 at 11:59 P.M. (only for 3 days); Tylenol 8-hour tablet Extended Release (acetaminophen ER) 650 mg to give 1300 mg by mouth every six hours as needed for chronic pain, (do not exceed more than 4 gm of acetaminophen within 24 hours from all sources); ibuprofen tablet 600 mg to give one tablet by mouth every eight hours as needed for swelling/pain; Tylenol (acetaminophen) give 650 mg by mouth every 6 hours as needed for pain, (do not exceed more than 4 gm of acetaminophen within 24 hours from all sources); Tylenol (acetaminophen) give 650 mg by mouth every 6 hours as needed for mild pain, (do not exceed more than 4 gm of acetaminophen within 24 hours from all sources); and tramadol HCl tablet 50 mg, to give one tablet by mouth at bedtime for chronic pain and to give 50 mg, by mouth every eight hours as needed for Rheumatoid Arthritis. Review of nurse's progress note dated 07/21/22 at 9:59 P.M., documented pharmacy has yet to deliver medications. Resident was admitted at 3:00 P.M. today. Writer will follow up with pharmacy. Review of the medication administration record (MAR) for 07/21/22 revealed no medications were documented as being administered. The MAR did not contain an order for the Oxycodone. There were no assessments of pain levels. Review of the E-box dispense records revealed Oxycodone 5 mg was dispensed on 07/22/22 at 12:17 A.M., for Resident #196. Review of nurse's progress note dated 07/22/22 at 8:03 A.M., documented still waiting on pharmacy to deliver resident's medications. This writer followed-up with pharmacy and was told it will be on first delivery this morning (07/22/22). This writer was able to give her pain med from the E- box. Resident slept well throughout the entire night with no complaints. Review of nurse's progress note dated 07/22/22 at 10:33 A.M., documented waiting on pharmacy. Review of the progress note dated 07/22/22 at 5:25 P.M., documented by Certified Nurse Practitioner (CNP) #525, stated Resident #196 was seen lying in bed groaning. The note documented the resident had a fixation of a fractured left ankle with a splint in place. Resident #196 complained of a lot of pain to ankle and rated 10/10. The note documented the blood pressure slightly elevated (156/68) probably due to pain, which the resident rated at 10/10. The note documented the resident had had no pain medications at that time. CPN #525 documented she will start the resident on Percocet (narcotic pain medication) as needed (PRN). Resident #196's ankle fracture was dated 07/19/22, the splint was noted it would be removed by the surgeon at follow up appointment. Review of a nurse's progress note dated 07/22/22 at 5:36 P.M., documented the family was in, and wishing to better control pain, requesting for Percocet instead of current regimen. CNP will honor family wishes and sent order for Percocet 5-325 mg every 6 hours to pharmacy. Review of a physician order dated 07/22/22, for Percocet Tablet 5-325 mg (Oxycodone-acetaminophen) to give one tablet by mouth every six hours as needed for moderate pain, (do not exceed more than 4 gm of acetaminophen within 24 hours from all sources) with ended date of 08/02/22. Review of the MAR dated 07/22/22, revealed the medication tramadol HCL 50 mg was documented as being administered at bedtime as ordered. No other pain medications were documented as being given. There was no documentation of any pain assessments being completed. Review of the MAR dated 07/23/22, revealed the medication Percocet was administered at 5:00 A.M. and at 5:55 A.M. documented as effective. Interview on 11/16/22 at 4:28 P.M., with Pharmacy Technician #520 (from the pharmacy utilized by the facility), stated the pharmacy received the prescription for tramadol on 07/21/22 at 3:03 P.M. and received by the facility on 07/22/22 at 7:23 A.M. The pharmacy did not receive a prescription for the Percocet until 07/22/22 at 4:52 P.M. The medication was delivered to facility on 07/23/22 at 7:56 A.M. The medication was not delivered until that time due to being submitted too late to the pharmacy, for the cut off time for the first delivery. The first dose was documented given on 07/23/22 at 5:00 A.M. Pharmacy Technician #525 indicated while waiting on a prescription to arrive at the facility, by review of the E-box controlled medications, Oxycodone 5 mg from a hospital discharge order dated 07/20/22 was dispensed from the e-box on 07/22/22 at 12:17 A.M. Review of the MAR for July 2022 revealed the Tramadol 50 mg at bedtime dose was not documented as being given on 07/21/22, 07/23/22, 07/24/22, 07/25/22. Review of the Inventory Replenishment Report revealed pain medications were available in the emergency box (E-box). The following medications were listed: Oxycodone-acetaminophen 5-325 mg, Oxycodone IR 5 mg and tramadol 50 mg were available for administration. Interview on 11/16/22 at 2:59 P.M., with CNP #525 regarding Resident #196 revealed CNP #525 did not remember the resident. CNP #525 stated she would have expected the resident's pain would have been assessed twice each shift. She would have also expected she would have received pain medication if there were orders, or if there was no prescription, they were to call her so she could put the electronic orders in her computer. Review of email correspondence with the Director of Nursing (DON) dated 11/15/22 at 6:35 P.M., revealed the DON verified the first pain medication received by the resident was Oxycodone IR, 5 mg on 07/22/22 at 12:17 A.M. She was not administered oral pain medication again until she received Percocet 5-325 mg on 07/23/22 at 5:00 A.M.; at that time her pain was rated a six on the scale of 0-10 with 10 being the worst pain. A request had been sent for documentation of the resident's pain assessments and on a pain scale to be provided, but this was the only date it was received for. Review of the policy entitled Administering Pain Medications Level 3 updated March 2020 revealed acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The policy indicated a pain assessment was to be conducted as indicated, evaluate, and document the effectiveness of non-pharmacological interventions, administer pain medications as ordered, and re-evaluate the resident's level of pain 30-60 minutes after administering. The results of the pain assessment as well as the medication given were to be documented in the resident's medical record. This deficiency represents the noncompliance investigated under Complaint Number OH00136510.

