Every finding on record at Meadows of Kalida

2. Observation on 05/21/25 at 12:49 P.M. of the 200-hall main medication room refrigerator, with the Director of Nursing (DON), revealed a plastic container which held eight vials of insulin. There were two vials of Novolog N 100 units per 10 milliliters (U/ml) with expiration dates of 12/31/24 and 01/31/25, a vial of Novolog R 100 U/10 ml with an expiration date of 03/31/25, two vials of Novolog 70/30 with an expiration date of 01/31/25 and one vial of Novolin R 100 U/10 ml with an expiration date of 03/31/25. Interview on 05/21/25 at 1:05 P.M. with the DON revealed the vials of insulin in the mail medication room refrigerator were used by all three halls of the facility for emergency situations, such as residents out of insulin or with new admissions. The DON verified the eight vials of insulin in the main medication room refrigerator were expired. Review of the facility policy titled, Medication Storage in the Facility, dated November 2018, revealed medications were stored safely, securely and properly, following manufactures recommendations or those of the supplier. Further review revealed outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled or without secure closures were immediately removed from inventory. All expired medications would be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Based on observation, staff interview, medical record review and review of the facility policy, the facility failed to ensure medications were not left unattended at a resident's bedside. This affected one (#111) of five residents reviewed for medication administration. In addition, the facility failed to ensure medications were removed from use and disposed of upon expiration. This had the potential to affect eight (#16, #22, #27, #30, #36, #39, #44 and #49) residents identified by the facility as receiving insulin. The facility census was 58. Findings include: 1. Review of the medical record reveal Resident #111 was admitted on [DATE]. Diagnoses included cellulitis of the left lower limb, hypertensive heart and chronic kidney disease, acute on chronic diastolic heart failure, chronic kidney disease stage III, rheumatoid arthritis, type two diabetes mellitus with diabetic neuropathy, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 03/13/25, revealed Resident #111 was cognitively intact and prescribed medications included anticoagulants, antibiotics, opioids, and anticonvulsants. Review of the Medication Administration Record (MAR) for May 2025 revealed on 05/18/25, during the morning medication administration, Resident #111 received the following medications: amiodarone (antiarrhythmic medication) 200 milligram (mg), bumetanide (diuretic) one mg, duloxetine (antidepressant) delayed release 60 mg, Eliquis (anticoagulant) five mg, folic acid (vitamin) one mg, gabapentin (antiseizure/nerve pain) 300 mg, glimepiride (diabetic medication) two mg, Jardiance (diabetic medication) 25 mg, levothyroxine (thyroid medication) 88 microgram (mcg), midodrine (antihypotensive) five mg, multivitamin tablet, oxybutynin chloride (urinary) tablet extended release 10 mg, pantoprazole (proton pump inhibitor) 40 mg, potassium chloride 20 milliequivalent (mEq), prednisone (corticosteroid) five mg, senna (supplement) 8.6 mg, and spironolactone (diuretic) 12.5 mg. Observation on 05/18/25 at 9:54 A.M. revealed Resident #111 was sitting in her wheelchair, just outside of the resident's room door. Upon entering the resident's room, with the resident, a half full medication cup was observed on the bedside table. Interview on 05/18/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) #283 verified leaving Resident #111's medications unattended at the bedside.

Based on medical record review, review of the Pre-admission Screening and Resident Review (PASRR - screening to determine if specialized services are needed) and staff interview, the facility failed ensure PASRR screenings were accurately completed. This affected one (#19) of three residents reviewed for PASRR screenings. The facility census was 58. Findings include: Review of the medical record for Resident #19 revealed an admission date of 03/13/25. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified hearing loss, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 03/31/25, revealed Resident #19 had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent upon staff for activities of daily living (ADLs). Review of the PASRR, completed on 03/11/25, revealed Resident #19's diagnosis of unspecified psychosis not due to a substance or known physiological condition was not documented on the screening. Interview with Social Services Director (SSD) #272 verified Resident #19's PASRR did not accurately reflect the resident's mental health diagnosis and further confirmed a diagnosis of unspecified psychosis not due to a substance or know physiological condition should have been included on the PASRR screening.

