Every finding on record at Manor at Perrysburg

Based on resident interview, observation, staff interview and record review, the facility failed to ensure wound treatments were completed as physician ordered. This affected one (#13) of one resident reviewed for wound treatments. The facility census was 106.Findings include:Review of the medical record for Resident #13 revealed an admission date of 09/30/23 with diagnoses including type II diabetes mellitus, non-pressure chronic ulcer of other part of right foot, congestive heart failure, and non-pressure chronic ulcer of right calf.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition and had open lesions of the foot, other than ulcers, rashes or cuts.Review of the physician orders dated 12/19/25 revealed Resident #13 had a wound to the right foot with treatment directions to cleanse with normal saline, pat dry, apply calcium alginate with silver, wrap with kerlix then ACE wrap, every day shift for open area. There were treatment directions to cleanse the right toe and right side upper thigh with normal saline, pat dry, apply calcium alginate with silver and wrap with kerlix every day shift for wound. The wound to the right shin had treatment directions to cleanse with normal saline, pat dry, apply alginate with silver and cover with island dressing daily and as needed, every day shift for skin tear.Review on 12/24/25 at 1:25 P.M. of the Treatment Administration Record (TAR) dated December 2025 revealed each of the above noted physician orders was documented on 12/23/25 with HN and staff initials. Each of the above noted physician orders were documented on 12/24/25 with a checkmark with staff initials. Additional review of the Chart Codes on the TAR revealed HN meant Hold/See Nurse Notes.Review of the progress notes for Resident #13, dated 12/23/25, revealed no indication why the wound treatment was not completed.Interview on 12/24/25 at 1:02 P.M. with Resident #13 revealed her wound treatments were not completed since Monday (12/22/25). Resident #13 stated her wound treatments should be completed daily.Interview on 12/24/25 at 1:25 P.M. with Licensed Practical Nurse (LPN) #201, and concurrent review of Resident #13's TAR confirmed LPN #201 charted she completed the wound treatments to Resident #13's right leg on 12/24/25 but had not yet completed them.Observation on 12/24/25 at approximately 1:30 P.M. and concurrent interview with LPN #201 revealed Resident #13's right leg was wrapped in an ace wrap. LPN #201 confirmed Resident #13's ace wrap showed indication of wound seepage around the calf and toes. LPN #201 further confirmed Resident #13's right upper outer calf had exposed open wound areas due to the drooping of the wound covering and ace bandage. Continued observation revealed LPN #201 removed the ace wrap from Resident #13's right leg, exposing gauze from upper right calf to the tips of her toes. At the top of the right foot, written in pen on the gauze, was the date 12/22/25 with staff initials. Continued interview with LPN #201, and concurrent review of Resident #13's December TAR, confirmed the initials on the gauze matched the initials of the nurse who documented treatments were completed on 12/22/25. Additionally, the initials on the TAR for 12/23/25 were a different nurse (LPN #202). Interview on 12/24/25 at 1:42 P.M. with the Director of Nursing (DON) and review of Resident #13's TAR and progress notes confirmed there was no indication in Resident #13's chart to explain why the wound treatment was not completed on 12/23/25. The DON further stated Resident #13's wound treatments should have been completed on 12/23/25, as ordered by the physician.Follow-up interview on 12/24/25 at 2:28 P.M. with the DON revealed she spoke with LPN #202, who charted on Resident #13's chart on 12/23/25. The DON stated LPN #202 confirmed she did not complete Resident #13's wound treatments because she ran out of time on her shift.This was an incidental finding identified during the complaint survey completed 12/24/25.

Based on observation, review of meal tickets, staff and resident interviews, and review of Resident Council meeting minutes, the facility failed to ensure residents received menu items as selected at mealtime. This affected two (#11 and #15) of four residents reviewed for accuracy of meal tray food items. The facility census was 106.Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 01/09/24 with diagnoses including hemiplegia, type II diabetes mellitus, and overactive bladder. Review of the annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition and was able to eat independently.Interview on 12/24/25 at 8:48 A.M. with Resident #11 revealed she generally did not receive the choices she selected on her menus for lunch and dinner.Observation during meal service on 12/24/25 at 12:55 P.M. with Licensed Practical Nurse (LPN) #203, and concurrent interview, confirmed Resident #11 did not receive the vegetable soup she selected on her meal ticket. Further interview with LPN #203 revealed residents complained about not receiving items they select on their meal tickets.Interview on 12/24/25 at 12:59 P.M. with Certified Nursing Assistant (CNA) #101 revealed she was able to provide Resident #11's vegetable soup upon request from the surveyor.2. Review of the medical record for Resident #15 revealed an admission date of 10/22/25 with diagnoses including hypertensive heart disease, type II diabetes mellitus, and heart failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition and required setup or clean-up assistance for eating.Observation during meal service on 12/24/25 at 12:05 P.M. revealed Certified Nursing Assistant (CNA) #102 providing Resident #15 her noon meal. Concurrent interview and review of the selective menu for Resident #15 revealed she selected crackers and did not receive them on her tray. CNA #102 was able to provide the crackers from an unused meal tray for a resident who was out of the facility.Interview on 12/24/25 at 12:59 P.M. with CNA #101 confirmed CNAs were responsible for passing out menu tickets for lunch and dinner meals the day before service, and ensuring the meal tickets were completed by residents and returned to the kitchen by 6:00 P.M. Additionally, CNA #101 confirmed residents complained about not receiving the items they requested. CNA #101 further stated she was able to coordinate with her co-workers and the kitchen to obtain the requested items timely during meal service. Review of the Resident Council Food Committee notes, dated 11/03/25, revealed a concern regarding menus not being filled out and residents not getting what they request.This deficiency represents non-compliance investigated under Complaint Number 2664244.

Based on observation, interview, record review, and policy review the facility failed to ensure that residents were served together during dining in the memory care unit. This had the potential to affect all 24 residents who reside on the memory care unit. Additionally the facility failed to ensure a female resident was free from long facial hair. This affected one (#27) of one resident reviewed for facial hair. The facility census was 96. Findings include: 1.Observation on 08/18/25 at 8:58 A.M. of breakfast trays being delivered to the dining room on the memory care unit revealed the staff began delivering trays to the tables. Staff removed the plates and drinks from the trays and placed them in front of the residents. Staff did not serve the residents by tables. One table with two residents sitting at the table had one resident that was served at 9:00 A.M. while the other resident was served at 9:14 A.M. The staff were observed serving tables at random from the cart. Observation of another two top table revealed one resident was served at 9:04 A.M. and the other resident was served at 9:08 A.M. Four other tables were observed with only one resident eating and the other resident was waiting to be served. The average wait time of residents watching the other residents eat was between four to eight minutes. Interview on 08/18/25 at 9:07 A.M. with Resident #41 revealed he would like to eat at the same time as his friend. Resident #41 stated he had been in the dining room since 6:30 A.M. Interview on 08/18/25 at 9:15 A.M. with Certified Nursing Assistant (CNA #446) revealed the trays do not come out in sequence of the tables. CNA #446 verified the tables were not served together and the residents were watching the other resident at the table eating. CNA #446 stated they serve the trays as they come off the cart. Observation on 08/19/25 at 8:50 A.M. of breakfast trays being delivered to the dining room on the memory care unit revealed the trays were on a open cart. Staff were observed to start passing trays at 8:54 A.M. 16 residents were observed in the dining room at 8:57 A.M. Two more residents arrived at 8:58 A.M. One big table observed in the dining room had seven residents sitting at the table. One resident at the big table was observed to be served their meal at 9:04 A.M. Staff were observed serving other tables while the six other residents at the big table were without breakfast. The second resident at the big table was served at 9:09 A.M. Observation of another two top table revealed one resident served at 9:06 A.M. and the other resident was served at 9:13 A.M. The big table was observed with five out of seven residents not served at 9:12 A.M. Four staff members were observed passing trays. The last resident at the big table was served at 9:20 A.M. Interview on 08/19/25 at 8:08 A.M. with CNA #446 revealed almost all the residents from the unit come to the dining room for meals. CNA #446 stated they did not have any residents that consistently eat in their room. Interview on 08/19/25 at 10:00 A.M. with CNA #446 it was verified the residents sitting together at the dining tables were not served together this morning. CNA #446 stated they did try to serve the residents together, but the meal trays were not delivered to the unit on the cart that way and it made it more difficult to do. Observation on 08/20/25 at 8:51 A.M. revealed 17 residents were in the dining room on the memory care unit. Staff were observed not passing trays by table. At 8:51 A.M. the big table with seven residents had three residents out of seven residents who had been served their meal. One resident at a two top table was observed with a meal at 8:52 A.M. and the second resident was served at 8:58 A.M. Two more residents were observed entering the dining room bringing the total to 19 residents in the dining room. Two staff members were observed passing the trays in the dining room. At 9:06 A.M. four residents at the big table were waiting on breakfast. At 9:10 A.M. two residents at the big table still were waiting on food. The last resident at the big table was served at 9:15 A.M. Interview on 08/20/25 at 9:19 A.M. with CNA #446 it was verified the residents in the dining room were not served by tables again this morning. Observation on 08/20/25 at 12:24 P.M. of lunch on the memory care unit revealed the first meal trays were delivered already. 18 residents were observed in the dining room. Observation of the big seven top table revealed all but one resident had been served lunch. The second meal cart was delivered to the dining room at 12:30 P.M. The last resident at the big seven top table was served at 12:32 P.M. Interview on 08/20/25 at 12:42 P.M. with Dietary Supervisor (DS #438) revealed the dietary staff had been putting the trays on the cart according to the type of diet prior to lunch today. DS #438 stated that today at the lunch meal they started splitting the two meal delivery carts and having the first cart have all of the seven top table resident's meals on it and the rest of the meals were delivered on the second cart. 2. Review of the medical record for Resident #27 revealed an admission date of 05/18/23 with diagnoses of Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition and required setup or clean-up assistance for personal hygiene. Review of the current care plan, updated 08/03/25, revealed Resident #27 required one staff for setup and assistance with personal hygiene. Review of the electronic medical record (EMR) indicated Resident #27 received a shower on 08/19/25 at 5:30 A.M. Observation and interview on 08/18/25 at 10:13 A.M. revealed Resident #27 sitting in her recliner in her room. Resident #27 had several long chin hairs she was able to pull at with her fingers. Resident #27 stated she did not have the eyesight to remove them herself, but would like them removed. Resident #27 stated she did not ask staff to remove them. Interview on 8/19/25 at approximately 4:00 P.M. with Certified Nursing Assistant (CNA) #469 and concurrent review of the EMR confirmed Resident #27 received a shower on the morning of 08/19/25. Continued interview and concurrent observation of Resident #27 confirmed her chin hairs remained long and visible. Resident #27 again stated she would like the chin hairs removed as she found them embarrassing. CNA #469 confirmed Resident #27's chin hairs should have been removed during her shower. Review of the policy Quality of Care Policy/Activities of Daily Living, revised 04/2016, revealed the facility would provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on record review and interview the facility failed to ensure the psychotropic education form was completed prior to starting medications. This affected one (#30) of five residents reviewed for psychotropic medications. The facility census was 96. Findings include: Review of the medical record for Resident #30 revealed an admission date of 06/25/25 with diagnoses of insomnia, bipolar disorder, depression, stroke, and dementia. Review of the 5-day MDS assessment dated [DATE] revealed Resident #30 was rarely/never understood. Review of the physician order initiated 06/25/25, discontinued 08/20/25, and re-initiated 08/20/25, revealed Resident #30 received Divalproex Sodium (an anticonvulsant) oral tablet delayed release 250 milligrams (mg), twice daily for bipolar disorder. Review of the physician order initiated 07/24/25, discontinued 08/20/25, and re-initiated 08/20/25, revealed Resident #30 received Sertraline Hydrochloride (HCl) (an antidepressant) oral tablet 50 mg once daily for depression. An additional physician order dated 07/24/25 revealed Resident #30 received Sertraline HCl oral tablet 100 mg once daily for depression. Review of the physician order initiated 07/24/25, discontinued 08/20/25, and re-initiated 08/20/25, revealed Resident #30 received Trazodone HCl (an antidepressant) oral tablet 50 mg once daily for insomnia. Interview on 08/20/25 at 2:50 P.M. with the Director of Nursing (DON) confirmed the facility could not provide any evidence Resident #30 or her representative was provided education and alternatives to psychotropic medications Divalproex Sodium, Sertraline HCl, or Trazodone HCl prior to Resident #30 receiving them.