Based on closed medical record review, review of emergency medical services (EMS) run report, review of the facility abuse policy and procedure, staff interview, and Emergency Medical Technician (EMT) interview, the facility failed to ensure Resident #151 was free from abuse and neglect by not providing timely care and services to ensure respectful and dignified treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On [DATE] at approximately 9:30 A.M. Licensed Practical Nurse (LPN) #17 and LPN #18 initiated Cardiopulmonary Resuscitation (CPR) to Resident #151, four hours after he had been deceased and after post mortem care was already provided. This resulted in Immediate Jeopardy that included actual harm occurred based on the reasonable person concept including caring for a deceased resident's body with sensitivity and facility staff disregarded this concept when staff were aware the resident, who was a full code, had been found unresponsive, approximately four hours earlier and chose to initiate CPR at 9:30 A.M. LPN #17 and LPN #18 failed to share this information with the local fire department who arrived on scene and took over care of the resident including performing CPR for 30 minutes per their protocol. This affected one resident (#151) of fifteen residents reviewed for death. The facility census was 147. On [DATE] at 1:25 P.M., the Executive Director, Regional Corporate Nurse #50, and the Director of Nursing (DON) were notified of Immediate Jeopardy, which began on [DATE] at approximately 5:30 A.M., when LPN #11 was notified by State tested Nurse's Aide (STNA) #04 and STNA #05 that Resident #151 was not breathing. LPN #11 assessed Resident #151 to confirm no respiration, no pulse, or vital signs could be obtained. LPN #11 failed to provide CPR to Resident #151 as she stated he was too frail and too old. LPN #11 instructed STNA #04 and STNA #05 to provide postmortem care. On [DATE] at approximately 9:00 A.M., LPN #12 reviewed the resident's chart when she realized Resident #151 was a Full Code status. At that time, she notified both unit managers, LPN #17, and LPN #18, who were her supervisors. At approximately 9:30 A.M., LPN #17 and LPN #18 proceeded to the resident's room and placed Resident #151 on the floor and initiated CPR. Nine-one-one (911) was called at 9:40 A.M. At 9:50 A.M., the local fire department arrived on scene and took over care. The facility failed to notify the fire department when they arrived that Resident #151 had been deceased for four hours. The fire department provided care with no change in response from the resident. The local emergency department physician #18 was notified and pronounced Resident #151 deceased at 10:17 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE], LPN #11, who had not performed CPR, was verbally educated by the Executive Director on the requirements as set forth in the facility regarding CPR Policy and Procedure. LPN #11 was suspended and removed from the schedule pending the outcome of the facility Self-Reported Incident (SRI), also initiated on [DATE]. LPN #11 was suspended since approximately 8:30 A.M. on [DATE] and was terminated on [DATE]. · On [DATE], the Executive Director provided one on one education to Unit Managers (LPN #17 and LPN #18) at the facility on the policy/procedure for CPR. This education included: 24-hour availability of care team members properly trained on CPR Identification of code status Initiation of CPR as required and appropriate Emergency services notification Reporting requirements Abuse · On [DATE], the Executive Director issued written discipline to both Unit Managers (LPN #17 and LPN #18) for providing CPR four hours later and not calling the physician for further guidance when the delay had already occurred. · On [DATE], Unit Managers (LPN #17 and LPN #18) provided education on policy/procedure for CPR to all licensed nurses in the building and to the next shift. Licensed nursing staff, who were not able to be educated in person, were educated and/or called prior to working his/her next shift at the facility and completed on [DATE]. · On [DATE], the facility Unit Managers (LPN #17 and LPN #18) audited all current resident records to ensure proper/correct code status was indicated. Two residents (#51 and #97) needed correction and were updated immediately upon discovery. · On [DATE] the local Police were made aware of the incident by an unidentified third party prior to the facility initiation. · The Medical Director #60 and his team was made aware on [DATE] of the incident., and follow-up on all of the corrective action initiated since the incident was completed on [DATE]. · On [DATE] the Executive Director contacted the local Police Department to inquire about the status of the police report associated with the visit noted above. The police department informed the Executive Director the report was not available at this time due to it was an open investigation. · The Director of Nursing and/or designee will audit new admission charts within the first 72 hours of admission for the code status to be identified and documented in the resident record. This will occur at the time of admission and/or readmission to the facility. New admission charts are audited within the first 72 hours of admission - code status is verified as a part of this process. The code status will be verified as part of the quarterly care planning meetings. · Licensed Nursing staff will continue to be educated on policies/procedures including Abuse and CPR upon hire, as assigned during monthly education assignments and skills checks (both in person and online), and as needed. The Director of Nursing and/or designee will complete skills checks on the above randomly every month (five nurses per month). · All resident deaths occurring in the facility will be audited within 72 hours during morning Quality Assurance Performance Improvement (QAPI) meeting to ensure proper procedures were followed and documented per policy. · On [DATE], a QAPI related to CPR and event initiated with Interdisciplinary Team (IDT) team as part of the morning meeting. Staff members in attendance included: The Executive Director, the Director of Nursing, the Assistant Director of Nursing #12, the Therapy Manager #20, the Social Services #30, the Dietary manager #60, the Minimum Data Set (MDS) #70, the Activities Director #90, and the Regional Director of Clinical Services #100. Root Cause analysis discussed and completed. Plan including components noted above initiated on [DATE]. · On [DATE], the Executive Director was terminated. · On [DATE] a new Executive Director was hired and upon review of the incident LPN #17 was terminated and LPN #18 will be terminated immediately upon return from medical leave. The Director of Nursing at the time of this incident submitted her resignation and her last day worked was [DATE]. · On [DATE], A Quality Assurance Performance Improvement was held related to CPR and this incident and was facilitated by the new Executive Director. It will include the following staff members: Assistant Director of Nursing #12, the Therapy Manager #20, the Social Services Director #30, the Dietary Manager #60, the MDS Coordinator #70, the Activities Director #90, and the Regional Director of Clinical Services #100. The new Executive Director will be responsible to share the meeting results with the new Director of Nursing upon her return from leave and the Medical Director during the normally scheduled QAPI meeting process. Effective leadership and effective action was discussed to improve the culture of the facility. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of the medical record revealed Resident #151 was admitted to the facility on [DATE] and expired on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order dated [DATE] revealed Resident #151 was a Full Code. Review of the progress note dated [DATE] at 5:35 A.M. revealed Resident #151 was found unresponsive. His pupils were fixed with no respirations or heart rate noted. Several outreach attempts were made to Resident #151's family. Review of the progress note dated [DATE] at 9:33 A.M. revealed Resident #151 was unresponsive with no pulse. The code status revealed Resident #151 was a Full Code. After visualization of Resident #151 by the nurse, 911 was called and CPR was initiated. When EMS arrived on scene, they took over care. Review of the progress note dated [DATE] at 6:48 P.M. revealed arrival into Resident #151's room, he was found with no pulse and skin cool to the touch. Unit managers were notified of the findings. CPR was started immediately, and 911 was called. EMS arrived and took over CPR. The EMS had no change in response, and Resident #151 was pronounced dead at 10:17 A.M. Resident #151's physician and family were notified. The local funeral home was notified and picked up Resident #151's body. Review of the EMS Care Report Summary dated [DATE] revealed upon arrival Resident #151 was found on the floor in his room where facility staff were performing CPR. Per facility staff, unknown time Resident #151 went down and was found just prior to 911 call, which was received at 9:40 A.M. EMS found Resident #151 to be pulseless and apneic. The mechanical CPR device was placed on Resident #151. Ventilation and oxygen were initiated. After 30 minutes of resuscitation were completed with no change in response, a field termination was made. A call was made to the local emergency department (ED), where Resident #151 was pronounced dead by the ED physician #18 at 10:17 A.M. Interview on [DATE] at 9:21 A.M., with LPN #11 revealed Resident #151 was stable throughout the night. LPN #11 reported around 5:30 A.M. the STNA #04 came to get her because he was unresponsive. LPN #11 went into Resident #151's room and completed an assessment and vital signs. LPN #11 reported Resident #151 had no vitals, respirations, or heart rate. She stated his hands and feet were cold and his skin was pale for an African American. LPN #11 advised STNA #04 and STNA #05 to complete postmortem care on Resident #151. LPN #11 reported she was unaware that Resident #151 was a Full Code, and that was why she had not initiated CPR. LPN #11 explained under her scope of practice she was not able to pronounce death. LPN #11 stated she faxed the physician a notification to alert him Resident #151 had passed away at approximately 6:00 A.M. Interview on [DATE] at 10:01 A.M. with the DON revealed she was unable to elaborate on the events that took place from 5:30 A.M. when Resident #151 was found unresponsive without a pulse to 9:30 A.M. when CPR was initiated by LPN #17 and LPN #18. Interview on [DATE] at 10:25 A.M. with LPN #12 revealed she received report from LPN #11 around 7:00 A.M. on [DATE]. At that time, LPN #11 explained Resident #151 had passed away around 5:30 A.M. and the only duty needed to be completed was to notify his family. LPN #12 reported she went to his room to ensure postmortem care had been provided. Around 9:00 A.M. while completing medication pass, LPN #12 reviewed Resident #151's chart. At that time, she confirmed Resident #151 was a Full Code and CPR or 911 was never initiated. LPN #12 immediately notified unit managers (LPN #17 and LPN #18). Unit managers #17 and #18 entered Resident #151's room to assess him. LPN #12 assisted LPN #17 and LPN #18 lower Resident #151 to the ground. At approximately 9:30 A.M., LPN #17 and LPN #18 initiated CPR and 911 was called. LPN #12 reported EMS arrived at the facility and took her over care on Resident #151. EMS pronounced Resident #151 dead at 10:17 A.M. LPN #12 notified Resident #151's family at approximately 10:20 A.M. Interview on [DATE] at 11:17 A.M. with LPN #18 revealed she was made aware at approximately 9:30 A.M. of Resident #151's death. LPN #18 explained he was a Full Code and 911 had not been called. LPN #18 reported she and LPN #17 went to assess Resident #151. Upon assessment, Resident #151 was lying in bed, no pulse or vital signs, and pupils were not reactive. At that time, LPN #17 and LPN #18 placed Resident #151 onto the floor and initiated CPR. EMS arrived and pronounced Resident #151 dead at 10:17 A.M. Interview on [DATE] at 9:35 A.M. with the Executive Director revealed LPN #17 and LPN #18 took it upon themselves to initiate CPR four hours after Resident #151 had been deceased . The Executive Director reported no staff members directed LPN #17 and LPN #18 to perform CPR on Resident #151. Interview on [DATE] at 10:39 A.M. with STNA #05 revealed she worked on the day shift on [DATE]. STNA explained when LPN #12 was passing medications and got to Resident #151's room, STNA #05 observed a change in LPN #12's demeanor. At that time, LPN #12 left the unit and went to get the unit managers (LPN #17 and LPN #18). STNA #05 observed LPN #17 and LPN #18 place Resident #151 on the ground but had not initiated CPR. STNA #05 reported LPN #18 came out of Resident #151's room and told staff they were going to act like Resident #151 just went down and to notify LPN #17 and LPN #18 when EMS services arrived. STNA #05 stated she had not agreed with this and would not take part in those acts. STNA #05 reported LPN #17 and LPN #18 started CPR when EMTs arrived. STNA #05 reported LPN #17 and LPN #18 had not notified the EMS that Resident #151 had been down for four hours. STNA #05 stated once EMS services left the facility, LPN #17, and LPN #18 instructed STNA #05 to provide postmortem care. STNA #05 reported about twenty minutes after EMS services left, the local police department showed up to question the events that had occurred with Resident #151. Telephone interview on [DATE] at 12:29 P.M., with the Emergency Medical Technician (EMT) #01 revealed the facility staff stated Resident #151 had just went down before EMS was called. EMT #01 was not told Resident #151 had been deceased since 5:30 A.M. EMT #01 reported if him and his team would have known Resident #151 was down since 5:30 A.M., they would have called the local emergency department to confirm a time of death at that time instead of initiating life saving measures. A follow-up telephone interview on [DATE] at 11:24 A.M., with LPN #18 revealed she was made aware by LPN #12 that Resident #151 was a full code and CPR and 911 had not been initiated. She