Based on review of the medical record, staff interview, and review of facility policy, the facility failed to ensure medications were received from the pharmacy in a timeframe to allow for the timely initiation of physician's orders for new medications. This affected two (Resident #15 and #205) of seven residents reviewed for medications. The facility census was 55. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with diabetic [CONDITION(S)], [CONDITION(S)] without rupture, [CONDITION(S)] stage 4, [CONDITION(S)] with behavioral disturbance, [CONDITION(S)] disorder, and hypertension. Review of the physician order, dated 11/04/22, revealed an order for the antibiotic [MEDICATION(S)]/[MEDICATION(S)] 500 milligram (mg) twice a day. Review of the progress note, dated 11/05/22 revealed [MEDICATION(S)]/[MEDICATION(S)] was not received in tote prior night and was not able to be pulled from Cubex. Pharmacy was contacted and stated it would be in that evening's tote. Facility staff voiced concerns that the medication was put into matrix care before 2:00 P.M. on 11/04/22 so it should have been in the prior night's tote. It was reported the pharmacy will drop ship today's antibiotic doses for Resident #15. Review of Medication Administration Record (MAR), dated November 2022, revealed [MEDICATION(S)] was not administered on 11/04/22 and 11/05/22. Comments included could not find medication and medication was to be dropped shipped and was not received. Interview on 11/09/22 at 11:59 P.M. with the Director of Nursing (DON) verified Resident #15 did not receive the antibiotic ordered on 11/04/22 until 11/06/22 due to not receiving the antibiotic timely from pharmacy. The DON reported a drop shipment should be received within two hours. 2. Review of the medical record revealed Resident #205 was admitted on [DATE]. Diagnoses included [CONDITION(S)], acute [CONDITION(S)] with [CONDITION(S)], acute kidney failure, type two diabetes mellitus without complications, and nicotine dependence. Review of progress note, dated 11/04/22, revealed Resident #205's daughter requested a nicotine patch be ordered due to Resident #205 being a current cigarette smoker of one to two packs per day. Review of the physician order, dated 11/04/22, revealed an order for nicotine patch 24 hour 21 mg/24 hour one patch applied transdermal once a day. Review of the Medication Administration Review (MAR), dated November 2022, revealed on 11/04/22, 11/05/22, and 11/06/22 the nicotine patch 24 hour 21 mg was not administered due to the drug/item not available. Interview on 11/08/22 at 3:48 P.M. with Licensed Practical Nurse (LPN) #412 verified working on 11/06/22. LPN #412 stated he had called the pharmacy due to Resident #205 not receiving nicotine patches as ordered. Pharmacy stated their new system was the reason for delay. LPN #412 verified the nicotine patches were ordered on 11/04/22 and the resident did not receive the patch until 11/07/22. Review of policy titled Medication Ordering and Receiving from Pharmacy, revised January 2017, revealed medications and related products are received from the dispensing pharmacy.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure weights were obtained in a consistent manner to ensure accuracy. This affected one (#11) of three residents reviewed for nutrition. The facility census was 55. Findings include: Review of Resident #11's medical record revealed an admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/13/22 revealed Resident #11 was severely cognitively impaired, required extensive assistance with activities of daily living (ADLs) and had no weight loss or weight gain. Review of a plan of care, revised 10/26/22, revealed Resident #11 experienced a significant weight gain. Interventions included obtain weight as ordered. Additional review of a plan of care, revised 08/23/22, revealed Resident #11 had a potential for complications related to congestive heart failure (CHF). Interventions included weight as ordered, medications per orders, diet per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed to weigh the resident on the spa scale for consistency. Review of weights revealed Resident #11 weighed 350.2 pounds (lbs.) on 11/01/22, 376.4 lbs. on 11/02/22, 356.8 lbs. on 11/03/22, 356 lbs. on 11/04/22, 375 lbs. on 11/05/22, 375.6 lbs. on 11/06/22, and 358 lbs. on 11/07/22. Interview on 11/08/22 at 2:21 P.M. with Regional Clinical Support (RCS) #481 verified significant variances in Resident #11's weights. RCS #481 stated the variances may have been due to staff not subtracting Resident #11's wheelchair on the dates he weighed 375 lbs. RCS #481 confirmed Resident #11's wheelchair weighed 58 lbs. and the weight of the wheelchair exceeded the differences in the Resident's weights. Follow up interview on 11/08/22 at 2:49 P.M., RCS #481 revealed Resident #11 had been weighed on different scales, which likely accounted for the weight variations. RCS #481 confirmed Resident #11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/09/22 at 9:07 A.M., Licensed Practical Nurse (LPN) #336 revealed she had assisted in obtaining some of Resident #11's weights. LPN #336 stated she was unsure why the resident's weights were so off from each other. LPN #336 stated the spa scale was not wide enough for Resident #11's wheelchair and the only thing she could think was that some staff were pushing the wheelchair onto the spa scale, with the weight not being evenly distributed, resulting in inaccurate weights. Review of facility policy titled Guidelines for Weight Tracking, reviewed 03/16/22, revealed to the extent possible, the same scale, same person, same wheelchair (if applicable) should be used to ensure consistency.

Based on medical record review, staff interview and review of facility policy, the facility failed to notify the physician of weight gain per physician order. This affected one (#11) of one residents reviewed for notification of change. The facility census was 55. Findings include: Review of Resident #11's medical record revealed an admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs) and had no weight loss or weight gain. Review of a plan of care, revised 10/26/22, revealed Resident #11 experienced a significant weight gain. Interventions included obtain weight as ordered. Additional review of a plan of care, revised 08/23/22, revealed Resident #11 had a potential for complications related to congestive heart failure (CHF). Interventions included weight as ordered, medications per orders, diet per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . in one week. Review of weights revealed Resident #11 weighed 356 lbs on 11/04/22 and 375 lbs on 11/05/22, indicating a weight gain of 19 lbs in one day. Further review of Resident #11's medical record revealed no evidence the CHF clinic was notified of Resident #11's weight gain on 11/05/22. Interview on 11/08/22 at 8:45 A.M., Licensed Practical Nurse (LPN) #372 revealed CHF was a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #372 confirmed Resident #11 was to be weighed daily and a weight increase of three pounds in a day was to be reported to the CHF clinic. Interview on 11/08/22 at 2:21 P.M., Regional Clinical Support (RCS) #481 confirmed Resident #11's medical record did not reflect CHF clinic notification of Resident #11's weight gain on 11/05/22. RCS #481 provided documentation weight increases were faxed to the clinic on 11/02/22 and 11/07/22 but no notification was made on 11/05/22. Review of facility policy titled Notification of Change in Condition, reviewed 12/01/21, revealed the resident representative and provider should be notified of change in condition in a timely manner.