Based on record review, interview, and policy review the facility failed to ensure the comprehensive care plan included all resident care areas. This affected two (#77 and #98) of 26 residents reviewed for care plans. The facility census was 96.Findings include:1.Review of medical record for Resident #77 revealed an admission date of 09/01/25 with diagnoses including but not limited to Alzheimer's disease, dementia, and visual hallucinations.Review of minimum data set (MDS) dated [DATE] revealed the resident had severely impaired cognition. No pressure ulcers during the look back period.Review of current physician orders revealed right lateral foot cleanse with wound wash, pat dry, cover with foam dressing every third day and as needed if soiled.Review of care plan dated 08/01/25 revealed the resident is at risk for skin breakdown related to decreased mobility. Interventions included apply lotion/moisture barrier cream as needed, encourage frequent repositioning, encourage to lay down after meals to offload, offload heels with pillows, and skin assessment as needed.Further review of care plan revealed no care plan for the actual skin impairment and interventions.Interview on 08/21/25 at approximately 1:40 P.M. with Regional Clinical Nurse (RCN #550) revealed the resident did not have an actual skin impairment care plan until today. RCN #550 stated they were waiting for wound physician to classify wound before implementing a care plan.2.Review of medical record for Resident #98 revealed an admission date of 08/01/22 with diagnoses including but not limited to Alzheimer's disease, generalized anxiety disorder, dementia, and post-traumatic stress disorder (PTSD).Review of the quarterly MDS dated [DATE] revealed the resident had severe cognitive impairment. Resident #98 had PTSD.Review of the care plan dated 06/23/25 revealed Resident #98 had no care plan their diagnosis of PTSD.Interview on 08/19/25 at 11:22 A.M. with MDS Coordinator #472 revealed the MDS Nurse typically completes the care plans for the residents. MDS Coordinator #472 stated that the facility is currently training the other nurse managers to complete certain parts of the care plans as well. MDS Coordinator #472 verified Resident #98 did not have a care plan addressing their PTSD and triggers or interventions.Review of policy titled Care Plan Policy dated 05/2025 revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, record review and facility policy review, the facility failed to ensure resident fingernails were cleaned and groomed. This affected one (#68) of three residents reviewed for activities of daily living. The facility census was 96.Findings Include: Review of the medical record for Resident #68 revealed an admission date of 09/20/19 with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and depression. Review of the comprehensive annual Minimum Data Set (MDS) assessment, dated 07/02/25, revealed Resident #68 had intact cognition and was dependent on staff for personal hygiene. Review of the current care plan, updated 07/10/25, revealed Resident #68 required staff participation with personal hygiene. Interview and observation on 08/18/25 at 9:11 A.M. revealed Resident #68 lying in bed. Resident #68 stated his fingernails needed to be trimmed and observation revealed there was debris under his fingernails on both hands. Interview on 08/19/25 at 7:59 A.M. with Certified Nursing Assistant (CNA) #471 revealed she received in report from night shift Resident #68 was showered and dressed during night shift. Continued interview and concurrent observation of Resident #68 revealed his nails were long and there was debris under the nails of the first two fingers of each hand. CNA #471 confirmed nails should be cleaned and trimmed during showers. Review of the policy Quality of Care Policy/Activities of Daily Living, revised 04/2016, revealed the facility would provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, record review, and facility policy review, the facility failed to timely ensure a resident's wound was accurately assessed and documented. This affected one (#77) of two residents reviewed for wounds. The facility census was 96.Findings include:Review of medical record for Resident #77 revealed an admission date of 09/01/22 with diagnoses including but not limited to Alzheimer's disease, dementia, and visual hallucinations.Review of minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. No pressure ulcers were coded on the assessment.Review of current physician orders revealed on order dated 08/01/25 for right lateral foot, cleanse with wound wash, pat dry, cover with foam dressing every third day and as needed if soiled.Review of the form titled Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) shower reviews dated 08/11/25 and 08/04/25 revealed the diagram of the body had no skin alterations marked on the diagram, and the CNA had hand written on the form no new skin issues/area.Review of progress note dated 07/20/25 at 12:48 A.M. revealed Skin issue has not been evaluated, Location: Right lateral fore foot. Issue type documented as other skin issue. Other skin issue description: red blister wound acquired in house. Wound is new.Review of the form titled Nursing Weekly Skin and Body Reviews dated 07/30/25 and 08/10/25 revealed no new areas noted.Review of hospice note dated 07/10/25 revealed no wounds.Review of hospice note dated 07/15/25 revealed wound to right outer pinky toe/foot as dry flat red area measuring 1.5 centimeters (cm) in length by 0.4 cm in width.Review of hospice note dated 07/25/25 revealed no wounds.Review of hospice note dated 08/01/25 revealed a pressure injury to right lateral foot measuring 1.2 cm in width by 1.5 cm in length by 0.02 cm in depth.Review of hospice note dated 08/08/25 revealed pressure injury to right lateral foot measuring 2.9 cm in length by 1.4 cm in width by 0.1 cm in depth.Review of hospice note dated 08/14/25 revealed right lateral foot pressure ulcer was present, however no there was no wound assessment included and it was documented wound care was not completed as it was not due that day.Review of wound evaluation and management summary dated 08/21/25 by wound physician revealed wound one was a non-pressure wound of the right foot with undetermined thickness measuring 0.5 cm length by 0.6 cm width by non-measurable depth. Wound had dried fibrinous exudate (scab) with no signs of infection noted. Second wound was non-pressure wound of the right foot full thickness measuring 1.6 cm length by 1.4 cm width by 0.1 cm depth. Peri wound with erythema, blanchable erythema surrounding wound, no evidence of deep tissue injury to suggest pressure injury at this time. Heavy Serosanguinous drainage. 100 percent granulation tissue.Review of previous wound documentation provided by the facility revealed only one wound was observed and documented for Resident #77. Observation on 08/20/25 at 11:36 A.M. of Resident #77's wound to the right lateral foot revealed there are two wounds. The wound located on the lateral side of the right foot midline is about the size of a dime and is beefy red with no drainage or odor. The second area is located on the lateral side of the foot just below the pinky toe and extends down to approximately mid ball of the foot. The wound presents as an open area, beefy red approximately 0.3 cm in width by four to five cm in length. No drainage or odor is noted. Wound edges and peri wound were intact.Interview on 08/20/25 at 2:26 P.M. with Regional Clinical Nurse (RCN #550) stated she would try to locate wound documentation that contained measurements and description of Resident #77's wound/wounds. RCN #550 verified the resident was not seeing the facility wound physician. Interview on 08/20/25 at approximately 4:00 P.M. with RCN #550 revealed the facility was unable to locate any wound documentation from 06/27/25 through 07/15/25 with wound description and measurements for Resident #77. RCN #550 verified the facility had no wound documentation with wound description and measurements from 07/15/25 through 08/01/25. RCN #550 verified no wound documentation with description and measurements could be located from 08/08/25 through present date.Interview on 08/21/25 at 11:03 A.M. with RCN #550 revealed Resident #77 was seen by the wound physician inhouse and they classified the wound as trauma due to the wounds being blanchable in the surrounding tissue of both wounds. RCN #550 stated she would inform hospice that the wounds are not pressure.Review of policy titled Pressure Ulcer Policy dated 04/2016 revealed should a pressure area present either upon admission or in house, the wound will be monitored at least weekly and should have documentation including: location and staging, size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth, and the presence, location and extent of any undermining or tunneling/sinus tract, drainage, the amount and characteristics, pain if present and characteristics, and wound bed and surrounding tissue.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure interventions to prevent skin breakdown were implemented as ordered by the physician. This affected one of two residents (#2) reviewed for pressure ulcer care prevention and treatment. The facility census of 96. Findings include:Resident #2 admitted to the facility on [DATE] with the diagnoses including, end stage renal disease, asthma, chronic kidney disease, congestive heart failure, urinary tract infection, chronic pain syndrome, anemia, lymphedema, dependence on renal dialysis, neuromuscular dysfunction of bladder, hypertension, anxiety disorder, and bipolar disorder. According to the most current minimum data set assessment dated [DATE] Resident #2 had intact cognition, no recorded behaviors, impaired range of motion to bilateral lower extremities, was dependent on staff for the provision of activities of daily living, and at risk for pressure ulcer development with a current stage II and stage IV pressure ulcer. On 02/27/24 a physician order was implemented for heel offloading/suspension boots at all times. On 01/18/25 a nursing plan of care was developed to address Resident #2's risk for skin breakdown related to impaired mobility cognition, and moisture. Interventions included the application of a low air loss air mattress, keep right heel off bed float both as tolerated, float right calf as able, observe skin for redness or open areas, notify the nurse, and offloading boots as tolerated. According to wound physician specialist (WPS) #1 evaluation and documentation dated 07/10/25 Resident #2 was evaluated for a stage II pressure ulcer to the right heel, stage IV full thickness pressure ulcer to the right buttock and two non-pressure wounds to the left thigh and buttock. WPS #1 noted the right heel wound as healed at the time of the evaluation on 07/10/25. Physician orders directed the continued implementation of pressure off-loading boots, floating heels in bed, with a preventative treatment of skin prep each shift to the right heel. On 08/14/25 WPS #1 assessed the resident and interventions were to continued as recommended on the 07/10/25 visit. On 08/16/25 Resident #2 was assessed at moderate risk of developing a pressure ulcer with a score of 14. Observations on 08/19/25 at 6:25 A.M., 10:24 A.M., 12:08 P.M., 3:03 P.M., 08/20/25 at 2:26 P.M., and on 08/21/25 at 6:27 A.M. noted Resident #2 in bed with heels resting on the mattress surface without pressure off-loading boots in use. On 08/21/2025 at 6:27 A.M. observation noted Resident #2 in bed awake and alert, resting on back with head of bed elevated. Resident #2 stated the pressure relief boots were not applied during the night and nursing staff did not offer the application. At 6:30 A.M. interview with Certified Nurse Aide (CNA) #457 during observation of Resident #2's heels verified the pressure relief boots were not offered or applied during the night. Observation of bilateral heels concurrently noted the bilateral heels with reddened skin. On 08/21/25 at 6:34 A.M. interview with Registered Nurse (RN) #466 verified the pressure relief boots had not been applied during the night. In addition RN #466 confirmed the boots were documented as applied in the medical record in spite of not being utilized. No documentation contained in the medical record documented an occurrence when Resident #2 refused the application of the heel offloading/suspension boots or heel elevation. Review of the Treatment Administration Record between 08/01/25 and 08/20/25 documented the heel offloading/suspension boots applied during the 7:00 A.M.-7:00 P.M. and 7:00 P.M.-7:00 A.M. shifts as indicated. Review of Pressure Ulcer Policy dated revised 04/2016. All residents will be assessed or pressure ulcer risk on admission, monitored weekly, and reviewed quarterly and as needed. Appropriate preventative interventions will be implemented.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure post-fall assessments were completed, including neurological assessments. This affected two (#30 and #78) of four residents reviewed for falls. Additionally, the facility failed to ensure fall prevention measures were in place for one (#12) of four residents reviewed for falls. The facility census was 96.Findings Include:1. Review of the medical record for Former Resident #53 revealed an admission date of 05/19/25 with diagnoses of type 1 diabetes mellitus, kidney transplant failure, and dependence on renal dialysis. Resident #53 discharged home with family on 08/08/25. Review of the 5-day Minimum Data Set (MDS) assessment, dated 07/31/25, revealed Resident #53 had intact cognition, had an impairment on one side of her lower extremity, and required partial/moderate assistance for toileting, bathing, dressing, bed mobility, sit-to-standing, and transfers. Further review revealed Resident #53 had one fall without injury since admission. Review of the incident log dated 05/18/25 through 08/18/25 revealed Resident #53 fell on [DATE], 06/25/25, and 07/30/25. Review of the facility investigations for the falls dated 06/22/25, 06/25/25, and 07/30/25 revealed the falls were unwitnessed. Resident #53 was assessed to have no injuries as a result of the falls. Further review of the record revealed no neurological assessments were completed after the falls on 06/22/25, 06/25/25 and 07/30/25. Additionally, the facility failed to complete post-fall assessments after the fall on 07/30/25. 2. Review of the medical record for Resident #68 revealed an admission date of 09/20/19 with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and depression. Review of the comprehensive annual MDS assessment, dated 07/02/25, revealed Resident #68 had intact cognition and required staff assistance for transfers. Further review revealed Resident #68 had one fall without injury since the previous assessment. Review of the incident log dated 05/18/25 through 08/18/25 revealed Resident #68 fell on [DATE] and 07/31/25. Review of the facility investigations for the falls dated 06/09/25 and 07/31/25 revealed the falls were unwitnessed. Resident #68 was assessed to have no injuries as a result of the falls. Further review of the record revealed no neurological assessments were completed after the falls on 06/09/25 and 07/31/25. Additionally, the facility failed to complete post-fall assessments after the fall on 07/31/25. Interview on 08/21/25 a 11:23 A.M. with Regional Director of Clinical Services (RDCS) #550 confirmed the facility protocol was to complete neurological assessments after unwitnessed falls. Interview on 08/21/25 at 1:52 P.M. with RDCS #550 confirmed no neurological assessments were completed after Resident #53’s falls on 06/22/25, 06/25/25, and 07/30/25. Further, RDCS #550 confirmed no neurological assessments were completed for Resident #68’s falls on 06/09/25 and 07/31/25. Interview on 08/21/25 at 2:42 P.M. with the Director of Nursing (DON) confirmed no post-fall assessments were completed for Resident #53’s fall on 07/30/25 or for Resident #68’s fall on 07/31/25. Review of the policy, “Head Injury Routine,” revised 03/2001, revealed no guidance regarding performing neurological assessments after an unwitnessed fall. Review of the policy, “Fall Reduction Policy,” revised 04/2016, revealed when a resident experienced a fall, follow-up documentation will be done each shift for a minimum of three days or longer if needed. This deficiency represents non-compliance investigated under Complaint Number 2579614. 3.Review of medical record for Resident #12 revealed an admission date of 02/28/25 with diagnoses including but not limited to Alzheimer’s disease, dementia with mood disturbance, hallucinations, major depressive disorder, and hypertension. Review of care plan dated 06/25/25 revealed the resident is at risk for falls related to potential adverse effects from prescribed medications and diagnosis of Alzheimer’s/dementia negatively impacting safety awareness. Interventions included encourage non-skid footwear, encourage to use walker, keep bed in lowest position, keep call light in reach, keep frequently used items in reach, encourage resident to wear non-skid socks at all times when shoes are not on, and keep room free from clutter. Review of fall investigation dated 04/16/25 at 3:15 A.M. revealed the staff heard the resident calling out for help. Resident #12 was observed sitting on the floor with back leaning against the bed with legs extended out in front of her. No non-skid footwear was on. The resident stated she slid off of the bed. Resident #12 was assessed with no injuries noted. New intervention was to encourage staff to apply non-skid socks at all times when shoes were not on. Review of fall investigation dated 07/12/25 at 10:35 P.M. revealed the resident was lying on her back on the bathroom floor with legs extended out in front of her with knees slightly flexed. The resident did not have her walker with her. Resident #12 was reoriented to walker and use for safety. Resident did not have shoes on. Non-skid socks were put on her feet and the resident was assessed with no injuries noted. New intervention was to place a reminder sign to use her walker. Interview on 08/20/25 at 2:36 P.M. with Regional Clinical Nurse (RCN #550) verified the resident did not have non-skid socks on when she had the fall on 07/12/25 which was the intervention put into place for the fall on 04/16/25. RCN #550 verified there was no documentation to support whether the resident was compliant with keeping the non-skid socks on.