immediately went into the room and started CPR. At that point, she was told Resident #151 had been deceased since 5:30 A.M. LPN #18 reported EMT was not made aware that Resident #151 had been down since 5:30 A.M. LPN #18 stated she was educated on CPR and the proper way to handle a full code resident who had been down for hours. LPN #18 also reported she was given a write-up regarding the incident on [DATE]. Telephone interview on [DATE] at 12:33 P.M., with LPN #17 revealed she was notified around 9:30 A.M. that there was a resident who was a full code who was unresponsive and CPR or 911 had not been initiated. LPN #17 reported she immediately called 911 and then applied her personal protective equipment (PPE). LPN #17 stated she did not go into Resident #151's room until EMTs arrived at the facility. LPN #17 reported she told EMTs she was unsure how long Resident #151 had been down because she was unable to verify this at 5:30 A.M. when this occurred and she didn't see Resident #151 prior to EMTs arriving. She did not perform CPR on Resident #151, but she did say chest compressions were being completed by staff when EMTs walked into the room. LPN #17 did not withhold information regarding the time Resident #151 had been down, she was not able to confirm that and that is why she told EMTs she was unsure when he went down. Review of the facility policy titled, Abuse Prevention Program, dated [DATE] revealed all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. The facility will condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representatives, sponsors, other residents, friends, or other individuals. All personnel, residents, family members, resident representatives, visitors, etc., are encouraged to report incident of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. Employees, facility consultants, and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Administrator. This deficiency substantiates Complaint Number OH 250, Complaint Number OH 229, and Complaint Number OH 119.

Based on closed medical record review, staff interview, local Emergency Medical Technician (EMT) interview, review of the local Emergency Medical Service (EMS) care report, review of the facility witness statements, review of the facility policy, and review of American Heart Association guidelines, the facility failed to initiate timely Cardiopulmonary Resuscitation (CPR) or call nine-one-one (911) to EMS. This resulted in Immediate Jeopardy when Resident #151, who was a Full Code, was found unresponsive without vital signs around 5:30 A.M. At approximately 9:30 A.M., Licensed Practical Nurse (LPN) #17 and LPN #18 initiated CPR on Resident #151 and called 911. The EMS arrived at 9:50 A.M. and took over care. At 10:17 A.M., Resident #151 was pronounced dead. This affected one resident (#151) out of three residents reviewed for CPR. The facility census was 147. On [DATE] at 1:25 P.M., the Executive Director, Regional Corporate Nurse #50, and the Director of Nursing (DON) were notified of Immediate Jeopardy, which began on [DATE] at approximately 5:30 A.M. when the facility failed to initiate timely CPR and call 911 for Resident #151, who was found unresponsive without vital signs and was a Full Code. The State tested Nurse Aide (STNA) #04 and STNA #05 were completing rounds between 5:15 A.M. and 5:30 A.M. when they noticed Resident #151 wasn't in bed. STNA #04 turned on his light and saw him kneeling next to his bed. STNA #04 went over to Resident #151 and attempted to stimulate him. STNA #04 observed Resident #151 was not breathing and was cool to the touch. The STNA #04 and STNA #05 alerted LPN #11. The LPN #11 went into Resident #151's room to assess him. The LPN #11 determined Resident #151 had no pulse, wasn't breathing, and had no vital signs. LPN #11 exited the room and returned a few minutes later. LPN #11 stated Resident #151 was a Full Code. The STNA #05 asked LPN #11 what she was going to do. The LPN #11 stated Resident #151 was too old and too frail to complete CPR. The LPN #11 reported she would call and notify his family. After LPN #11 left the room, STNA #04 and STNA #05 performed postmortem care on Resident #151. At approximately 7:00 A.M., LPN #11 gave report to LPN #12 and explained Resident #151 had passed away at approximately 5:30 A.M. LPN #11 reported she completed the duties regarding Resident #151's death however needed LPN #12 to notify his family. LPN #12 started her medication pass around 8:30 A.M. At approximately 9:00 A.M., LPN #12 was reviewing Resident #151's chart. LPN #12 noticed Resident #151 was a Full Code, and CPR or 911 was never attempted. LPN #12 immediately notified unit managers, LPN #17 and LPN #18, that LPN #11 failed to initiate CPR or call 911 for Resident #151. At approximately 9:30 A.M., LPN #17 and LPN #18 initiated CPR on Resident #151 and called 911. At 9:50 A.M., EMS arrived at the facility and completed life saving measures on Resident #151 with no change in response and were not made aware the resident had been unresponsive for four hours. At 10:17 A.M., Resident #151 was pronounced dead. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE], LPN #11, who had not performed CPR, was verbally educated by the Executive Director on the requirements as set forth in the facility regarding CPR Policy and Procedure. LPN #11 was suspended and removed from the schedule pending the outcome of the facility Self-Reported Incident (SRI), also initiated on [DATE]. LPN #11 was suspended since approximately 8:30 A.M. on [DATE] and was terminated on [DATE]. · On [DATE], the Executive Director provided education to Unit Managers (LPN #17 and LPN #18) at the facility on the policy/procedure for CPR. This education included: 24-hour availability of care team members properly trained on CPR Identification of code status Initiation of CPR as required and appropriate Emergency services notification Reporting requirements and [NAME] Policy and Procedure related to CPR · On [DATE], the Executive Director provided written discipline to LPN #17 and LPN #18 for their actions displayed during the incident with Resident #151. · On [DATE], Unit Managers (LPN #17 and LPN #18) provided education on policy/procedure for CPR to all licensed nurses in the building and to the next shift. Licensed nursing staff, who were not able to be educated in person, were educated and/or called prior to working his/her next shift at the facility and completed on [DATE]. · On [DATE], the facility Unit Managers (LPN #17 and LPN #18) audited all current resident records to ensure proper/correct code status was indicated. Two residents (#51 and #97) needed correction and were updated immediately upon discovery. · On [DATE] the local Police were made aware of the incident by an unidentified third party prior to the facility initiation. · On [DATE] the Medical Director #60 and his team were made aware of the incident and follow-up