Based on review of Quality Assessment and Assurance (QAA) Committee/Quality Assurance Improvement Program (QAPI) meeting sign in sheets, staff interview, and review of a facility policy, the facility failed to ensure QAA Committee/QAPI meetings occurred at least quarterly. This affected all 55 residents residing in the facility. The census was 55. Findings include: Review of QAA Committee/QAPI meeting sign in sheets between December 2021 and October 2022 revealed the facility did not hold a QAA Committee/QAPI meeting in the first quarter (January, February, and March) of 2022. The facility held meetings on 12/09/21, 04/28/22, 07/29/22, and 10/26/22. Interview on 11/09/22 at 12:49 P.M. with Executive Director #402 verified the facility had no documentation of a QAA Committee/QAPI meeting occurring during the first quarter of 2022. Review of a facility policy titled Quality Assessment and Assurance Committee/Quality Assurance and Performance Improvement (QAPI) Program, revised 11/14/19, revealed the Quality Assessment and Assurance Committee shall meet at least quarterly.

Based on medical record review, staff interview, review of the hospital record, and policy review, the facility failed to timely and adequately treat a change in condition. This resulted in Actual Harm when Resident #01's abnormal laboratory values along with vomiting and diarrhea were not adequately treated and subsequently was hospitalized for [CONDITION(S)]. This affected one resident (#01) of three residents reviewed for a change in condition. The facility census was 57. Findings included: Review of Resident #01's medical record revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #01 had intact cognition. Resident #01 was coded to have [CONDITION(S)] and malnutrition. Review of the most recent care plan revealed Resident #01 was at risk for dehydration and fluid imbalance. Review of the nurses notes dated 08/09/2022 at 12:59 P.M. revealed Resident #01 complained of having a slight headache. Pain medication was administered and was successful. Review of the nurses note dated 08/11/2022 at 7:10 A.M. revealed Resident #01's cognition was slower but overall, well. The note at 8:51 A.M. revealed the resident returned from therapy due to dry heaving, had a flushed face, and was diaphoretic. Vital signs were obtained and were stable but Resident #01 reported not feeling well. The note at 9:16 A.M. revealed Resident #01's daughter was in to visit and was updated on the events of the last 24 hours. The physician/Certified Nurse Practitioner (CNP) were notified and due to the resident having a history of a brain bleed and taking a blood thinner the daughter and the nurse felt it was best to send the resident to the hospital for an evaluation. Resident #01 continued to have nausea. Review of the nurses note dated 08/11/22 revealed Resident #01 returned to the facility with her family. The results showed no brain bleed on the scan and no other procedures were completed at the local hospital. The CNP was notified and gave orders for blood work and a urinalysis. Review of the nurses note dated 08/12/22 at 12:27 P.M. revealed Resident #01 continued to vomit and had diarrhea. The CNP was notified via a facsimile. Review of the laboratory results dated [DATE] and reported 4:28 P.M., revealed Resident #01 had a low sodium level of 129 milliequivalent per liter (mEq/L) where 135 mEq/L to 145 mEq/L was a normal range and a low chloride level of 93 mEq/L where 98 mEq/L to 110 mEq/L was a normal range. Review of the nurses note dated 08/12/22 at 6:17 P.M. revealed the laboratory and urinalysis results for Resident #01 were received. The results were faxed to Resident #01's primary physician. Review of the nurses note dated 08/14/22 at 1:39 P.M. revealed Resident #01 complained of nausea and [MEDICATION(S)] (antiemetic) was administered. The physician was made aware via a facsimile. Review of the nurses note dated 08/14/22 at 2:44 P.M. revealed Resident #01's daughter was in to visit and voiced concerns related to the laboratory results and asked for coverage. The daughter, (a nurse) noted the sodium level was low and requested to transfer her mother to the hospital. The resident was resting with her eyes closed and lethargic at the time. The resident was transferred to the hospital where she was admitted . Review of the hospital record dated 08/14/22 revealed Resident #01 presented to the emergency room after routine laboratory work up from the rehabilitation center showed [CONDITION(S)] and had projectile vomiting with every meal. Resident #01 was admitted to the hospital for [CONDITION(S)], generalized weakness, and projectile vomiting. Resident #01 received intravenous (IV) fluids to raise the sodium level and continue to trend sodium level correct six to eight mEq per 24 hours. Telephone interview with Resident #01's daughter on 08/23/22 at 9:50 A.M., revealed the facility nurses informed her on 08/12/22 that the resident's laboratory results were within normal limits and they were reviewed by the physician. On 08/14/22 the daughter requested a copy of the results from staff and found the sodium levels were low. She was then informed by a nurse that the results had been faxed to the physician's office on a Friday night which meant they would most likely not be reviewed until Monday. The daughter reported Resident #01 was placed in the intensive care unit at the hospital, treated, then moved to another facility. Interview with the Director of Nursing (DON) on 08/23/22 at 9:55 A.M., revealed Resident #01's laboratory results were faxed to the physician's office on 08/12/22 (Friday) at 6:17 P.M. The lab failed to notify the nurse that this was a critical lab value, so the nurse had not thought it was an issue and therefore had not contacted the physician or CNP by phone. The physician/CNP were notified of issues via facsimile a majority of the time. Telephone interview with CNP #600 on 08/23/22 at 10:55 A.M., revealed the facility staff failed to notify her or the physician regarding the laboratory results. No phone call was received regarding the critical low sodium levels nor the symptoms the resident was having regarding nausea, vomiting, and a change in cognition. The CNP #600 revealed she would not have seen the results nor other faxes from the facility until Monday at the office and she thought the nurses should have realized with the low sodium level and other symptoms the resident was experiencing Resident #01 was suffering from [CONDITION(S)]. Review of the facility policy titled Notification of Change in Condition dated 12/01/21 revealed to ensure appropriate individuals are notified of change in condition, the facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when a deterioration in health, mental or psychosocial status is either life threatening conditions or clinical complications and when a critical lab value which requires an immediate intervention. This deficiency substantiates allegations in Master Complaint Number OH 123.