Based on observation, staff interview, and record review, the facility failed to ensure nutrition supplements were provided as ordered. This affected one (#50) of five residents reviewed for nutrition. The facility census was 96.Findings Include: Review of the medical record for Resident #50 revealed an admission date of 09/27/24 with diagnoses of Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive. Resident #50 was under the care of hospice. Review of the significant change comprehensive minimum data set (MDS) assessment, dated 07/21/25, revealed Resident #50 was rarely/never understood and was dependent for all activities of daily life.Review of the physician order dated 01/17/25 revealed Resident #50 received a nutrition supplement (Magic Cup) twice daily with meals.Interview on 08/21/25 at 10:08 A.M. with Dietetic Technician, Registered (DTR) #551 confirmed Resident #50 received Magic Cup twice daily to supplement her calorie intake. Interview on 08/21/25 at 12:05 P.M. with Certified Nursing Assistant (CNA) #451, and concurrent observation of Resident #50's noon meal tray revealed no nutrition supplement was on the tray. Further interview with CNA #451 and observation of Resident #50's meal ticket revealed Resident #50 should have received a Magic Cup on her noon meal tray.Interview on 08/21/25 at 12:35 P.M. with Dietary Manager (DM) #438 confirmed the facility had Magic Cup in stock and DM #438 confirmed Resident #50 was supposed to receive the nutrition supplement on her lunch and dinner trays.

Based on observation, staff interview, record review and policy review, the facility failed to ensure proper equipment for residents with a tracheostomy were available at bedside. This affected one (#7) of one resident reviewed for a tracheostomy. Resident #7 was the only resident in the facility with a tracheostomy. The facility census was 96.Findings Include:Review of the medical record for Resident #7 revealed an admission date of 03/15/25 with respiratory failure and tracheostomy status.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/25, revealed Resident #7 had intact cognition and had a tracheostomy.Review of the care plan initiated 03/15/25 for Resident #7 revealed to keep an extra tracheostomy tube and obturator (a curved rod designed to help the tracheostomy tube fit into the trachea) at bedside.Review of the current physician order initiated 03/18/25 revealed Resident #7 had an order to change tracheostomy tube with size 5.5 and style 41c65 Name of Tracheostomy Shiley every day shift every 90 day(s) for tracheostomy maintenance with Pulmonologist present. Review of the current physician order initiated 07/08/25 revealed Resident #7 had an order for tracheostomy type/size: 4UN65H #4 Shiley flex cuffless every shift for monitoring. Interview on 08/18/25 at 12:27 P.M. with Licensed Practical Nurse (LPN) #455, and concurrent observation of emergency tracheostomy and respiratory supplies in Resident #7's room, revealed a re-sealable bag with a single size 5.5 inner cannula tracheostomy tube and a single size #7 cuffless tracheostomy outer cannula. Further interview and concurrent review of the physician orders revealed LPN #455 could not determine if the size #7 cuffless tracheostomy outer cannula was equivalent to the physician order for a #4 cuffless tracheostomy tube. Continued observation and interview at that time revealed LPN #455 could find no other outer tracheostomy tubes amongst the care supplies stored on Resident #7's counter.Follow-up interview on 08/18/25 at 12:48 P.M. with LPN #455 revealed LPN #455 spoke with respiratory services and determined the #7 cuffless trach was a size 7 millimeter (mm) and Resident #7 required a #4, which was a size 6.5 millimeter. Follow-up interview on 08/18/25 at 1:13 P.M. with LPN #455 confirmed the tracheostomy outer canula #7 was too big for Resident #7 and was not appropriate. LPN #455 further confirmed she found the correct tracheostomy outer cannula size 6.5 mm in a box in Resident #7's room under other supplies.Review of the policy, Tracheostomy Tube Guide, revised 05/01/24, revealed all residents with a tracheostomy should have a spare tracheostomy or at minimum an obturator at bedside in case of accidental decannulation or airway obstruction.

Based on record review, interview, and policy review the facility failed to ensure pre and post dialysis assessments were completed. This affected one (#54) of one resident reviewed for dialysis. The facility census was 96.Findings include:Review of the medical record for Resident #54 revealed an admission date of 07/05/25 with diagnoses including but not limited to Alzheimer's disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder depressive type, end stage renal disease, and vascular dementia.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #54 received dialysis.Review of current physician orders revealed the resident had dialysis on Monday, Wednesday, and Friday.Further review of the electronic medical records revealed no dialysis assessments.Interview on 08/20/25 at 11:26 A.M. with Regional Clinical Nurse (RCN #550) revealed the facility did not do the post dialysis assessments when the residents return from dialysis. RCN #550 stated there were pre and post dialysis assessments in the electronic medical record system the facility used however the staff were not completing that. RCN #550 stated the facility was doing a pre assessment and sending that with the resident to the dialysis center for them to fill out their portion and send the form back with the resident.Interview on 08/20/25 at approximately 3:15 P.M. with RCN #550 verified the facility could not produce pre and post dialysis assessments.Review of policy titled Dialysis Care Policy dated 02/2018 revealed the manor will provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.