on all of the corrective action initiated since the incident was completed on [DATE]. · On [DATE], the Executive Director and Regional Director of Clinical Operations #01 completed an audit regarding deaths of residents who needed CPR or 911 called, and none were found. · On [DATE], the Director of Human Resources #40 began completing an audit of licensed nurse files to verify presence of CPR certification and completed on [DATE]. Licensed nurses without a copy of current CPR certification were identified and arrangements to provide opportunities for on-site certification will be established. Review of the audit revealed one Registered Nurse (RN) #21 was identified without a current CPR certification. Arrangements were made to have this completed. · On [DATE] the Executive Director contacted the local Police Department to inquire about the status of the police report associated with the visit noted above. The police department informed the Executive Director the report was not available at this time due to it was an open investigation. · The Director of Nursing and/or designee will audit new admission charts within the first 72 hours of admission for the code status to be identified and documented in the resident record. This will occur at the time of admission and/or readmission to the facility. New admission charts are audited within the first 72 hours of admission - code status is verified as a part of this process. The code status will be verified as part of the quarterly care planning meetings. · Licensed Nursing staff will continue to be educated on policies/procedures including Abuse and CPR upon hire, as assigned during monthly education assignments and skills checks (both in person and online), and as needed. The Director of Nursing and/or designee will complete skills checks on the above randomly every month (five nurses per month). · All resident deaths occurring in the facility will be audited within 72 hours during morning Quality Assurance Performance Improvement (QAPI) meeting to ensure proper procedures were followed and documented per policy. · CPR certified staff will be identified on the daily staffing sheet to ensure the availability of 24-hour availability of CPR certified staff. Nursing scheduler #13 will update staffing sheets as needed. · On [DATE], a QAPI related to CPR and event initiated with Interdisciplinary Team (IDT) team as part of the morning meeting. Staff members in attendance included: The Executive Director, the Director of Nursing, the Assistant Director of Nursing #12, the Therapy Manager #20, the Social Services #30, the Dietary manager #60, the Minimum Data Set (MDS) #70, the Activities Director #90, and the Regional Director of Clinical Services #100. Root Cause analysis discussed and completed. Plan including components noted above initiated on [DATE]. · On [DATE], the Executive Director was terminated. · On [DATE] a new Executive Director was hired and upon review of the incident LPN #17 was terminated and LPN #18 will be terminated immediately upon return from medical leave. The Director of Nursing at the time of this incident submitted her resignation and her last day worked was [DATE]. · On [DATE], A Quality Assurance Performance Improvement was held related to CPR and this incident and was facilitated by the new Executive Director. It will include the following staff members: Assistant Director of Nursing #12, the Therapy Manager #20, the Social Services Director #30, the Dietary Manager #60, the MDS Coordinator #70, the Activities Director #90, and the Regional Director of Clinical Services #100. The new Executive Director will be responsible to share the meeting results with the new Director of Nursing upon her return from leave and the Medical Director during the normally scheduled QAPI meeting process. Effective leadership and effective action was discussed to improve the culture of the facility. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of the closed medical record revealed Resident #151 was admitted to the facility on [DATE] and expired on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order dated [DATE] revealed the Resident #151 was a Full Code. Review of the care plan dated [DATE], revealed Resident #151 was at risk for respiratory distress related to confirmed COVID-19. Interventions included administer medications as ordered and observe for effectiveness and adverse side effects. The staff should assess for fever, cough, or shortness of breath every shift and as needed. The staff should notify the physician of changes in respiratory status, fever, or new or worsening cough or shortness of breath. The staff should observe for changes in orientation, increased restlessness, anxiety, and air hunger. Review of the progress note dated [DATE] at 5:35 A.M. written by LPN #11 revealed Resident #151 was found unresponsive. His pupils were fixed with no respirations or heart rate noted. Several outreach attempts were made to Resident #151's family. Review of the progress note dated [DATE] at 9:33 A.M. written by LPN #17 revealed Resident #151 was unresponsive with no pulse. The code status revealed Resident #151 was a Full Code. After visualization of Resident #151 by the nurse, 911 was called and CPR was initiated. When EMS arrived on scene, they took over care. Review of the progress note dated [DATE] at 6:48 P.M. written by LPN #12 revealed arrival into Resident #151's room, he was found with no pulse and skin cool to the touch. Unit managers were notified of the findings. CPR was started immediately, and 911 was called. EMS arrived and took over CPR. The EMS had no change in response, and Resident #151 was pronounced dead at 10:17 A.M. Resident #151's physician and family were notified. The local funeral home was notified and picked up Resident #151's body. Review of the EMS Care Report Summary dated [DATE] revealed upon arrival Resident #151 was found on the floor in his room where facility staff were performing CPR. Per facility staff, unknown time Resident #151 went down and was found just prior to 911 call, which was received at 9:40 A.M. EMS found Resident #151 to be pulseless and apneic. The mechanical CPR device was placed on Resident #151. Ventilation and oxygen were initiated. After 30 minutes of resuscitation were completed with no change in response, a field termination was made. A call was made to the local emergency department (ED), where Resident #151 was pronounced dead by the ED physician #18 at 10:17 A.M. Review of STNA #05's statement written on [DATE] revealed STNA #04 and STNA #05 were starting their rounds when they noticed Resident #151 on the floor. STNA #04 touched Resident #151, who was cold, and she thought he had passed. STNA #04 left the room to find LPN #11. LPN #11 and STNA #04 returned to the room. LPN #11 obtained vital signs and listened for a heartbeat. LPN #11 left the room, and then she returned and stated