Based on medical record review and staff interview, the facility failed to ensure the medication to treat seizures were administered to the resident per physician order. This affected one (Resident #27) of four residents reviewed for medication. The facility identified one resident (#27) who was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 54. Findings include: Review of the medical record for Resident #27 revealed an admitted [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's plan of care dated 07/14/22 revealed there was a risk of injury related to [CONDITION(S)] disorder. The intervention included to administer medications per physician order. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes for Resident #27 dated 07/15/22 at 2:57 P.M. revealed a fax was sent to the doctor regarding not having been sent with a hard copy prescription for [MEDICATION(S)]. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Choice Pharmacy medication prescription information needed form dated 07/18/22 revealed the Certified Nurse Practitioner (CNP) wrote the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #27. Review of the Medication Error Event for Resident #27 dated 08/02/22 revealed the error occurred on 07/14/22 and was found on 08/02/22. The order was for [MEDICATION(S)] 60 mg by mouth BID. The error was because Resident #27 was admitted on [DATE] and the facility did not receive a signed script for the medication until 07/18/22 resulting in missed doses. Resident #27 was observed for [CONDITION(S)] activity with no negative effects. The physician was notified. Interview on 08/02/22 at 11:45 A.M. with Regional Nurse #200 verified the medication [MEDICATION(S)] was not administered as physician ordered for Resident #27. The physician was faxed about the medication which needed a hard copy prescription. The physician was on vacation at this time, and once this was recognized, the facility contacted the CNP who wrote a prescription which could be sent to the pharmacy. This deficiency substantiates Master Complaint Number OH 307 and Complaint Number OH 537.

Based on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure the facility administered medications as ordered. This affected one (Resident #3) of three residents reviewed for medications. The facility census was 52. Findings include: Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. Resident #3 went to the hospital on 02/08/22 and was readmitted back to the facility on [DATE]. Diagnoses include [CONDITION(S)] of the left lower leg, acute kidney failure, hypertensive [CONDITION(S)], heart failure, [CONDITION(S)] (irregular heart rhythm), cardiomegaly (enlarged heart), chronic obstructive pulmonary disease, obstructive sleep apnea, dementia with behaviors, [CONDITION(S)] and [CONDITION(S)]. Review of a five-day admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #3 had some cognitive deficits with physical behaviors during one to three days of the assessment period. Resident #3 received antipsychotic, antidepressant and diuretic medications. Review of the physician's orders dated 01/28/22 revealed Resident #3 was to receive [MEDICATION(S)] (uric acid reducer) 100 milligrams (mg) once daily. The order was discontinued on 03/08/22 and rewritten the same day with the same dose. Review of the Medication Administration Record (MAR) dated 03/2022 revealed the [MEDICATION(S)] was not administered on 03/05/22, 03/06/22, 03/07/22 and 03/08/22 because it was not available. The MAR further revealed the [MEDICATION(S)] that was re-ordered on 03/08/22 and was re-written with the same dose. The 03/08/22 dose was held with the comment it had already been given on 03/08/22, (which had previously been marked as not available), and 03/09/22 was also marked as not given due to not being available. Review of the physician's orders dated 01/28/22 revealed Resident #3 was to receive the medication Losartan-[MEDICATION(S)] ( blood pressure-water pill) 100 mg-25 mg, one-half tablet by mouth once daily. Review of the MAR dated 03/2022 revealed the medication was held on 03/08/22 due to not being available. Review of the physician's orders dated 01/28/22 revealed Resident #3 was to receive [MEDICATION(S)] (blood pressure) extended release 25 mg by mouth once daily. The order was discontinued on 03/08/22 and re-ordered with the same dose. Review of the MAR dated 03/2022 revealed the medication was held due to not being available on 03/06/22 and 03/09/22. Review of the physician's orders dated 01/28/22 revealed Resident #3 was to receive [MEDICATION(S)] (anti-psychotic medication) 0.5 mg by mouth twice daily. The order was discontinued on 03/08/22 and re-written on the same date with the same dose. Review of the MAR dated 03/2022 revealed the [MEDICATION(S)] was held due to not being available on 03/06/22 for the 6:00 P.M. to 10:00 P.M. dose and on 03/07/22 for the 6:00 A.M. to 10:00 A.M. dose. After the medication was re-ordered, the MAR revealed the medication was not available for administration for the 6:00 A.M. to 10:00 A.M. dose on 03/08/22, 03/09/22, 03/10/22 and for the 6:00 P.M. to 10:00 P.M. doses on 03/09/22 and 03/10/22. Review of the physician's orders dated 01/28/22 revealed Resident #3 was to receive [MEDICATION(S)] (blood thinning medication) 20 mg by mouth once daily. The order was discontinued on 03/08/22 and re-written on the same date with the same dose. Review of the MAR dated 03/2022 revealed the [MEDICATION(S)] was held due to not being available on 03/05/22, 03/06/22, and 03/09/22. Interview with the Director of Nursing and Regional Clinical Nurse #20 on 03/14/21 at 2:00 P.M. verified the above medications ([MEDICATION(S)], Losartan-[MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]) for Resident #3 were not administered as ordered. The DON stated the resident had gone out to the hospital and there were issues getting the medications re-ordered into the computer correctly, and the pharmacy did not re-supply the medications. Review of the facility's policy titled Medication Administration-General Guidelines, dated 11/2018, revealed medications were to be administered as prescribed. The MAR was to be used during the medication being provided and the date, time, dosage, route were to be verified. Medications were to be documented directly after the medication was given. If a dose of regularly scheduled medication was withheld, refused or not available or given at a time other than the scheduled time, it was to be documented on the MAR and an explanatory note was to be entered. This deficiency substantiates Complaint Number OH 825.