Based on record review, physician interview, staff interview, and review of Medscape website the facility failed to ensure residents were not given unnecessary medications. This affected one (#10) of six residents reviewed for unnecessary medications. The facility census was 96.Findings include:Review of medical record for Resident #10 revealed an admission date of 09/08/20 with diagnoses including Alzheimer's disease with late onset, epilepsy, major depressive disorder severe with psychotic features, dementia with psychotic disturbance, delusional disorders, generalized anxiety disorder, other schizoaffective disorders, and subdural hematoma.Review of minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment.Review of current physician orders revealed Lovenox (blood thinner) injection prefilled syringe kit 40 milligrams (mg)/0.4 milliters (ml) daily for prevention of blood clot request clarification with Neurosurgery follow up on 06/23/25 (started on 06/11/25 and continued until 08/21/25). Plavix (platelet inhibitor) 75 mg give one tablet daily for blood clot prevention started on 06/10/25 with no stop date indicated. Review of hospital discharge orders dated 06/09/25 revealed Lovenox 30 mg/0.3 mls twice daily with no stop date. Note to change the Lovenox to 40 mg/0.4 mls daily until follow up then request clarification on aspirin, Plavix, and Lovenox (blood thinners).Review of Nurse Practitioner (NP) note dated 06/10/25 revealed the resident had been discharged on Lovenox for deep vein thrombosis (DVT) prophylaxis. Plan to continue Lovenox daily until activity is back to baseline and until follow up with neurosurgery as scheduled 06/23/25.Review of NP note dated 06/17/25 revealed no mention of Lovenox. Plavix remains on hold until follow up with neurosurgery.Review of Neurology follow up note dated 06/23/25 revealed continue medications for Lovenox 30 mg/0.3 mls twice daily and Plavix 75 mg daily. The duration of Lovenox was not addressed.Review of NP note dated 07/01/25 revealed no mention of Lovenox. Plavix remains on hold until follow up with neurosurgery.Review of Neurology follow up note dated 07/08/25 revealed continue medications for Lovenox 30 mg/0.3 mls twice daily. Progress note revealed CT scan improvement. Okay to resume Plavix. Repeat CT of head in one to two weeks after restarting Plavix. Follow up in three to four weeks. The duration of Lovenox was not addressed.Review of progress notes from 06/11/25 through 08/20/25 revealed no record of the facility asking for clarification of Lovenox order.Review of health status note dated 08/20/25 at 5:10 P.M. revealed the writer attempted several times to call neurology Certified Nurse Practitioner (CNP) office to talk to one personnel stated that the CNP was busy with a patient and obtained the facility phone number for a return call. No return call received as of this time.Interview on 08/21/25 at 1:15 P.M. with CNP #600 via phone revealed the neurology office did not manage Lovenox. CNP #600 stated the resident was residing in a facility and her attending physician or cardiologist would or should monitor that. CNP #600 stated the facility had contacted her earlier today and she did state that the resident would not need to take Lovenox now that her Plavix had been restarted.Interview on 08/21/25 at 1:30 P.M. with the Director of Nursing (DON) revealed that she verified the physician visit dated 06/10/25 stated the resident had been discharged on Lovenox for DVT prophylaxis and the plan was to continue Lovenox daily until activity was back to baseline and until follow up with neurosurgery on 06/23/25. DON verified that in subsequent visits on 06/17/25 and 07/01/25 there was no mention of the plan for Lovenox. DON verified no documentation was present to determine if the staff had contacted the physician or CNP #600 for clarification on the stop date for Lovenox.Review of the Medscape Lovenox dosage and indication revealed for DVT prophylaxis for medical patients with restricted mobility: Duration of administration is six to 11 days; up to 14 days has been administered in clinical trials.

Based on record review, staff interview and policy review, the facility failed to ensure nutrition assessments were completed timely. This affected one (#50) of five residents reviewed for nutrition. The facility census was 96. Findings Include:Review of the medical record for Resident #50 revealed an admission date of 09/27/24 with diagnoses of Parkinson's disease, type II diabetes mellitus, unspecified psychosis, and adult failure to thrive. Review of the significant change comprehensive minimum data set (MDS) assessment, dated 07/21/25, revealed Resident #50 was rarely/never understood and was dependent for all activities of daily life. Review of the physician order dated 07/15/25 revealed Resident #50 was admitted to hospice. Review of the medical record revealed a quarterly nutrition progress note was completed on 04/29/25. Further review revealed no more recent quarterly or annual nutrition assessment was completed. Additionally, no comprehensive nutrition assessment was completed after Resident #50 had a significant change and was admitted to hospice on 07/15/25.Interview on 08/21/25 at 10:08 A.M. with Dietetic Technician, Registered (DTR) #551 confirmed a comprehensive nutrition assessment should be completed when residents were admitted to hospice. DTR #551 further confirmed no comprehensive nutrition assessment was completed for Resident #50 since she was admitted to hospice on 07/15/25. Review of the policy, Nutritional Assessment, reviewed 01/2018, revealed resident reviews were to be completed yearly and as significant changes occur.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure enhanced barrier precautions were practiced during tracheostomy care. This affected one resident (#7) observed for tracheostomy care. The facility identified only one resident with a tracheostomy in the facility. The facility census was 96. Findings Include:Review of the medical record for Resident #7 revealed an admission date of 03/15/25 with respiratory failure, tracheostomy status, and history of methicillin resistant staphylococcus aureus (MRSA) (a drug resistant bacteria) infection. Review of the current physician orders for August 2025 for Resident #7 revealed she did not have an order for Enhanced Barrier Precautions (EBP) (precautions used to prevent infections for residents with areas of enhanced portals of entry such as tracheostomy or wounds). Review of the care plan initiated in March 2025 for Resident #7 revealed she was care planned for EBP due to have a tracheostomy and gastric feeding tube with a goal of understanding that staff will wear personal protective equipment (PPE) when providing care during high contact resident care activities. Observation on 08/19/2025 at 8:33 A.M. of Resident #7 revealed she had an EBP sign above her bed in her room and there was personal protective equipment available for use in her room. Observation on 08/21/25 at 7:00 A.M. of tracheostomy care for Resident #7 provided by Registered Nurse (RN) # 490 revealed RN #490 did not don (put on) a gown when she provided tracheostomy care for Resident #7.Interview on 08/21/25 at 7:15 A.M. with RN #490 verified Residents #7 was on EBP and verified that during tracheostomy care she did not wear gown when providing care during a high contact resident care activity. RN #490 verified PPE was available in the room for use. Review of the EBP signage posted in Resident #7's room revealed EBP everyone must wear gown and gloves for the following high-contact resident care activities include device care or use: central line, urinary catheter, feeding tube, and tracheostomy. Review of the facility policy titled, Standard Precautions, dated 08/22, revealed it is the intent of this facility to used Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for residents to prevent transmission of Multi-drug Resistant Organism (MDRO) in our care community. The facility will use EBP to prevent transmission of MDRO from an infected or colonized resident through an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. High contact resident care activities include but are not limited to device care or use such as feeding tube, tracheostomy/ventilator, central line, and/or urinary catheter.

Based on review of facility electronic medical record (EMR), review of external provider documents, staff interview, interview with external provider staff, and policy review, the facility failed to ensure a resident timely received medications upon discharge. Additionally, the facility failed to ensure timely notification of Social Security (SS) of discharge. This affected one (#110) of three residents (#110, #112, and #114) reviewed for discharge rights. Findings include: 1. Review of the EMR for Resident #110 revealed an admission date of 07/25/24 and a discharge date of 03/12/25 with diagnoses including frontotemporal neurocognitive disorder, type two diabetes mellitus (DM2), Vitamin D deficiency, hyperlipidemia, frontal lobe and executive dysfunction, retention of urine, dementia in other diseases classified elsewhere, gastroesophageal reflux disease (GERD), constipation, atrial fibrillation (a. fib), hereditary and idiopathic neuropathy, hypertension (HTN), and multiple myeloma not having received remission. Review of the most recent State Minimum Data Set (MDS) Assessment for Resident #110, dated 03/11/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #110 was relatively cognitively intact. Review of the EMR for Resident #110 revealed a discharge date of 03/12/25 to his personal home. a. Review of the Interdisciplinary Discharge Summary and Plan of Care (DC POC) revealed Resident #110 was discharged on 03/12/25 with a three-day supply of medication and prescriptions (Rx) were called to the external pharmacy by RSC #320 on 03/13/25. Prescriptions included with the DC POC included Eliquis Oral Tablet 5 mg (milligram), give 1 tablet by mouth two times a day for anticoagulant, a-fib related to essential hypertension; Cardizem CD Capsule Extended Release 24 Hour 120 mg , give 1 capsule by mouth one time a day for a-fib; Ropinirole Hydrochloride 1 mg, give 1 tablet by mouth one time a day for restless legs at HS (bedtime); Atorvastatin Calcium Tablet 10 mg (Atorvastatin Calcium), give 1 tablet by mouth one time a day for cholesterol related to hyperlipidemia; Lisinopril Oral Tablet 5 mg, give 1 tablet by mouth one time a day for heart related to hypertension; Isosorbide Mononitrate ER Tablet Extended Release 24 hour 30 mg, give 1 tablet by mouth one time a day for hypertension related to essential hypertension; Acyclovir Oral Tablet (Acyclovir), give 400 mg by mouth one time a day for prevention of herpes zoster secondary to above diagnosis related to multiple myeloma; Dutasteride Oral Capsule 0.5 mg, give 1 capsule by mouth one time a day related to urinary retention; Flomax Capsule 0.4 mg, give 1 capsule by mouth one time a day related urinary retention; Lyrica Oral Capsule 75 mg, give 1 capsule by mouth three times a day for neuropathy related to neuropathy; Cholecalciferol Tablet 1000 unit, give 1 tablet by mouth one time a day for Vitamin D3 deficiency; Artificial Tears Ophthalmic Solution 1-0.3% (Propylene Glycol-Glycerin), instill 1 drop in both eyes every 12 hours as needed for dry eyes; and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/mL (milliliter), inject 1 dose subcutaneously one time a day every Fri (Friday) for Diabetes Mellitus. Review of external pharmacy records for Resident #110 revealed prescriptions for his discharge medications were not sent from the facility to the external pharmacy until 03/20/25. The following medications were sent to the pharmacy on 03/20/25: Eliquis 5 mg (milligrams), take 1 tablet by mouth twice daily for anticoagulant; Diltiazem ER 120 mg, take 1 tablet by mouth daily at bedtime for restless legs; Ropinirole HCL 1 mg, take 1 tablet by mouth daily at bedtime for restless legs; Atorvastatin 10 mg, take 1 tablet by mouth for hyperlipidemia; Lisinopril 5 mg, take 1 tablet by mouth daily; Isosorbide Mono ER 30 mg, take 1 tablet by mouth daily for hypertension; Acyclovir 400 mg, take 1 tablet by mouth daily; Dutasteride 0.5 mg, take 1 capsule by mouth daily for retention of urine; and Tamulosin HCL 0.4 mg, take 1 capsule by mouth daily for retention of urine. Interview on 04/28/25 at 12:57 P.M., with Resident Services Coordinator (RSC) #320 verified Resident #110 was discharged on 03/12/25 and revealed he was discharged with a three-day supply of medication. Interview on 04/28/25 at 1:56 P.M., with Certified Pharmacy Technician (CPT) #315 revealed the facility did not send prescriptions for Resident #110's medications until 03/20/25. CPT #315 stated the external pharmacy received the prescriptions electronically, filled, and delivered all ordered medications on 03/20/25. Further interview with CPT #315 revealed the external pharmacy had received no prescriptions for Resident #110 from the facility prior to 03/20/25. Interview on 04/28/25 at 3:23 P.M., with RSC #320 revealed she believed she sent Resident #110's discharge prescriptions via facsimile (fax) to the external pharmacy on 03/12/25 and did not call them in via telephone as stated on the DC POC. Interview on 04/28/25 at 4:24 P.M., with RSC #320 revealed she had no confirmation of sending Resident #110's discharge prescriptions via fax to the external pharmacy on 03/12/25. Interview on 05/14/25 at 11:29 A.M., with Resident #110's son revealed the facility discussed contacting Mobile Meals during the discharge conference with Resident #110 and his son, but Resident #110 refused. Resident #110 stated that he did not want that service as prior to his admission, he had Mobile Meals, and they discovered Resident #110 with altered mental status (AMS) and called 911. Concurrent interview with Resident #110's son revealed that the delay in receiving his medication did not cause any physical or psychosocial harm from the delay in receiving his medications. Further interview with Resident #110's son revealed Resident #110 wanted to be discharged from the facility and return to the home he was residing in prior to his admission to the facility. Further interview with Resident 110's son revealed Resident #110 has always had food available in his home since his discharge from the facility. Review of the facility policy titled, Discharge Summary, dated 11/02/16, revealed when the facility anticipates discharging a resident must have a discharge summary that includes reconciliation of all pre-discharge medications, with the resident's post-discharge medications (both prescription and over the counter). b. Interview on 04/28/25 at 3:36 P.M., with the Business Office Manager (BOM) #1 verified Resident #110 was discharged from the facility on 03/12/25 and she did not notify SS that Resident #110 discharged until 03/25/25. BOM #1 stated she was unable to send notification to SS as the fax machine was broken and the Administrator was on vacation, and she does not have access to the S-fax (a fax sent through the computer not a traditional fax machine). Further interview with the BOM #1 revealed she does not believe that this 13-day timeframe is timely notification of SS of Resident #110's discharge. Interview on 05/14/25 at 10:47 A.M., with Administrator revealed the facility has three free-standing fax machines located at various points. Interview on 05/14/25 at 12:37 P.M., with the BOM #1 revealed the facility does not have a written policy regarding the timely notification of SS of a resident discharge. BOM #1 stated that prior to 04/28/25, she was directed by her regional manager that she had 30 days to notify SS of a resident discharge. BOM #1 further stated that on or after 04/28/25, she was given direction by the facilities corporate office that SS was to be notified within three days of a resident's discharge from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00164542.