Resident #151 was a Full Code. STNA #05 asked LPN #11 what she was going to do. LPN #11 reported Resident #151 was [AGE] years old and too fragile. LPN #11 stated she would call his family. STNA #04 and STNA #05 provided postmortem care to ensure he would be presentable for family. Review of the interview statement with LPN #11 facilitated by the Executive Director on [DATE] revealed at approximately 5:15 A.M. STNA #04 reported to LPN #11 that Resident #151 was found unresponsive and appeared to be without vital signs. LPN #11 immediately went to Resident #151's room and checked for vital signs. LPN #11 reported Resident #151 was without a heartbeat or respirations, his pupils were fixed and dilated, and his skin was cool to the touch with evidence of discoloration. LPN #11 reported the last time she visualized Resident #151 was earlier in her shift while she was passing medications. LPN #11 reported Resident #151 was awake and took medications without incident. LPN #11 stated she had been a Hospice nurse for [AGE] years prior to her employment with the facility and noted these signs as indicators of irreversible death, so CPR was not initiated at that time. LPN #11 attempted to notify Resident #151's family several times with no response. LPN #11 reported family notification would be completed by oncoming nurse. Review of STNA #04's witness statement written on [DATE] revealed STNA #04 completed a round around 3:30 A.M. and saw Resident #151 was sleeping in bed with visible respirations. At approximately 5:30 A.M., STNA #04 and STNA #05 were making rounds. When walking past Resident #151's room, STNA #04 stated she didn't see him in bed. STNA #04 entered the room and turned the light on. STNA #04 stated Resident #151 was on his knees with his elbows resting on the bed. STNA #04 walked over to Resident #151 talking to him when she placed her hand on him to find him cold and not breathing or moving. STNA #04 stated to STNA #05 she thought he was gone. STNA #04 went to go get LPN #11 and the vitals machine. STNA #04 and STNA #05 assisted Resident #151 back into bed. LPN #11 assessed Resident #151, and then she left the room. After a few minutes, LPN #11 came back into the room and said Resident #151 was a Full Code. STNA #05 asked LPN #11 what she was going to do. LPN #11 stated Resident #151 was too old and fragile to do compressions, and she was going to call his family. STNA #04 and STNA #05 provided postmortem care to Resident #151. After care was completed on Resident #151, STNA #04 and STNA #05 completed their rounds. Interview on [DATE] at 9:21 A.M., with LPN #11 revealed Resident #151 was stable throughout the night. LPN #11 reported around 5:30 A.M. the STNA #04 came to get her because he was unresponsive. LPN #11 went into Resident #151's room and completed an assessment and vital signs. LPN #11 reported Resident #151 had no vitals, respirations, or heart rate. She stated his hands and feet were cold and his skin was pale for an African American. LPN #11 advised STNA #04 and STNA #05 to complete postmortem care on Resident #151. LPN #11 reported she didn't know Resident #151 was a Full Code, and that was why she had not initiated CPR. LPN #11 explained under her scope of practice she was not able to pronounce death. LPN #11 stated she faxed the physician a notification to alert him Resident #151 had passed away at approximately 6:00 A.M. Interview on [DATE] at 10:01 A.M. with the DON revealed she was unable to elaborate on the events that took place from 5:30 A.M. when Resident #151 was found unresponsive without a pulse to 9:30 A.M. when CPR was initiated by LPN #17 and LPN #18. Interview on [DATE] at 10:25 A.M. with LPN #12 revealed she received report from LPN #11 around 7:00 A.M. on [DATE]. At that time, LPN #11 explained Resident #151 had passed away around 5:30 A.M. and the only duty needed to be completed was to notify his family. LPN #12 reported she went to his room to ensure postmortem care had been provided. Around 9:00 A.M. while completing medication pass, LPN #12 reviewed Resident #151's chart. At that time, she confirmed Resident #151 was a Full Code and CPR or 911 was never initiated. LPN #12 immediately notified unit managers (LPN #17 and LPN #18). Unit managers #17 and #18 entered Resident #151's room to assess him. LPN #12 assisted LPN #17 and LPN #18 lower Resident #151 to the ground. At approximately 9:30 A.M., LPN #17 and LPN #18 initiated CPR and 911 was called. LPN #12 reported EMS arrived at the facility and took her over care on Resident #151. EMS pronounced Resident #151 dead at 10:17 A.M. LPN #12 notified Resident #151's family at approximately 10:20 A.M. Interview on [DATE] at 11:17 A.M. with LPN #18 revealed she was made aware at approximately 9:30 A.M. of Resident #151's death. LPN #18 explained he was a Full Code and 911 had not been called. LPN #18 reported she and LPN #17 went to assess Resident #151. Upon assessment, Resident #151 was lying in bed, no pulse or vital signs, and pupils were not reactive. At that time, LPN #17 and LPN #18 placed Resident #151 onto the floor and initiated CPR. EMS arrived and pronounced Resident #151 dead at 10:17 A.M. Interview on [DATE] at 10:39 A.M. with STNA #05 revealed she came onto shift at 11:00 P.M. on [DATE]. STNA #05 reported STNA #04 and herself completed a round around 5:15 A.M. At that time, STNA #04 and STNA #05 found Resident #151 on the floor on his knees. STNA #04 tried to arouse him but was unable to. STNA #04 notified LPN #11. STNA #5 reported LPN #11 came into the room and listened for a heartbeat. STNA #05 stated LPN #11 left the room, and then she came back and stated Resident #151 was a Full Code. STNA #05 stated she asked LPN #11 what she was going to do. LPN #11 responded with Resident #151 was [AGE] years old and very fragile. LPN #11 reported she was going to call Resident #151's family. STNA #05 stated STNA #04 and herself provided postmortem care to Resident #151 and continued their rounds. STNA #05 reported she worked on dayshift on [DATE]. STNA explained when LPN #12 was passing medications and got to Resident #151's room, STNA #05 observed a change in LPN #12's demeanor. At that time, LPN #12 left the unit and went to get the unit managers (LPN #17 and LPN #18). STNA #05 observed LPN #17 and LPN #18 place Resident #151 on the ground but did not initiate CPR. STNA #05 reported LPN #18 came out of Resident #151's room and told staff they were going to act like Resident #151 just went down and to notify LPN #17 and LPN #18 when EMS services arrived. STNA #05 stated she didn't agree with this and wouldn't take part in those acts. STNA #05 reported LPN #17 and LPN #18 started CPR when EMTs arrived. STNA #05 reported LPN #17 and LPN #18 hadn't notified the EMS that Resident #151 had been down for four hours. STNA #05 stated once EMS services left the facility, LPN #17 and LPN #18 instructed STNA #05 to provide postmortem