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure a resident's antibiotic medications were administered per physician order resulting in a significant medication error. This affected one (#10 out of four residents reviewed for medication administration. Facility census was 52. Findings include: Record review of Resident #10 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set, (MDS), assessment dated [DATE] revealed the resident had intact cognition and was not receiving antibiotic medications during the assessment review. Review of Resident #10's care plans dated 08/22/21 revealed a focus for surgical incision. Interventions including observe the incision for signs and symptoms of infection and notify the physician for any signs. Another focus in the care plans dated 08/23/21 for potential problems with skin integrity was included in the care plans. Interventions included monitor skin, report any changes and monitor wounds for signs and symptoms of infection. Review of Resident #10's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the physician note the physician was ordering the medications for [CONDITION(S)] related to the resident's wound on the left lower leg. Review of Resident #10's current medication orders revealed there were no ordered to receive any antibiotics during the time of the survey. Review of Resident #10's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's nurses' notes dated from 08/2021 to 09/2021 revealed on 09/02/21 the nurse documented drainage from the left elbow wound. Per the note the wound appeared red and the resident was complaining of pain, the resident denied any fever or chills. Per the note the resident was sent to the orthopedic office for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the note 09/03/21 the resident and her family representative discussed the 'missed' orders for the resident's antibiotics. Per the note Resident #10 denied the [MEDICATION(S)] injection but agreed to the cefradroxil oral antibiotic. Review of Resident #10's physician orders dating from 08/2021 to 09/22/21 revealed on 09/04/21 the resident was ordered to receive [MEDICATION(S)], (antibiotic) 500 mg orally twice a day for six days for skin infections to the left shin and left elbow. On 09/11/21 the resident was ordered to receive the [MEDICATION(S)] for six more days until 09/17/21. Review of Resident #10's orthopedic physician notes dated 08/23/21 and 09/03/21 revealed the resident was being treated by the orthopedic physician for care of the left elbow post-surgery. On 09/03/21 the physician documented the resident's surgical wound was revised and the physician documented no evidence of infection in the wound but fragile skin with sutures not holding secure in the wound. Per the orthopedic physician's notes no evidence of infection in the wound was documented. Further review of Resident #10's medical record including laboratory results, assessments, orthopedic physician notes, and vital signs revealed no clinical signs of infection in the left elbow surgical wound. Interview on 09/22/21 at 2:02 P.M. with Registered Nurse, (RN), #100 revealed Resident #10 was out of the facility for a doctor appointment. Per RN #100 the resident has not been showing any signs or symptoms of infection regarding her surgical wound. RN #100 stated the resident did complete a course of antibiotics recently, but the nurse was unsure of the exact date the antibiotic started. RN #100 stated the Medical Director comes to the facility and put his actual orders into his progress notes then uploads the notes into the electronic system. Per RN #100 the floor nurses may not get the updated medication lists until the following day depending on the times the physician uploads his progress notes. Interview on 09/22/21 at 2:15 P.M. with Director of Health Services, (DHS), and Regional Support Registered Nurse, (RSRN), #9 revealed the medical director assessed Resident #10 on 08/26/21 for [CONDITION(S)] of her lower left leg. Per RSRN, the facility's physician was not treating her left elbow. DHS stated the orthopedic surgeons were providing orders for the care of the left elbow from admission to 09/22/21. RSRN #9 stated the antibiotic order on 08/26/21, was in the physician's progress note dated 08/29/21 and back dated to 08/26/21 and was not added to the medication list and was not started until 09/04/21 after the order had been noted by a facility nurse on 09/03/21. RSRN #9 stated the resident did go to the orthopedic surgeon for treatment to her left elbow wound for a possible infection, however after the surgeon assessed the resident no infection was found in the wound. DHS stated she reviewed the orthopedic documentation and laboratory results from the culture of the wounds and the white blood cell count collected on 09/03/21. Review of the orthopedic office results with DHS during the interview, for culture results revealed there was no new growth indicating an infection in the wound and the white blood cell count was within normal limits, indicating the Resident #10 had no systemic infection on 09/03/21. Both RSRN #9 and DHS did state the facility's physician had ordered oral antibiotics for Resident #10 to be started on 08/26/21 and the antibiotics were not administered until 09/04/21. Review of the facility policy titled, 'Medication Administration' dated 11/2018 revealed all medications are to be administered per prescribed orders in accordance with good nursing practices by the persons who are legally permitted to administer medications. This deficiency substantiates Complaint Number OH 835.

Based on observation, staff interview, review of the signage on the entrance door and policy review, the facility failed to implement the policy on employee screening to prevent the spread of COVID 19, when two employees entered the facility without being screened. Furthermore, the facility failed to cleanse the thermometer between screening people upon entrance to the facility, when the thermometer contacted people's forehead. This had the potential to affect 47 of 47 residents residing in the facility. Findings include: Observation on 06/08/20 at 1:55 P.M., revealed two employees, Resident Care Assistant (RCA) #130 and Certified Resident Care Assistant (CRCA) #120 approached the table from the resident living area, and did not enter through the front door. When asked how they got in the building, both answered, Through the door near the breakroom. Admission Counselor (AC) #100 stated they were not supposed to be using that door and there was a sign posted. Both RCA #130 and CRCA #120 stated they had not been told that. Observation of the entrance door near the breakroom revealed a 13-inch by 9-inch white paper with black lettering to include, All employees are to use the front door between 8:00 A.M. and 6:00 P.M. Observations on 06/08/20 between 1:55 P.M. and 2:05 PM, of Environmental Services (ES) #110 assisting with temperature screening as employees were screened, revealed ES #110 used a no-touch thermometer yet contacted the foreheads of three staff members. ES #110 did not wipe the thermometer with any disinfecting wipes between people. Interview on 06/08/20 at 2:05 P.M., with ES #110 provided verification of the thermometer touching the foreheads of three employees without disinfecting between people. Interview on 06/08/20 at 2:10 P.M., with Administrator provided verification the staff had not followed policy when entering through a door other than the designated entrance. Review of the facility policy titled Guidelines for COVID-19 dated 03/11/20 revealed Campus to designate one main entrance, limit deliveries and place signage on all doors. Review of the facility policy titled COVID-19: Screening FAQ dated 06/04/20 revealed each campus must have a minimum of one thermometer dedicated to screening. The thermometer surface must be able to be disinfected.