Based on observation, review of the facility policy, and staff interview, the facility failed to ensure medications were administered via feeding tube per physician orders. This affected one resident (#15) out of 6 residents reviewed for medications. The census was 95. Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include sick sinus syndrome, traumatic brain injury, dysphagia, and dementia. Review of Resident #15's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving nutrition through a feeding tube. Review of Resident #15's care plans dated 02/19/25 revealed a focus for alteration in gastro-intestinal status related to Percutaneous Endoscopic Gastronomy (PEG) tube for tube feeding and nothing per mouth due to dysphagia. Interventions include administering medications per order. Further review of the care plans dated 03/16/25 revealed a focus for nutrition and hydration relating to the PEG tube. Interventions include dietician to monitor and make diet changes as needed. Review of Resident #15's physician orders dating from 02/19/25 to 03/26/25 revealed the resident was ordered to receive Clopidogrel 75 milligrams (mg) by mouth, Enalapril Maleate 20 mg by mouth, Ferrous Sulfate 7.4 milliliters (ml) by mouth, Flomax 0.4 mg capsule by mouth, hydrochlorothiazide 12.5 mg by mouth, Vitamin D3 250 micrograms (mcg), Apixaban 5 mg, Metoprolol 25 mg by mouth, and Gabapentin 8 ml by mouth. Further review of Resident #15's physician orders revealed on 03/25/25 at 3:52 P.M. the resident's diet and medication orders were advanced to medications to be crushed in applesauce or pudding, upright for meals, no cream or wheat or coffee. 1500 ml fluid restriction document total intake of eternal. Observation on 03/25/25 at 9:59 A.M. Licensed Practical Nurse (LPN) #100 was observed preparing medications for Resident #15's morning administration. LPN #100 was observed preparing the Clopidogrel, Enalapril Maleate, Flomax, hydrochlorothiazide, Vitamin D3, Apixaban, and Metoprolol tablets and crushed them and placing the crushed pills in a medication cup, no applesauce or pudding was added. LPN #100 was observed pouring the Gabapentin and Ferrous Sulfate liquids into a medication cup. During the observation LPN #100 entered the resident's room and told Resident #15 she had his medications for his PEG tube. Resident #15 stated he has been eating recently and taking fluids by mouth. LPN #100 stated she knew his tube feedings were discontinued and stated 'I am so glad you can eat and swallow again'. Resident #15 asked about his medications and LPN #100 stated she planned to administer them through his PEG tube. During the observation LPN #100 was observed preparing the tube for the administration. LPN #100 washed her hands, retrieved a large syringe with no plunger, and retrieved a container of water in the bathroom. LPN #100 assessed the tube site by looking at the insertion site. LPN #100 began the administration of the medications by pouring the crushed pills into the tube without adding any water to the medication cup. The surveyor observed the tube becoming clogged with crushed pills. LPN #100 was observed taking the syringe with the crushed medications out of the PEG tube and shaking the pills into the container of water. LPN #100 was observed pouring the container of water into the PEG tube. LPN #100 was observed pouring the fluid medications into the tube and then pouring more of the water with the medications down the tube. Interview during the observation with LPN #100 verified she did not pour water into the crushed pill medication prior to administering them to the PEG tube which caused the tube to clog. LPN #100 stated she also pour the crushed medications into the water container which she intended to flush the tube after medication administration. LPN #100 stated she did review the physician orders prior to the medication administration and thought the resident did not have any tube flushes ordered and was unsure if he had any fluid restrictions. Interview and review of medication orders on 03/26/25 at 2:00 P.M. with the Director of Nursing (DON) verified there was an order on 03/25/26 to change the route of medication administration to oral instead of PEG tube in Resident #15's records. DON stated it was facility procedure to flush water through the PEG tube prior to administering crushed medications, crushed medications were to have water added prior to being poured into the tube, and the nurse should have reviewed the orders for route administration prior to giving the medications via the PEG tube. DON stated she was discussing Resident #15's condition with the primary physician and was awaiting the physician's guidance. Interview on 03/26/25 at 4:00 P.M. the DON produced a written signed physician order dated 03/26/25 for Resident #15's medications to be changed back to PEG tube administration. Review of the facility policy titled, 'Medication Administration,' dated 03/20/18 revealed if a resident is tube-fed medications are to be crushed finely and administered as to not clog the tube. Medications are to be administered in accordance with the physician's order. Medications are to be administered without unnecessary interruptions and are to be administered at the time they are prepared. This deficiency represents non-compliance investigated under Complaint Number OH00163556.