care. STNA #05 reported about twenty minutes after EMS services left, the local police department showed up to question the events that had occurred with Resident #151. Interview on [DATE] at 12:29 P.M. with Emergency Medical Technician (EMT) #01 revealed facility staff stated Resident #151 had just went down before EMS was called. EMT #01 wasn't told Resident #151 had been deceased since 5:30 A.M. EMT #01 reported him, and his team performed 30 minutes of care per protocol. With no apparent change in Resident #151's status, EMT #01 and his team called a field termination. At that time, the local ED was called, and the ED physician gave a time of death at 10:17 A.M. to Resident #151. Telephone interview on [DATE] at 5:45 P.M., with the Nurse Practitioner (NP) #30 revealed his on-call NP received notification at 10:28 A.M. on [DATE] that the Resident #151 had passed away. He further reported when nurses found a resident who was a full code who is unresponsive without a heartbeat, he stated they should initiate CPR right away and call 911. Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE] revealed the facility must provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. The facility must ensure that care team members properly trained in basic lifesaving support and first aid are available 24 hours per day to provide immediate basic life support and/or first aide to residents when indicated. If a resident experiences [CONDITION(S)], facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives, or in the absence of advance directions or a do not resuscitate order. Review of American Heart Association guidelines, dated [DATE], included Part 5: Adult Basic Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Basic Life Support (BLS) was the foundation for saving lives following [CONDITION(S)]. Fundamental aspects of BLS include immediate recognition of sudden [CONDITION(S)] (SCA) and activation of the emergency response system, early cardiopulmonary resuscitation, and rapid defibrillation with an AED. The guidelines included a core set of actions provides a universal strategy for achieving successful resuscitation. These actions were termed links in the chain of survival. For adults they include, immediate recognition of [CONDITION(S)] and activation of the emergency response system, early CPR that emphasizes chest compressions, rapid defibrillation if indicated, effective advanced life support, and integrated post-[CONDITION(S)] care. This deficiency substantiates Complaint Number OH 250, Complaint Number OH 229, and Complaint Number OH 119.

Based on closed medical record review, review of the emergency squad run sheet, staff interviews, coroner's office interview, review of the facility neurological checks post fall and review of the facility policy, the facility failed to ensure a resident who sustained a fall with a head injury was treated timely when a change in the resident's neurological condition occurred. This resulted in Immediate Jeopardy and serious injury when Resident #200 was found on the floor on his right side, by the left side of his bed, on [DATE] at 12:32 P.M. Neurological checks were abnormal at the initial assessment, and no treatment was initiated. Consequently, the resident was found unresponsive approximately nine hours later, was sent to the hospital for evaluation and diagnosed with [REDACTED]. The resident expired at the hospital on [DATE]. This affected one (#200) of three residents reviewed for falls. The facility census was 187. On [DATE] at 2:20 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on [DATE] at 12:32 P.M. when Resident #200 had a change in neurological condition post fall and immediate treatment was not initiated. At 9:30 P.M., the resident was discovered in bed, unresponsive, with agonal breathing and dried blood around his nostrils. The resident was transferred to the hospital and expired on [DATE]. The hospital identified a right sided intracranial bleed and the county coroner listed the resident's preliminary cause of death as a subdural [MEDICATION NAME] subarachnoid hemorrhage. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Facility Nurse Supervisor #01 was in-serviced by the ADON on physician notification with change of condition, neurological checks, and sending out a resident by squad with a significant change. · On [DATE], all staff were in-serviced by the ADON and the Unit Managers on facility procedures for immediate notification when there is a change in condition and with a significant change of condition to call 911 to send the resident out. · On [DATE], the DON and ADON were in-serviced by the Chief Operating Officer on daily monitoring of change of condition and notifying 911 if significant changes noted. This is completed by reviewing daily nurse progress notes, Situation Background Assessment Recommendation (SBAR), clinical alerts and incident charting. · On [DATE], a house audit was completed to review residents with change of condition to ensure other change of conditions noted were promptly addressed, the physician was notified and any resident with a significant change of condition was sent out by squad. There were no other concerns identified. · On [DATE], the facility created a follow-up form to ensure with any change of condition, the physician is to be notified promptly and with any significant change of condition the resident is to be sent out by squad. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #200 revealed an admitted to the facility on [DATE] and was transferred to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of physician orders dated [DATE] revealed the resident was prescribed [MEDICATION NAME] Sodium (a blood thinning medication), 5.5 milligrams (mg) by mouth daily for [MEDICAL CONDITION] and [MEDICATION NAME] Sodium ([MEDICATION NAME]), a blood thinning medication, 80 mg by injection twice a day for blood thinning. Review of the care plan, initiated [DATE], revealed Resident #200 was on anticoagulant therapy for [MEDICAL CONDITION]. Interventions included to monitor, document, and report to medical doctor as needed any signs and symptoms of anticoagulant complications including vomiting, bruising, and for blood in urine or stool. Assess for any bleeding that may occur. Resident #200 was also at risk for falls related to [MEDICAL CONDITION] and a history of falls. Interventions included assist with positioning, always encourage non-skid footwear to be worn, encourage to use call light for assistance and bed in low position. Review of the comprehensive Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had intact cognition. The resident was a two person assist for bed mobility, transfers, and ambulation. Review of the nursing progress note dated [DATE] at 4:21 P.M. as a late entry, documented Resident #200 was found at 12:32 P.M. that day lying on the floor on the left side of his bed. He was lying on his