Based on observation, staff interview, review of food recipes, and review of a facility policy, the facility failed to provide nutritional and appetizing bread for a pureed meal. This affected nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms. The facility identified two (#27 and #31) additional residents with orders for pureed diets who received their meals in their rooms. The census was 55. Findings include: Observation on 09/25/19 at 11:25 [NAME]M., revealed Cook #400 preparing pureed textured foods in the facility kitchen. Cook #400 explained the recipe for pureed textured foods had a minimal serving size of 25 servings, and since the facility had less than 25 residents on pureed diets they would recalculate the recipe to make it for 15 servings. Cook #400 asked Dietary Manager #290 to recalculate a recipe for pureed bread to make 15 servings instead of 25. Dietary Manager #290 presented Cook #400 with a revised recipe to aide in making pureed bread for the lunch meal. Review of an undated pureed bread recipe number 157 revealed the recipe was set up for serving sizes of 25, 50, 75, 100, and 150 and ingredients including pureed bread mix, hot water, and low-sodium chicken base. Review of the undated, unnamed and revised recipe given to Cook #400 revealed an example for ingredients in black and white cookies for eight, sixteen, forty, eighty, and 120 servings with ingredients of flour, baking powder, salt, and milk. The recipe did not address ingredients for pureed bread or the quantity of the ingredients needed. Further observation on 09/25/19 at 11:30 [NAME]M., revealed Cook #400 removed slices of bread from the steamer and placed them in the food processor mixing it with an undetermined amount of hot water, melted butter, and chicken broth. After all food items were blended together, Cook #400 used a spatula to scrap the pureed bread from the food processor into a metal holding pan at which time the consistency of the pureed bread was very thin in an almost liquid form. Interview 09/25/19 at 11:40 [NAME]M., with Cook #400 stated she would place the pureed bread back in the steamer and it would thicken up. Observation on 09/25/19 at 12:08 P.M., revealed Cook #560 serving residents meals from the steam table in the main dining room. Further observation revealed Cook #560 scoop pureed bread from the steam table and place it on plates. The consistency of the pureed bread was very runny and did not require Cook #560 to use the clicker on the side of the scoop. When Cook #560 placed the scoop into the pureed bread and lifted the scoop, pureed bread mixture was dripping off the scoop, and when the pureed bread was plated it did not hold a form and ran on the plate into other food items. Interview on 09/25/19 at 12:30 P.M., with Cook #560 and Dietary Manager #290 stated the pureed bread was too runny and should have been more formed. Dietary Manager #290 stated he did not observe the pureed bread after Cook #400 prepared it. The facility identified nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms on 09/25/19 between 12:00 P.M. and 12:30 P.M. Review of a facility policy titled, Standardized Recipes, dated 05/31/16, revealed any recipe changes made by the Director of Food Services should be reviewed and approved by the Registered Dietitian.

Based on observation, staff interview, and review of food menus and spreadsheets, the facility failed to serve appropriate food servings to residents with a pureed diet. This affected nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms. The facility identified two (#27 and #31) additional residents with orders for pureed diets who received their meals in their rooms. The census was 55. Findings include: Observation on 09/25/19 at 12:08 P.M., revealed Cook #560 serving residents meals from the steam table in the main dining room. Cook #560 served all meals to residents in the main dining room and restorative and was asked what scoop sizes were used while serving food items. Interview on 09/25/19 at 12:14 P.M., with Cook #560 stated the pureed cornflake chicken breast, scalloped potatoes, and sautéed cabbage and spinach were served using a #10 (3/8 cup) scoop. Review of menu for the spring and summer Midwest 2019 week 2 revealed the lunch meal was cornflake chicken breast, scalloped potatoes, sauteed cabbage and spinach, a Southern biscuit, cherry cobbler, butter cup, coffee and tea, and garnish. Review of a spreadsheet for the spring and summer Midwest 2019 diet revealed purred cornflake chicken breast was to be served with a #6 (5/8 cup), pureed scalloped potatoes with a #8 (1/2 cup), and pureed sautéed cabbage and spinach with a #12 (1/3 cup) scoop. Interview on 09/25/19 at 12:30 P.M., with Cook #560 and Dietary Manager #290 verified the incorrect scoop sizes were used when serving the pureed cornflake chicken breast, scalloped potatoes, and sautéed cabbage and spinach in the main and restorative dining rooms on 09/25/19. Interview on 09/26/19 at approximately 10:30 [NAME]M., with Director of Health Services #101 verified none of the 11 (#8, #16, #21, #22, #23, #27, #29, #31, #34, #38, and #44) residents with orders for pureed diets had any significant weight loss in the last 30 days.