Based on observation, record review, review of the facility policies, and staff interview, the facility failed to ensure all nursing care was provided in accordance with standards and practices. This affected three residents (#15, #16, and #18) of three residents observed for medication administration. The current census was 95. Findings include: 1. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include sick sinus syndrome, traumatic brain injury, dysphagia, and dementia. Review of Resident #15's Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving nutrition through a feeding tube. Review of Resident #15's care plans dated 02/19/25 revealed a focus for alteration in gastro-intestinal status related to Percutaneous Endoscopic Gastronomy (PEG) tube for tube feeding and nothing per mouth due to dysphagia. Interventions include administering medications per order. Further review of the care plans dated 03/16/25 revealed a focus for nutrition and hydration relating to the PEG tube. Interventions include dietician to monitor and make diet changes as needed. Review of Resident #15's physician prescribed medication orders dating from 02/19/25 to 03/26/25 revealed the resident was ordered to receive Clopidogrel 75 milligrams (mg) by mouth, Enalapril Maleate 20 mg by mouth, Ferrous Sulfate 7.4 milliliters (ml) by mouth, Flomax 0.4 mg capsule by mouth, hydrochlorothiazide 12.5 mg by mouth, Vitamin D3 250 micrograms (mcg), Apixaban 5 mg, Metoprolol 25 mg by mouth, and Gabapentin 8 ml by mouth. Further review of Resident #15's physician orders revealed on 03/25/25 at 3:52 P.M. the resident's diet and medication orders were advanced to medications to be crushed in applesauce or pudding, upright for meals, no cream or wheat or coffee. 1500 ml fluid restriction document total intake of eternal. Observation on 03/25/25 at 9:59 A.M. Licensed Practical Nurse (LPN) #100 was observed preparing medications for Resident #15's morning administration. LPN #100 was observed preparing the Clopidogrel, Enalapril Maleate, Flomax, hydrochlorothiazide, Vitamin D3, Apixaban, and Metoprolol tablets and crushed them and placing the crushed pills in a medication cup, no applesauce or pudding was added. LPN #100 was observed pouring the Gabapentin and Ferrous Sulfate liquids into a medication cup. During the observation LPN #100 entered the resident's room and told Resident #15 she had his medications for his PEG tube. Resident #15 stated he has been eating recently and taking fluids by mouth. LPN #100 stated she knew his tube feedings were discontinued and stated 'I am so glad you can eat and swallow again'. Resident #15 asked about his medications and LPN #100 stated she planned to administer them through his PEG tube. During the observation LPN #100 was observed preparing the tube for the administration. LPN #100 washed her hands, retrieved a large syringe with no plunger, and retrieved a container of water in the bathroom. LPN #100 assessed the tube site by looking at the insertion site. LPN #100 began the administration of the medications by pouring the crushed pills into the tube without adding any water to the medication cup. The surveyor observed the tube becoming clogged with crushed pills. LPN #100 was observed taking the syringe with the crushed medications out of the PEG tube and shaking the pills into the container of water. LPN #100 was observed pouring the container of water into the PEG tube. LPN #100 was observed pouring the fluid medications into the tube and then pouring more of the water with the medications down the tube. Interview during the observation with LPN #100 verified she did not pour water into the crushed pill medication prior to administering them to the PEG tube which cause the tube to clog. LPN #100 stated she also pour the crushed medications into the water container which she intended to flush the tube after medication administration. LPN #100 stated she did review the physician orders prior to the medication administration and thought the resident did not have any tube flushes ordered and was unsure if he had any fluid restrictions. Interview and review of medications orders on 03/26/25 at 2:00 P.M. with the Director of Nursing (DON) verified there was an order on 03/25/26 to change the route of medication administration to oral instead of PEG tube in Resident #15's records. DON stated it was facility procedure to flush water through the PEG tube prior to administering crushed medications, crushed medications were to have water added prior to being poured into the tube, and the nurse should have reviewed the orders for route administration prior to giving the medications via the PEG tube. DON stated she was discussing Resident #15's condition with the primary physician and was awaiting the physician's guidance. Interview on 03/26/25 at 4:00 P.M. the DON produced a written signed physician order dated 03/26/25 for Resident #15's medications to be changed back to PEG tube administration. 2. Record review for Resident #16 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #16 include atrial fibrillation, heart failure, depression and anxiety. Review of the comprehensive MDS assessment for Resident #16 revealed the resident had intact cognition. Review of Resident #16's physician prescribed medications dated from 02/16/25 to 03/26/25 revealed the resident was to receive Amiodarone 200 mg, Biotin 1 mg, Cholecalciferol 2000 units, Metoprolol 60 mg, Miralax 17 grams, multi-vitamin tablet, Omeprazole 20 mg, Sertraline 100 mg, Wellbutrin 300 mg, Zinc 50 mg, Colace 100 mg, Eliquis 5 mg, and Gabapentin 300 mg. Observation on 03/26/25 from 9:15 A.M. to 9:30 A.M. LPN #100 was observed at the medication cart preparing Resident #15, Resident #16, and Resident #18's medications at the same time. LPN #100 verified multiple times she prepares more than one resident's medications during her medication pass. LPN #100 was observed reviewing the medication orders for Resident #16 and stated she would administer each resident's medications separately. LPN #100 was observed preparing the Amiodarone, Biotin, Cholecalciferol, Metoprolol, MiraLAX, Multi-Vitamin, Omeprazole, Sertraline, Wellbutrin, Zinc, Colace, Eliquis, and Gabapentin medications for Resident #16. During the same observation, LPN #100 was observed taking two medication cups, one with pills and one with liquids and placing them into the top drawer of the medication cart. LPN #100 stated those medications were for Resident #15 and she would have to prepare them for his tube so she couldn't bring those medications cups into the room. LPN #100 was observed taking three medication cups with pills and one eight ounce cup with MiraLAX 17 grams added to water, one eight ounce cup of water with glycol powder added, one insulin flex-pen and an alcohol swab with a pair of gloves into Resident #16's room. LPN #100 stated she had Resident #18's medications in her left hand and Resident #16's medications in her right hand so she did not confuse them. LPN #100 verified with the surveyor this is her usual procedure for medication administration. LPN #100 was observed giving Resident #16 her medications with the medications for Resident #18 on her left hand. Interview on 03/26/25 at 10:00 A.M. with LPN #100 verified she had taken another resident's medications into Resident #16's rooms during her medication. LPN #100 stated her usual duties were on nightshift and she passes medications as a charge nurse to all residents in the facility during her shifts. 3. Record review for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include diabetes type two, chronic obstructive pulmonary disease, and obesity. Review of Resident #18's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition and was receiving insulin injections. Review of Resident #18's care plans dated 09/21/23 revealed a focus for diabetes mellitus. Interventions include checking blood glucose per physician order and to administer medications per order. Review of Resident #18's physician ordered medications dating from 09/30/23 to 03/25/25 revealed the resident was ordered to receive Amiodarone 200 mg, Bumetanide 2 mg, Cholecalciferol 1000 units, Ferrous Sulfate 325 mg, folic acid 1 mg, Januvia 100 mg, Jardiance 10 mg, Lisinopril 5 mg, oyster shell vitamin D 1 tab, glycol powder 17 grams, Trintellix 10 mg, Docusate 100 mg, Eliquis 5 mg, magnesium oxide 400 mg, Insulin Aspart Flex-Pen insulin on a sliding scale, and Metoprolol 100 mg. Review of Resident #18's Medication Administration Record (MAR) dated 03/2025 revealed LPN #100 documented the resident's blood glucose was 216 for the Insulin Aspart medication on 03/26/25 morning dose. Observation on 03/26/25 from 9:15 A.M. to 9:30 A.M. of LPN #100 revealed the nurse was observed preparing Resident #18's medications in a medication cup. The nurse prepared the Amiodarone, Bumetanide, Cholecalciferol, Ferrous sulfate, folic acid, Januvia, Jardiance, Lisinopril, oyster shell, Trintellix, Docusate, Eliquis, magnesium oxide, and Metoprolol pills into the cup and pouring the glycol powder into the 8-ounce water cup. LPN #100 stated Resident #18 had continuous blood glucose monitor and the resident will monitor the current blood glucose, and the nurse will know how much insulin to give her per the scale. Further observations revealed after LPN #100 entered Resident #16's room and administered the resident's medications she held Resident #18's medications in her left hand. LPN #100 was observed entering Resident #18's room and giving her the eight ounce cup and the medication cup with pills. LPN #100 asked the resident what her blood glucose was, and the resident took her phone and showed her blood glucose reading was 228. LPN #100 was observed washing her hands in the bathroom, applying gloves, swabbing the resident upper right bicep area, taking the insulin Flex-pen and drawing up 2 units, pushing the plunger, and then drawing up 4 units. LPN #100 stated the resident's sliding scale required 4 units for a blood glucose of 228. LPN #100 was observed placing the Flex-pen on Resident #18's upper bicep and pushing the plunger quickly and removing the pen from the resident. The surveyor asked if the nurse had held the pen and stated the injection went quickly. LPN #100 stated that's how she always gives injections, 'I'm very fast'. Interview on 03/26/25 at 2:00 P.M. with the DON and Regional Director of Nursing (RDON) revealed it was the facility's practice to only prepare one resident's medications at a time, to not enter a room with another resident's medications, and to hold the Flex-pen injections for insulin for a full 10 seconds per manufacturer's guidelines. DON verified LPN #100's medication administrations observed were not facility practice. Interview on 03/26/25 at 4:00 P.M. the DON verified LPN #100 documented in Resident #18's MAR dated 03/26/25 for the morning dose of the Insulin Aspart the resident's blood glucose as being 216, not 228 per the observation. The DON verified LPN #100 was a charge nurse for nightshift and the nurse administers medications to all of the residents in the facility. Review of the facility's policy titled, 'Insulin Pen Administration,' dated 08/31/16 revealed after the dose of the insulin is dialed into the pen the nurse shall leave the needle in the skin and hold for a count of at least 10 seconds. Review of the facility policy titled, 'Medication Administration,' dated 03/20/18 revealed if a resident is tube-fed medications are to be crushed finely and administered as to not clog the tube. Medications are to be administered in accordance with the physician's order. Medications are to be administered without unnecessary interruptions and are to be administered at the time they are prepared. This deficiency represents non-compliance investigated under Complaint Number OH00163556.

Based on observation, review of the facility policies, staff interview, and review of medical records, the facility failed to ensure a medication error rate lower than 5%. The error rate on 03/26/24 was 19%, this affected three residents (#15, #17, and #18) of three residents observed for medication administration. The current census is 95. Findings include: Observation on 03/26/25 from 9:15 A.M. to 10:01 A.M. of Licensed Practical Nurse (LPN) #100 administering medications to the residents on the B-hall revealed there to be 11 medication errors noted during 3 medication administrations for Resident #15, Resident #17, and Resident #18. LPN #100 was observed administering 57 medications to four residents during the observation. 1. Review of Resident #15's care plans dated 02/19/25 revealed a focus for alteration in gastro-intestinal status related to Percutaneous Endoscopic Gastronomy tube, (PEG) for tube feeding and nothing per mouth due to dysphagia. Interventions include administering medications per order. Further review of the care plans dated 03/16/25 revealed a focus for nutrition and hydration relating to the PEG tube. Interventions include dietician to monitor and make diet changes as needed. Further review of Resident #15's physician orders revealed on 03/25/25 at 3:52 P.M. the resident's diet and medication orders were advanced to medications to be crushed in applesauce or pudding, upright for meals, no cream or wheat or coffee. 1500 ml fluid restriction document total intake of eternal. Review of Resident #15's physician prescribed medication orders dating from 02/19/25 to 03/26/25 revealed the resident was ordered to receive Clopidogrel 75 milligrams (mg) by mouth, Enalapril Maleate 20 mg by mouth, Ferrous Sulfate 7.4 milliliters (ml) by mouth, Flomax 0.4 mg capsule by mouth, hydrochlorothiazide 12.5 mg by mouth, Vitamin D3 250 micrograms (mcg), Apixaban 5 mg, Metoprolol 25 mg by mouth, and Gabapentin 8 ml by mouth. Observation on 03/25/25 at 9:59 A.M. Licensed Practical Nurse (LPN) #100 was observed preparing medications for Resident #15's morning administration. LPN #100 was observed preparing the Clopidogrel, Enalapril Maleate, Flomax, hydrochlorothiazide, Vitamin D3, Apixaban, and Metoprolol tablets and crushed them and placing the crushed pills in a medication cup. LPN #100 was observed pouring the Gabapentin and Ferrous Sulfate liquids into a medication cup. During the observation LPN #100 entered the resident's room and told Resident #15 she had his medications for his PEG tube. Resident #15 stated he has been eating recently and taking fluids by mouth. LPN #100 stated she knew his tube feedings were discontinued and stated 'I am so glad you can eat and swallow again'. Resident #15 asked about his medications and LPN #100 stated she planned to administer them through his PEG tube. During the observation LPN #100 was observed preparing the tube for the administration. LPN #100 washed her hands, retrieved a large syringe with no plunger, retrieved a container of water in the bathroom. LPN #100 assessed the tube site by looking at the insertion site. LPN #100 began the administration of the medications by pouring the crushed pills into the tube without adding any water to the medication cup. The surveyor observed the tube becoming clogged with crushed pills. LPN #100 was observed taking the syringe with the crushed medications out of the PEG tube and shaking the pills into the container of water. LPN #100 was observed pouring the container of water into the PEG tube. LPN #100 was observed pouring the fluid medications into the tube and then pouring more of the water with the medications down the tube. Interview during the observation with LPN #100 verified she did not pour water into the crushed pill medication prior to administering them to the PEG tube which cause the tube to clog. LPN #100 stated she also pour the crushed medications into the water container which she intended to flush the tube after medication administration. LPN #100 stated she did review the physician orders prior to the medication administration and thought the resident did not have any tube flushes ordered and was unsure if he had any fluid restrictions. Interview and review of medications orders on 03/26/25 at 2:00 P.M. with the Director of Nursing (DON) verified there was an order on 03/25/26 to change the route of medication administration to oral instead of PEG tube in Resident #15's records. DON stated it was facility procedure to flush water through the PEG tube prior to administering crushed medications, crushed medications were to have water added prior to being poured into the tube, and the nurse should have reviewed the orders for route administration prior to giving the medications via the PEG tube. DON stated she was discussing Resident #15's condition with the primary physician and was awaiting the physician's guidance. Interview on 03/26/25 at 4:00 P.M. the DON produced a written signed physician order dated 03/26/25 for Resident #15's medications to be changed back to PEG tube administration. 2. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #17 include chronic obstructive pulmonary disease, heart disease, and atrial fibrillation. Review of Resident #17's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition and received supplemental oxygen. Review of Resident #17's care plans dated 06/07/24 revealed a focus for oxygen therapy. Interventions include give medications per order and observe for side effects and effectiveness. Review of Resident #17's physician ordered medications dating from 06/2024 to 03/25/25 revealed the resident was ordered to receive Ipratropium-Albuterol inhalation solution 0.6-2.5 mg in 3 ml of solution, inhale every six hours for chronic obstructive pulmonary disease. Review of Resident #17's Medication Administration Record (MAR) dated 03/2025 revealed LPN #100 had documented the resident received the Ipratropium-Albuterol inhalation treatment. Observation on 03/26/25 at 9:50 A.M. LPN #100 was observed pouring the Ipratropium-Albuterol solution into Resident #17's nebulizer and placing the breathing mask back into the nebulizer holder. LPN #100 did not turn on the machine. LPN #100 did not as Resident #17 if she wanted to wait for her nebulizer treatment. LPN #100 administered the resident's pills and left the room. LPN #100 verified she did not observe Resident #17 start her nebulizer inhalation treatment. Interview on 03/26/25 at 2:00 P.M. with the DON revealed it was facility practice to observe the start of each nebulizer treatment prior to leaving the resident's room. DON verified LPN #100 had documented the resident received the treatment in the record. 3. Review of Resident #18's care plans dated 09/21/23 revealed a focus for diabetes mellitus. Interventions include checking blood glucose per physician order and to administer medications per order. Review of Resident #18's physician ordered medications dating from 09/30/23 to 03/25/25 revealed the resident was ordered to receive Amiodarone 200 mg, Bumetanide 2 mg, Cholecalciferol 1000 units, Ferrous Sulfate 325 mg, folic acid 1 mg, Januvia 100 mg, Jardiance 10 mg, Lisinopril 5 mg, oyster shell vitamin D 1 tab, glycol powder 17 grams, Trintellix 10 mg, Docusate 100 mg, Eliquis 5 mg, magnesium oxide 400 mg, Insulin Aspart Flex-Pen insulin on a sliding scale, and Metoprolol 100 mg. Review of Resident #18's Medication Administration Record (MAR) dated 03/2025 revealed LPN #100 documented the resident's blood glucose was 216 for the Insulin Aspart medication on 03/26/25 morning dose. Observation on 03/26/25 from 9:15 A.M. to 9:30 A.M. of LPN #100 the nurse was observed preparing Resident #18's medications in a medication cup. The nurse prepared the Amiodarone, Bumetanide, Cholecalciferol, Ferrous sulfate, folic acid, Januvia, Jardiance, Lisinopril, oyster shell, Trintellix, Docusate, Eliquis, magnesium oxide, and Metoprolol pills into the cup and pouring the glycol powder into the 8-ounce water cup. LPN #100 stated Resident #18 had continuous blood glucose monitor and the resident will monitor the current blood glucose, and the nurse will know how much insulin to give her per the scale. Further observations revealed after LPN #100 entered Resident #16's room and administered the resident's medications she held Resident #18's medications in her left hand. LPN #100 was observed entering Resident #18's room and giving her the 8-ounce cup and the medication cup with pills. LPN #100 asked the resident what her blood glucose was, and the resident took her phone and showed her blood glucose reading was 228. LPN #100 was observed washing her hands in the bathroom, applying gloves, swabbing the resident upper right bicep area, taking the insulin Flex-pen and drawing up 2 units, pushing the plunger, and then drawing up 4 units. LPN #100 stated the resident's sliding scale required 4 units for a blood glucose of 228. LPN #100 was observed placing the Flex-pen on Resident #18's upper bicep and pushing the plunger quickly and removing the pen from the resident. The surveyor asked if the nurse had held the pen and stated the injection went quickly. LPN #100 stated that's how she always gives injections, 'I'm very fast'. Interview on 03/26/25 at 2:00 P.M. with the DON and Regional Director of Nursing, (RDON) revealed it was the facility's practice to only prepare one resident's medications at a time, to not enter a room with another resident's medications, and to hold the Flex-pen injections for insulin for a full 10 seconds per manufacturer's guidelines. DON verified LPN #100's medication administrations observed were not facility practice. Interview on 03/26/25 at 4:00 P.M. the DON verified LPN #100 documented in Resident #18's MAR dated 03/26/25 for the morning dose of the Insulin Aspart the resident's blood glucose as being 216, not 228 per the observation. The DON verified LPN #100 was a charge nurse for nightshift and the nurse administers medications to all of the residents in the facility. Review of the facility's policy titled, 'Insulin Pen Administration,' dated 08/31/16 revealed after the dose of the insulin is dialed into the pen the nurse shall leave the needle in the skin and hold for a count of at least 10 seconds. Review of the facility policy titled, 'Medication Administration,' dated 03/20/18 revealed if a resident is tube-fed medications are to be crushed finely and administered as to not clog the tube. Medications are to be administered in accordance with the physician's order. Medications are to be administered without unnecessary interruptions and are to be administered at the time they are prepared. This deficiency represents non-compliance investigated under Complaint Number OH00163556.

