Every finding on record at Mt Airy Gardens Rehabilitation and Nursing Center

Based on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen. This affected all residents except for three residents (#31, #57 and #66) who were identified by the facility as not receiving any food from the kitchen. The facility census was 91.Findings include:Observation of the kitchen on 09/08/25 at 8:20 A.M. revealed a sticky substance on the floor at the entrance to the kitchen, chipped and peeling floor by the walls of the kitchen, a brown substance on the floor under the dishwasher and along the walls of the kitchen, brown debris in two black rubber mats, an uncovered pipe with standing water and a rag in the pipe near the dishwasher, and a second pipe with standing brown water near the dishwasher. Concurrent interview with the Administrator verified the findings. This violation represents non-compliance investigated under Complaint Number 2580547.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the kitchen was free of pests. This affected all residents except for three residents (#31, #57 and #66) who were identified by the facility as receiving no food from the kitchen. The facility census was 91.Findings include: Observation of the kitchen on 09/08/25 at 8:20 A.M. revealed there were multiple gnats around the dishwasher and trash cans in the kitchen. Concurrent interview with the Administrator verified the gnats around the dishwasher and garbage cans.Interview with Dietary Aide (DA) #174 on 09/08/25 at 8:26 A.M. verified there were multiple gnats around the dishwasher and trash cans in the kitchen. DA #174 stated the facility had experienced an issue with gnats for several weeks.Review of the facility's undated pest control program policy revealed the facility would maintain an effective pest control program that eradicated and contained common household pests.This violation represents non-compliance investigated under Complaint Number 2580547.

Based on observation, staff interview, review of a scoop size chart, and review of dietary spreadsheets, the the facility failed to ensure appropriate portion sizes were served. This had the potential to affect all 77 residents in the facility. The facility census was 77. Findings include: Observation on 02/19/25 at 11:50 A.M. revealed Dietary [NAME] (DC) #378 was utilizing a green handled scoop for serving macaroni and cheese on the lunch trayline. When queried, DC #378 was unable to say what size scoop she was using for the macaroni and cheese. Review of the dietary spreadsheet for the 2024-2025 fall/winter menus for Wednesday of week two, revealed macaroni and cheese was to be a 4 ounce (oz) serving. Review of the Portion Control Chart, as provided by the facility, revealed a green-handled scoop provided 2 and 2/3 oz and a dark gray handled scoop provided 4 oz. Interview on 02/19/25 at 12:14 P.M., Dietary Director (DD) #371 verified DC #378 was using a green-handled scoop, which provided 2 and 2/3 oz, when the spreadsheet for the meal called for a 4 oz serving, which would have required the use of a dark gray scoop.