Based on medical record review, staff interview and policy review, the facility failed to provide bed hold notice to one resident. This affected one (#52) of four sampled residents reviewed for bed holds prior to transferring to the hospital. The facility census was 55. Findings include: Review of Resident #52's medical record revealed an admission date of [DATE] at 2:30 P.M. and discharged on [DATE] at 12:26 P.M. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed the MDS had not yet been completed as the resident was in the facility less than 24 hours. Review of the progress note dated 07/09/19 at 9:43 [NAME]M. revealed the Executive Director spoke with family regarding the bed hold on 07/08/19. The Executive Director mailed the Bed hold letter certified, with a self addressed stamped envelope enclosed. Interview on 09/26/19 at 2:15 P.M., with the Executive Director verified Resident #52 or their representative was not given notice of the bed hold policy within 24 hours. Review of the policy titled Bed Hold Notification, dated 09/24/18, revealed before transferring a resident to a hospital or allowing a resident to go on a therapeutic leave, the Nursing designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed hold and admission policies.

Based on medical record review, staff interview, and policy review, the facility failed to monitor a resident's [MEDICAL TREATMENT] access per facility policy. This affected one (#17) of one resident reviewed for [MEDICAL TREATMENT]. The facility census was 55. Findings include: Review Resident #17's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Interview on 09/26/19 at 7:11 [NAME]M. with Resident #17 revealed Resident #17 stated the staff don't check her arm very often here, but they do at [MEDICAL TREATMENT]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #17 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15. Resident #17 had no rejection of care during the assessment period. Resident #17 received [MEDICAL TREATMENT] services. Review of the care plan dated 06/25/19 revealed Resident #17 had [MEDICAL CONDITION] resulting in the need for [MEDICAL TREATMENT]. Resident will be free from complications associated with [MEDICAL TREATMENT]. Appropriate goal and interventions were included in the care plan specifically, monitor [MEDICAL TREATMENT] access as ordered. Review of the current physician orders [REDACTED]. Review of the Treatment Administration Record for 08/2019 and 09/2019 revealed there was documentation of monitoring the [MEDICAL TREATMENT] access. Interview on 09/26/19 at 9:55 [NAME]M. with the Director of Nursing revealed there was no order to monitor the [MEDICAL TREATMENT] access and there was no documentation of monitoring the [MEDICAL TREATMENT] access. Review of the policy titled Guidelines for Monitoring Shunt: [MEDICAL TREATMENT] Arteriovenous Access, dated 05/22/18, revealed to monitor the Arteriovenous shunt daily for redness, swelling, signs and symptoms of infections, complaints of pain, local warmth, exudates, tenderness, numbness, tingling, and extremity swelling distal to access. Monitor the Arteriovenous shunt daily for thrill and bruit.

Based on observation, staff interview, and review of facility policy, the facility failed to properly maintain the flooring in a resident's room. This affected one of 46 resident rooms observed. The facility census was 55. Findings include: Observation on 09/23/19 at 11:16 [NAME]M., revealed three large holes in the tile flooring in resident room [ROOM NUMBER]. The three holes are approximately two inches by four inches, four inches by six inches, and six inches by nine inches. The holes are near a resident's recliner. Interview on 09/25/19 at 11:38 [NAME]M., with the Director of Plant Operations #102 verified there are holes in the tiling flooring of resident room [ROOM NUMBER]. Director of Director of Plant Operations #102 verified a work order had not been received and the flooring definitely should have been fixed. Further interview at 12:04 P.M., verified the tile had completely ripped through to the under layment flooring. Interview on 09/26/19 at approximately 7:30 [NAME]M., with Administrator #100 verified the flooring should have been replaced. Review of facility policy titled,Flooring Preventative Maintenance, dated 02/06/18, verified vinyl tile is inspected for chipping and cracking quarterly and replaced as necessary.

Based on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure a resident's physician ordered diet was followed. This affected one resident (#32) of one residents reviewed for [MEDICAL TREATMENT]. The facility identified one resident on a renal diet. The facility census was 62. Findings include: Review of Resident 32's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status score of 15, indicating no impairment in cognition. The resident had no behaviors or rejection of care. She was on a therapeutic diet and required supervision with one staff assist for eating. Review of the resident's physician's orders [REDACTED]. Review of the resident's nutrition notes revealed an entry on 06/27/18 at 10:54 A.M. from Registered Dietitian (RD) #200 indicating the [MEDICAL TREATMENT] center wanted the facility dietitian to discuss high protein snacks or double protein meals with the resident, especially eggs. The resident's [MEDICATION NAME] level was down to 3.1 and she refused ProMod (protein supplement) so the order was discontinued. Continued review of the nutrition notes revealed an entry from RD #200 on 06/29/18 at 3:20 P.M. indicating the [MEDICAL TREATMENT] center RD would like the resident to increase her protein intake related to her recent low [MEDICATION NAME] level. RD #200 recommended double protein portions at meals. On 07/10/18 at 9:58 A.M., RD #200 documented the resident continued on [MEDICAL TREATMENT]. She received a CCHO, NAS, no bananas, oranges, orange juice, non-boiled potatoes/sweet potatoes, melon, soup beans, tomatoes or tomato juice, prunes or prune juice diet with double protein portions per [MEDICAL TREATMENT] center request. Intakes generally good and the resident's weight was stable and her body mass index was a 40, indicating [MEDICAL CONDITION]. No new significant laboratory levels/medications. No diet changes were recommended. Review of the resident's care plans revealed a care plan dated 02/25/18 and revised on 07/10/18 for nutritional needs. The care plan indicated the resident was to follow her diet as ordered by the physician. Protein, sodium, potassium, and phosphorous intake may need to be regulated based on kidney function. There was no documentation indicating the resident was non-compliant with her prescribed dietary order. Observation and interview with Resident #32 on 07/12/18 at 8:41 A.M. revealed the resident was eating breakfast in her room, a banana, bran flakes cereal, doughnut, coffee, and milk for her cereal. When asked about her dietary restrictions, the resident stated she was supposed to watch her salt and sugar intake. She was not aware of any particular food restrictions. She stated she was supposed to increase her protein and she had a half eaten extra protein peanut butter dark chocolate bar sitting on her bedside table. She stated she tried to eat one per day and her family brought them in for her. The resident stated the State tested Nursing Assistants (STNA) assist her in filling out her meal tickets. Review of the resident's meal ticket on her breakfast tray revealed it indicated she was on a regular, NAS, carbohydrate controlled (CC), double protein diet. There was no indication of foods the resident was not to eat per her dietary order. Interview with Licensed Practical Nurse (LPN) #105 on 07/12/18 at 8:57 A.M. verified Resident #32 was eating a banana for breakfast. She also verified the resident did not have any protein on her breakfast tray. She verified the resident's meal ticket did not match her dietary order. Interview with RD #200 on 07/12/18 at 1:23 P.M. revealed she had talked to the resident several times about her diet and she thought the resident understood her dietary order. She verified the kitchen did not have the correct dietary order and stated she was not sure why they had not received the resident's updated order. Interview with STNA #110 on 07/12/18 at 1:36 P.M. revealed the resident was compliant with her diet. Review of a facility policy titled Resident Dining and Nutrition Preferences dated 11/22/17 revealed the individual resident's food plan meets his or her nutritional needs. Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue.