right side with his arms curled near his face and his legs bent upwards towards his chest. The resident was assisted to bed. His vital signs were stable, and the assessment showed no injuries. The physician, family and unit manager were notified. Review of the Neurological Assessment Flow Sheet revealed neurological checks were started at 12:32 P.M. The resident's pupils were sluggish, and he was unable to follow commands to grasp hands. Extremity movement was documented as unable to determine. His blood pressure was ,[DATE], pulse was 91 beats per minute and respirations were 18. Neurological checks were documented at 12:45 P.M., 1:00 P.M., 1:15 P.M., 1:45 P.M., 2:15 P.M., 3:15 P.M., 4:15 P.M. and 6:15 P.M. All checks documented the resident's pupils were sluggish and he was unable to follow commands to grasp hands. Extremity movement was documented as unable to determine. However, at the bottom of the form in the other observations narrative, there was contradictory information. The narrative documented the resident was able to respond at 12:30 P.M. and 12:45 P.M.; at 1:00 P.M., the narrative read not able to respond and continued not able to respond until 6:15 P.M., when neurological checks were stopped. The resident's vital signs at 6:15 P.M. were blood pressure ,[DATE] and pulse 78 beats per minute. At 8:15 P.M., the form has a line through all blocks of assessment items; at 10:15 P.M., the form is marked hospital through the assessment items. There was no other documentation in the electronic medical record indicating the resident was observed by any staff member between 6:15 P.M., when the last neurological check was done, and 9:44 P.M., when the resident was found unresponsive. A fall note dated [DATE] documented at 9:44 P.M. revealed the resident had an acute change from prior assessment. The resident had altered mental status, decrease in level of consciousness, decreased responsiveness and a small amount of blood under his nostrils. The physician was notified and ordered Vitamin K stat (to control bleeding), hold the [MEDICATION NAME] and [MEDICATION NAME] and to [MEDICATION NAME] spray twice a day. The resident's responsible party was notified and after speaking with the responsible party, 911 was called. The note documented upon the arrival of the emergency medical personnel, the resident had foam like secretions coming from his mouth, pale skin, unresponsive to stimuli, fixed and dilated pupils and snoring respirations. Review of the fire department squad report dated [DATE] revealed the 911 call came at 10:04 P.M. The arrival time of the squad was 10:12 P.M. Resident #200 was found by the squad unconscious with fixed and dilated pupils and dried blood in his nostrils. An open wound to the cheek and temporomandibular area, right or left side not specified, was observed by the emergency personnel, however this wound was not identified in any of the nursing notes from the facility. The resident had non-purposeful movements and his mouth was dry and crusty. At 10:23 P.M., the resident was transported to the hospital. Review of the hospital records revealed Resident #200 was admitted to the emergency roiagnom on [DATE] with [DIAGNOSES REDACTED]. Review of the Computed [NAME]ography (CT) scan of the head dated [DATE] revealed diffuse acute subdural and subarachnoid hemorrhage throughout the bilateral hemisphere with corresponding mass effect on the supratentorial brain with a two-millimeter rightward midline shift. During an interview on [DATE] at 1:40 P.M. with the resident's physician revealed he was notified of the resident's fall on [DATE]. The physician was aware of the sluggish pupils and inability to communicate. He stated the resident was a Do Not Resituate Comfort Care (DNRCC) and they were trying to coordinate with the family concerning his DNRCC status. During interview on [DATE] at 9:50 A.M., Investigator #50 at the Hamilton County Coroner's Office revealed the resident's preliminary cause of death was a subdural [MEDICATION NAME] subarachnoid hemorrhage. During interview on [DATE] at 10:27 A.M., Licensed Practical Nurse (LPN) #10 revealed she was the nurse working at the time of the resident's fall on [DATE]. She stated when she assessed Resident #200 after he was found on the floor, she did not see any injuries. She stated she notified the family and physician of the resident's fall. The physician did not want to send the resident out and the family was all right with the facility monitoring the resident's condition. LPN #10 was unable to explain the contradictory information on the neurological flow sheet, documenting whether the resident was responsive. She was unable to state why the physician was not notified at 1:00 P.M., when it was documented the resident was unable to respond. LPN #10 also had no explanation for the resident's facial injuries documented by the emergency squad. During interview on [DATE] at 10:45 A.M., Unit Manager #300 revealed she came in around 4:00 P.M. on [DATE] to pick up her work laptop computer and was notified of the fall. She stated she went into the resident's room to make sure the fall mat was in place but did not assess the resident because he was sleeping. She stated she went home and came back around 9:00 P.M. to drop her laptop computer off and was informed by Agency Nurse #160 she had gone in to arouse the resident and could not get him awake. She stated the vitals were taken around 9:15 P.M. and the blood pressure was low, the pulse was elevated, and he was making a snoring sound when breathing. She called the physician who stated to continue to monitor neurological checks, give Vitamin K (used to decrease the effect of [MEDICATION NAME]) and do a stat International Normalized Ratio (INR). She called the resident's responsible party, who stated to send the resident to the hospital. During telephone interview on [DATE] at 11:40 A.M., Agency Nurse #160 revealed she came on duty at 7:00 P.M. She did not see Resident #200 until between 8:00 P.M. and 8:30 P.M., when she went in to give his medication and to do his vital signs. She stated his vital signs were normal, but she could not arouse him to give him his medication. She stated she thought he was tired, and she would come back and try to give them again a little later. She returned at approximately 9:00 P.M. and the resident did not seem himself. She stated she had Unit Manager #300 come in, who then took over the resident's care. She stated the physician did not want the resident sent out to the hospital, but the family did. When questioned why no neurological checks and vitals were documented when she saw the resident at 8:00 P.M., she stated she did not know. Review of the facility policy titled Neurological Assessment, revised (MONTH) 2010, revealed always include frequent vital signs. Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately. This deficiency substantiates Complaint Number OH 4426.