Based on observation, record review, review of the facility policies, and staff interview, the facility staff failed to properly administer insulin medications per the manufacturer's guidelines. This affected one resident (#18) out of five residents observed receiving medications. The current census was 95. Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include diabetes type two, chronic obstructive pulmonary disease, and obesity. Review of Resident #18's comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition and was receiving insulin injections. Review of Resident #18's care plans dated 09/21/23 revealed a focus for diabetes mellitus. Interventions include checking blood glucose per physician order and to administer medications per order. Review of Resident #18's physician ordered medications dating from 09/30/23 to 03/25/25 revealed the resident was ordered to receive Amiodarone 200 mg, Bumetanide 2 mg, Cholecalciferol 1000 units, Ferrous Sulfate 325 mg, folic acid 1 mg, Januvia 100 mg, Jardiance 10 mg, Lisinopril 5 mg, oyster shell vitamin D 1 tab, glycol powder 17 grams, Trintellix 10 mg, Docusate 100 mg, Eliquis 5 mg, magnesium oxide 400 mg, Insulin Aspart Flex-Pen insulin on a sliding scale, and Metoprolol 100 mg. Review of Resident #18's Medication Administration Record (MAR) dated 03/2025 revealed LPN #100 documented the resident's blood glucose was 216 for the Insulin Aspart medication on 03/26/25 morning dose. Observation on 03/26/25 from 9:15 A.M. to 9:30 A.M. of LPN #100 the nurse was observed preparing Resident #18's medications in a medication cup. The nurse prepared the Amiodarone, Bumetanide, Cholecalciferol, Ferrous sulfate, folic acid, Januvia, Jardiance, Lisinopril, oyster shell, Trintellix, Docusate, Eliquis, magnesium oxide, and Metoprolol pills into the cup and pouring the glycol powder into the 8-ounce water cup. LPN #100 stated Resident #18 had continuous blood glucose monitor and the resident will monitor the current blood glucose, and the nurse will know how much insulin to give her per the scale. Further observations revealed LPN #100 was observed entering Resident #18's room and giving her the 8-ounce cup and the medication cup with pills. LPN #100 asked the resident what her blood glucose was, and the resident took her phone and showed her blood glucose reading was 228. LPN #100 was observed washing her hands in the bathroom, applying gloves, swabbing with alcohol the resident upper right bicep area, taking the insulin Flex-pen and drawing up 2 units, pushing the plunger, and then drawing up 4 units. LPN #100 stated the resident's sliding scale required 4 units for a blood glucose of 228. LPN #100 was observed placing the Flex-pen on Resident #18's upper bicep and pushing the plunger quickly and immediately removing the pen from the resident. The surveyor asked if the nurse had held the pen long enough and stated the injection went quickly. LPN #100 stated that's how she always gives injections, 'I'm very fast'. Interview on 03/26/25 at 2:00 P.M. with the Director of Nursing, (DON), and Regional Director of Nursing, (RDON) revealed it was the facility's practice to hold the Flex-pen injections for insulin for a full 10 seconds per manufacturer's guidelines. DON verified LPN #100's medication administrations observed were not facility practice. Interview on 03/26/25 at 4:00 P.M. the DON verified LPN #100 documented in Resident #18's MAR dated 03/26/25 for the morning dose of the Insulin Aspart the resident's blood glucose as being 216, not 228 per the observation. The DON verified LPN #100 was a charge nurse for nightshift and the nurse administers medications to all of the residents in the facility. Review of the facility's policy titled, 'Insulin Pen Administration', dated 08/31/16 revealed after the dose of the insulin is dialed into the pen the nurse shall leave the needle in the skin and hold for a count of at least 10 seconds. This deficiency represents non-compliance investigated under Complaint Number OH00163556