Based on record review, review of facility policy, and family and staff interview, the facility failed to provide notice of bed hold availability when a resident was transferred to the hospital. This affected one (#49) residents family member during three family interviews conducted during stage one of the annual survey. The facility identified 32 residents with Medicaid funding. The facility census was 61. Findings include: Review of the record for Resident #49 revealed the resident was admitted to the facility on [DATE], was transferred to the hospital on [DATE] and returned to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an admission comprehensive assessment Minimum Data Set ((MDS) dated [DATE], revealed the resident was cognitively intact. The assessment indicated the resident required extensive assist for all activities of daily living, was short of breath, had skin breakdown, received [MEDICAL CONDITION] medications and was on [MEDICAL TREATMENT]. Review of progress notes for Resident #49 revealed the resident was transferred to the hospital on [DATE]. Further review of the record revealed there was no documentation of notification of available bed hold days as of the transfer on 04/20/17. Interview with a family member of Resident #49 on 05/07/17 at 10:36 A.M., revealed the facility did not provide information regarding available bed hold days at any time near the transfer to the hospital. Interview with Business Office Manager #103 on 05/10/17 at 11:30 A.M., verified Resident #49's family was not given information regarding available bed hold days when she was transferred to the hospital on [DATE]. Review of the facility admission agreement, dated 10/15/16, revealed the policy titled, Readmission: Bed Hold Policy, revealed if the resident was eligible for or receiving Medicaid assistance, the resident's bed would be reserved for the applicable number of days paid for a reserved bed under the Medicaid program. The policy revealed if the period of hospitalization of therapeutic leave exceeded the maximum time for reservation of the resident's bed under the Medicaid program, the resident would be entitled to the first available accommodation suitable for the required level of care. The policy indicated prior to the lapse of the bed reservation period covered by the Medicaid program, the resident may reserve his or her bed by providing a written notice to the facility and paying the Medicaid per diem rate.

Based on observations, staff interview and review of facility policy, the facility failed to ensure clean tables were being used for meals in resident rooms. This affected one (#20) of 12 residents observed for meal service. In addition, the facility failed to ensure proper infection control services were being maintained regarding transportation of meals in the corridor. This affected one (#78) of 12 residents observed receiving meals in their room. The facility census was 61. Findings include: Observations on 05/07/17 at 12:40 P.M., revealed State tested Nursing Assistant (STNA) #100, retrieved a meal tray from the cart and entered Resident #20's room, looked for a table and did not see one. STNA #100 placed the tray on the bed of Resident #20 and left the room. She located an overbed table near the nurses desk and pushed it into the room. STNA #100 moved the tray from the bed to the table and removed the plate from the tray and sat it on the overbed table. This table had been located in the hall and was not cleaned off prior to the use for Resident #20's meal. Observation 05/07/17 at 12:43 P.M. of the room tray service to residents, revealed the Director of Nursing (DON) carrying a tray with a plate cover over it. Included on the tray were a glass with red liquid and a cup with dark liquid in it, both uncovered. The trays being passed in the 100 and 200 halls also had uncovered liquids. Interview on 05/07/17 at 12:45 P.M. with STNA #100, verified the lack of cleansing of the table prior to use for Resident #20. Interview on 05/07/17 at 12:44 P.M. with the DON, verified the drinks were uncovered on the tray and were carried down the hall. Review of facility policy titled, Standard Precautions Guidelines, revised 05/11/16, revealed items and equipment in the resident's environment likely to have been contaminated must be handled so as to prevent the spread of infection.

Based on record review and staff interview, the facility failed to accurately assess one residents minimum data set (MDS) assessment. This affected one (#83) of nine residents reviewed for MDS assessments. The facility census was 61. Findings include: Review of the record for Resident #83 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the monthly physician orders [REDACTED]. Review of the quarterly MDS assessment dated [DATE], revealed the resident had short and long term memory deficits with no behaviors. Review of Section I active [DIAGNOSES REDACTED]. On 05/09/17 at 3:05 P.M., during an interview with MDS Coordinator Registered Nurse (RN) #102, verified she completed the MDS assessment and did not include depression in the active [DIAGNOSES REDACTED].