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 hospital records, review of a medication incident report, staff interview, review of a skills competency checklist, and review of facility policy, the facility failed to ensure a resident (#01) was free from a significant medication error. This resulted in Actual Harm for Resident #01 when staff administered more than twice the dose of the blood thinning medication [MEDICATION(S)], which resulted in elevated International Normalized Ratio (INR) levels (used to measure therapeutic blood ranges for individuals on blood thinners) requiring the resident to be hospitalized for stabilization. This affected one resident (#01) of three residents reviewed for [MEDICATION(S)] usage. The facility census was 85. Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set 3.0 assessment, dated 03/01/22, revealed the resident had no cognitive deficits. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the laboratory (lab) results for an international normalized ratio (INR) level (used to measure therapeutic blood ranges for individuals on blood thinners), dated 03/02/22 at 3:18 P.M., revealed the level to be elevated at 13.1 (normal upper end therapeutic level for the use of blood thinning medications was listed by the lab of 2.5-3.5). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the lab results for the INR level dated 03/03/22 at 9:32 A.M. revealed the INR remained elevated at 4.7. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of lab results for the INR level dated 03/04/22 at 6:35 A.M. revealed the INR was 2.4, which was a moderate level. The physician was notified. The lab report had written on it [MEDICATION(S)] on hold. Was on five mg. A new order was provided to administer [MEDICATION(S)] 4 mg daily and recheck the INR level on 03/07/22. Review of the March 2022 Medication Administration Record (MAR) revealed Resident #01 received both [MEDICATION(S)] 5 mg and [MEDICATION(S)] 4 mg, for a total of 9 mg, on 03/05/22 and 03/06/22. Review of lab results for the INR level dated 03/07/22 at 9:50 A.M. revealed the level was again elevated at 5.5. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order was written to hold [MEDICATION(S)] and recheck the level again on Wednesday, 03/09/22. Review of lab results for the INR level dated 03/07/22 at 7:32 P.M. revealed the INR level was elevated at 5.6. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 MAR revealed the resident was provided Vitamin K, 5 mg by mouth on 03/07/22 due to an elevated INR on 03/07/22. Review of lab results dated 03/08/22 at 10:08 A.M. revealed the resident's INR had increased to 8.3, which was critical. The physician ordered Resident #01 be sent to the emergency room . Review of progress notes dated 03/08/22 at 3:27 P.M. revealed Resident #01 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of hospital notes, dated 03/10/22, revealed Resident received fresh frozen plasma and medications with the INR level returning to 2.1. Interview on 03/30/22 at 10:20 A.M., the Director of Nursing (DON) verified Resident #01 received a total of 9 mg of [MEDICATION(S)] on 03/05/22 and 03/06/22 instead of the physician ordered 4 mg. She stated the original order for the [MEDICATION(S)] to be held on 03/03/22 and 03/04/22 should have been to discontinue the [MEDICATION(S)], and then a new order should have been written to re-start it at the desired dose. Review of a medication incident report for Resident #01 revealed an error occurred on 03/05/22 and 03/06/22 with a bedtime, extra dose of [MEDICATION(S)]. The report documented the resident had an order to administer [MEDICATION(S)] 4 mg by mouth on 03/05/22, 03/06/22 and 03/77/22 and was given 9 mg by mouth each of those nights. The medication error was discovered by Licensed Practical Nurse (LPN) #22 on 03/07/22 at 2:30 P.M. The cause of the error was documented as the original 5 mg dose of [MEDICATION(S)] was put on hold instead of being discontinued. The actual effect of the incident, when first observed, was slightly elevated lab work. The physician was notified on 03/07/22 at 2:30 P.M. by LPN #22. Both orders for [MEDICATION(S)] were discontinued. Interview with LPN #22 on 03/30/22 at 10:00 A.M. revealed she worked on 03/04/22 and got the order to restart the [MEDICATION(S)] after it had been held for two days. A blood level was ordered for 03/07/22. LPN #22 stated she did not work again from 03/04/22 until 03/07/22. She noticed Resident #01's INR was elevated, so she looked at the MAR and saw that over the weekend the resident received [MEDICATION(S)] 9 mg instead of 4 mg. LPN #22 further stated the physician was notified, labs were ordered, and the resident received two doses of Vitamin K to help clot the blood. The INR levels remained elevated and the resident was sent to the hospital. Interview on 03/30/22 at 10:30 A.M., with Administrator in Training (AIT) #10 and Corporate Nurse #45 verified the facility identified the medication error on 03/07/22 and put an action plan into place. The [MEDICATION(S)] dose had not been discontinued and resulted in the elevation of INR levels. The records for each resident who received [MEDICATION(S)] was reviewed and doses were verified. [MEDICATION(S)] doses were started to be monitored throughout the house with weekly lab draws. All 35 nurses were provided inservicing on the need to discontinue [MEDICATION(S)] orders and not hold them. The process was reviewed through the Quality Assurance committee and monitoring audits had been completed. Review of facility policy titled Medication Errors Policy, dated 04/29/16, revealed the facility would ensure residents were free of any significant medication errors. A medication error was defined as the observed preparation or administration of drugs or biologicals which was not in accordance with physician orders, manufacturer's specification regarding the preparation and administration of the drug, and accepted professional standards and principles which apply to professionals providing services. A significant medication error was defined as one which caused the resident discomfort or jeopardized the resident's health or safety. Determining of significance was a matter of professional judgement and could be due to the resident condition, drug category (if a drug from a category that usually required the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity), frequency of errors ( if the error occurred with any frequency, there is more reason to classify the errors as significant). Review of a Skills Competency Checklist-Medication Administration dated 04/2013, revealed nurses were to check the medication dosage, read the label, read the Medication Administration Record and re-read the label. Medications were to be given in the correct dosage form, correct route and the correct time. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 03/21/22. · On 03/08/22, Resident #01 was sent to the emergency room for evaluation and treatment. Resident #01 was admitted to the hospital and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] · On 03/07/22 the facilty developed a Best Practice for [MEDICATION(S)] Order to specify that [MEDICATION(S)] orders were not to be placed on hold, but were to be discontinued upon the receipt of new [MEDICATION(S)] orders. · On 03/07/22 , the DON sent an inservice text to all nurses regarding the revised [MEDICATION(S)] orders. The training was completed on 03/07/22. · On 03/07/22, the DON began weekly ongoing monitoring to ensure compliance with policy revision for [MEDICATION(S)] levels and dosages. As of 03/21/22 there had been no further incidents or concerns identified. · On 03/30/22 , the medical record for two (#02, #05) residents who received [MEDICATION(S)] revealed no concerns were identified. This deficiency substantiates Complaint Number OH 120.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility investigation, review of staff statements, review of facility policies, staff and resident interviews, the facility failed to ensure a resident was provided adequate assistance during a transfer. This resulted in actual harm for Resident #01, who was inappropriately transferred with only one staff member utilizing a standing lift and subsequently slid from the mechanical lift and suffered a fracture to the right humerus of the arm. This affected one (#01) of three residents reviewed for the use of a mechanical lift. The facility identified 27 residents who required the use of a stand-up or Hoyer lift. The facility census was 105. Findings include: Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a comprehensive annual Minimum Data Set (MDS) annual dated 04/20/19 revealed the resident had no cognitive deficits, fluctuating periods of inattention and delusions. The resident required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Two staff were needed for transfers. Functional limitations were present on one side of the upper extremities and both lower extremities. The resident was frequently incontinent of bowel and bladder and the resident had no falls or pressure areas. There had been no therapies or restorative programs. Review of a Kardex for Resident #01 revealed the resident was to have a mechanical lift used for transfers. Review of a written statement by State tested Nurse Aide (STNA) #55 dated 05/23/19 revealed she was attempting to get Resident #01 up with a stand-up lift and she slid off the side of the bed and was assisted to the floor. She stated STNA #60 assisted her in getting the resident back into bed. It further revealed she was provided immediate counseling by Registered Nurse (RN) #50 that two staff were required when operating any kind of lift with a resident. Review of a progress note dated 05/23/19 at 6:00 P.M., RN #50 completed a post fall assessment with no apparent injuries at this time. Review of a change in condition entry dated 05/23/19 at 8:30 P.M., revealed the Resident #01 was complaining of right shoulder pain during care when her arm was moved, and the resident was medicated at 7:30 P.M. for pain. Background information documented in the note, the resident had slipped out of a stand-up lift during a transfer to the toilet and had to be lowered to the floor. The assessment revealed at 8:30 P.M., the resident had visible swelling in her right lower arm as well as increased pain. The physician was notified, and the resident was sent to the hospital for x-rays and the family was notified. Review of progress note dated 05/24/19 at 12:27 P.M., documented the resident has a small [MEDICAL CONDITION] humerus. The resident's arm is in a sling and on her way back to the facility. Review of a fall investigation audit dated 05/28/19 for a fall on 05/23/19 revealed RN #50 was questioned and stated she was informed Resident #01 had slipped out of the stand lift and was lowered to the floor. RN #50 stated she went to check on the resident and she stated she had fallen and had right shoulder pain. RN #50 medicated the resident with ordered pain medication, but the resident did not have relief from the pain. The resident's right upper extremity was swollen, and RN #50 called the physician. The resident was sent to the hospital, had x-rays completed and returned to the facility with a fractured right humerus and her arm was in a sling. The investigation documented on 05/28/19 at 2:00 P.M., STNA #55 came in to demonstrate how the resident was placed in to standup lift. STNA #55 stated Resident #01 was cooperative at the time of transfer. When the resident was stood up in stand-up lift, the resident began slipping and yelling. The resident grabbed her right arm. The STNA came behind her and attempted to position her. Then resident went to sit and the STNA went to left side and lowered the resident to the floor. The resident has deficit to right side and went down to floor. Leaning to the right-side landing on her buttocks and arm on the foot of the stand-up lift. Review of a phone interview with STNA #60 dated 05/28/19, revealed when she arrived the resident was sitting on the floor with her back to the footboard, crying and moaning. She stated the sling from the lift was still connected to the lift. She stated she assisted the resident up off the floor. She verified a gait belt was not used and the nurse was notified of the fall until after the resident was placed back in bed. The investigation revealed education was provided over the phone regarding the use of gait belts and of notifying the nurse immediately of any fall. The facility's investigation further revealed the Assistant Director of Nursing (DON) #65 spoke with STNA #55 on 05/25/19 regarding the fall. STNA #55 told her there were two of them in the room at the beginning but STNA #60 had to leave and the resident needed to go to the bathroom. She verified she continued to work with the resident on her own and started raising the mechanical lift. The resident started sliding out of the sling, she took her left hand and grabbed Resident #01's arm and the resident slid down the side of the bed onto her butt. STNA #55 further stated she laid Resident #01 down on her right side and went to get STNA #60 for assistance. The two aides picked up the resident and placed her back in bed. STNA #55 stated the nurse assessed the resident after the resident was put back into bed. Interview with STNA #55 on 06/10/19 at 3:20 P.M., verified she attempted to transfer Resident #01 using the mechanical standing lift by herself. She verified she was aware there was supposed to be two staff for all transfers using a mechanical lift. She further stated she did not notify the nurse prior to assisting the resident back into bed. Interview with STNA #60 on 06/10/19 at 3:37 P.M., revealed she had been in the room with STNA #55 helping Resident #01 to sit up. She stated STNA #55 told her she could get it from there and she left. She stated she should not have left because she knew there had to be two staff to use the standing lift. She further stated she knew STNA #55 had not informed the nurse yet, when she helped STNA #60 get Resident #1 back to bed without the nurse checking her first like they should have. Interview with Resident #01 on 06/10/19 at 10:15 A.M., verified she had fallen while she was being transferred with a standing lift. She verified there was only one STNA that was helping her and was unable to catch her when she started sliding. The resident stated her arm got caught in the sling which made her start sliding. Interview with the DON on 06/10/19 at 8:20 A.M., verified Resident #01 did have a fall with a fracture of her right arm that she sustained when one STNA (#55) attempted to transfer the resident by herself using a mechanical lift. She stated all staff are instructed on hire and at least annually that two staff are needed when utilizing mechanical lifts. The DON stated all staff were educated after the fall, audits had been conducted for compliance and all residents who used the lifts had been re-evaluated. Review of facility policy Accidents and Incidents Policy dated 2005 revealed one an accident had occurred it must be reported as soon as possible to the appropriate supervisor. A licensed nurse was to examine all victim for any physical injury. Review of an undated Skills Competency Checklist- Mechanical Lifts revealed two staff were required at all times with the use of a mechanical lift. As a result of the incident, the facility took the following actions to correct the deficient practice by 05/28/19: · On 05/23/19, Resident #1 was assessed by a nurse and sent out for treatment at hospital. · On 05/23/19, Registered Nurse (RN) #50 provided immediate verbal counseling to STNA #55, that two staff were required when operating any kind of lift with a resident. · Review of a lift audit dated 05/24/19 performed by the DON revealed there were 27 residents who used mechanical lifts. They were assessed by the DON and found to be using the appropriate lifting device. · Review of in-service education records dated 05/24/19 revealed all nurses and STNA's were educated on the use of mechanical lifts and fall interventions. This always included the use of two staff with a mechanical lift and all nursing staff had to complete a mechanical lift check-off before they worked again. It also included the need to have the nurse check the resident after a fall before the STNA's moved the resident · Review of lift competencies dated 05/24/19 through 05/28/19 revealed all nurses and STNA's had provided a correctly performed return demonstration of using the mechanical lift. · Observation on 06/10/19 between 8:55 A.M. and 9:30 A.M., revealed two staff members were observed utilizing the mechanical lifts for Resident #2, #3 and #4. No safety issues were observed. · Interviews on 06/10/19 between 7:45 A.M. and 5:00 P.M., with STNAs #55, #60, #30, #100, #105, #110, #125, #145, Licensed Practical Nurse (LPN) #120 and #140, and RN #13, revealed the staff all verbalized being trained on the use of the mechanical lifts upon hire and again recently, as well as notifying the nurse immediately upon any incident with a resident. This deficiency substantiates Master Complaint OH 685 and Complaint Number OH 623.