Based on observation, staff interview, and policy review, the facility failed to store and handle food in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all 77 residents in the facility. The facility census was 77. Findings include: 1) Observation of the dry storage area in the kitchen on [DATE] at 9:50 A.M., with Dietary Director (DD) #371, revealed a jar of grape jelly, approximately half full, with no open date, and a jug of barbeque sauce, approximately half full and with no open date. Manufacturer labels on both the jelly and barbeque sauce indicated the products needed to be refrigerated after opening. Interview at the same time with DD #371, verified the jelly and barbeque sauce were opened, partially used, not dated, and should have been refrigerated once opened. 2) Observation of the walk-in cooler on [DATE] at 9:52 A.M., revealed a plastic crate of milk cartons stored directly on the floor. Interview at the same time with DD #371 verified the milk was stored directly on the floor. 3) Observation of the walk-in freezer on [DATE] at 9:54 A.M. revealed a box of cheese stored directly on the floor. Interview at the same time with DD #371 verified the cheese was stored directly on the floor. 4) Observation on [DATE] at 9:58 A.M. revealed Dietary Aid (DA) #354 utilizing the dishwasher for cleaning dishes following the breakfast meal. Upon surveyor request, DA #354 obtained a container of sanitizer test strips and placed a test strip in the machine. Further observation revealed the container of the sanitizer test strips had an expiration date of [DATE]. Interview at the same time with DA #354, verified the test strips had expired [DATE]. 5) Observation on [DATE] at 9:11 A.M. revealed two jars of grape jelly on a shelf in the food preparation area. One jar was approximately ,d+[DATE] full and not dated. The second jar was approximately ,d+[DATE] full and dated [DATE]. The labels on both jars of jelly indicated the need to refrigerate after opening. Interview at the same time, DD #371 verified the two jars of jelly were opened, partially used, and not refrigerated. 6) Observation on [DATE] at 10:09 A.M. revealed Dietary [NAME] (DC) #378 retrieved a pan of green beans from the stove, walked to the sink in the food preparation area, and hold the pan against the inside of the sink to drain the green beans. DC #378 then took the drained green beans and added them to the Robo-coup to begin the pureeing process. Interview at the same time, DC #378 verified she drained the green beans against the inside of the sink. DC #378 stated she wipes the sink out daily, and verified the green beans touched the surface of the sink while being drained. Interview on [DATE] at 10:13 A.M., Dietary Director (DD) #371 verified draining the green beans against the inside of the sink is not considered a sanitary practice. 7) Observation of the first-floor nourishment room on [DATE] at 12:49 P.M. revealed the following: a) a plastic jar of applesauce, approximately ,d+[DATE] remaining, which was coated with a blue and fuzzy substance, and was not labeled or dated. b) a bottle of chocolate syrup, opened but not labeled or dated. c) a bottle of coffee creamer, labeled with a resident's name and dated [DATE]. d) approximately 20 meat and cheese sandwiches, individually wrapped in a non-sealable sandwich bags with no label or date. e) a one-liter plastic bottle of orange soda, approximately ,d+[DATE] full, which was not labeled nor dated. f) a sandwich, wrapped in plastic wrap, containing the numbers 105 on it with no date. g) a slice of pie on a styrofoam plate, covered in plastic wrap, with no label or date. h) a bottle of Starbucks pumpkin spice latte iced espresso, opened with a manufacturer's expiration date of [DATE], not labeled or dated. i) an open bottle of caramel sauce with no label or date. j) a can of whipped cream with no lid and no label or date. k) a cardboard to-go container containing two slices of bread and a bag of Cheetos, which was not labeled or dated. l) a plastic grocery bag containing a salad and fruit, which was not labeled or dated. m) a carton of 2% milk, unopened, dated [DATE], and bulging. n) an open can of Dr. Pepper, approximately half full, not labeled or dated. Interview at the same time with Receptionist #507, verified the plastic jar of applesauce was coated with a blue and fuzzy substance and not labeled or dated. Observation, following verification of the applesauce, Receptionist #507 took the jar of applesauce left the nourishment room and was unable to be located. Observation at the same time revealed a sign, posted on the outside of the refrigerator door, which stated, Label and Date all foods, including resident's food! All unlabeled food will be discarded! Food will be discarded after this time period: sealed beverages and sealed foods-expiration date of 7 days, resident foods (opened)-3 days, frozen foods-30 days. Interview on [DATE] at 12:58 P.M., the Administrator verified the remaining contents of the refrigerator. The Administrator further verified all contents of refrigerators should be labeled, dated, and discarded as instructed on the aforementioned sign on the refrigerator. 8) Observation of the second-floor nourishment room refrigerator on [DATE] at 1:02 P.M., revealed a half gallon of whole milk, with an expiration date of [DATE], partially used, with label or open date, four plastic grocery bags containing miscellaneous food items, none contained a label or date, and a clear plastic pitcher, dated ,d+[DATE] with a small amount of red liquid contents remaining on the bottom. Further observation revealed the outside door of the refrigerator had the same sign posted as was present on the first-floor nourishment room. Interview at the same time, Licensed Practical Nurse (LPN) #359 verified the contents of the refrigerator and verified all items should be labeled, dated, and discarded following expiration. Review of the facility policy titled, Food Storage, dated 2023, revealed food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food should be stored a minimum of six inches above the floor. All foods should be stored off the floor in refrigerators and freezers. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within seven days or discarded. All foods should be labeled, dated, and routinely monitored to ensure foods will be consumed or discarded by their use-by dates. Review of the facility policy titled, Food Brought in from Outside Sources and Personal Food Storage, dated 2023, revealed foods and beverages brought in from outside sources that require refrigeration should be labeled with the resident's name and date. Unlabeled/undated food (s) whose date is outside the facility policy for food storage (usually seven days) can be disposed of by staff.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure catheter bags were covered. This affected two (Residents #235 and #236) of three residents reviewed for catheters. The facility census was 77. Findings include: 1. Review of the medical record for Resident #235 revealed an admitted [DATE] with diagnoses including metabolic encephalopathy, diabetes mellitus type two, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment for Resident #235 dated 02/10/25 revealed the resident had severe cognitive impairment, was always incontinent of bowel, had an indwelling foley catheter, and was dependent on staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #235 revealed an order dated 08/03/23 for staff to change the indwelling catheter and drainage bag as needed for leakage or blockage. Observation on 02/19/25 at 9:55 A.M. revealed Resident #235 was in his room, and his catheter bag was full of urine which was visible from the hallway. Resident #235's catheter bag was not covered with a dignity bag. Interview on 02/19/25 at 9:57 A.M. with Registered Nurse (RN)#315 confirmed Resident #235's catheter bag was not covered with a dignity bag and confirmed catheter bags should be covered. 2. Review of the medical record for Resident #236 revealed an admitted [DATE] with diagnoses of other complications of incontinent external stoma of urinary tract, chronic kidney disease stage, and cerebral infarction. Review of the MDS assessment for Resident #236 dated 01/30/25 revealed the resident was cognitively intact, was continent of bowel, had a nephrostomy tube, and required staff assistance with ADLs. Review of the plan of care for Resident #236 dated 01/24/25 revealed the resident had altered urinary elimination with an intervention to ensure a privacy bag covered the nephrostomy bag at all times. Observation on 02/19/25 revealed Resident #236 had the nephrostomy tube in place with a leg bag pinned to the outside of his pajama pants. The leg bag had visible urine in it and was not covered with a dignity bag. Interview on 02/19/25 at 10:05 A.M. with Licensed Practical Nurse (LPN) #500 confirmed Resident #236's nephrostomy bag was not covered with a dignity bag and confirmed catheter bags should be covered. Review of the policy titled Catheter Care, dated 2024 revealed the facility staff would ensure residents with indwelling catheters received appropriate care to maintain resident dignity and privacy when indwelling catheters were in use. Privacy bags would be available and catheter drainage bags would be covered at all times while in use.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the resident bedrooms provided full visual privacy. This affected one (Residents #8) of four residents reviewed for physical environment. The facility census was 77 residents. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including Alzheimer's dementia, psychotic disorder with delusions, and depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/29/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs). Observation on 02/18/25 at 12:29 P.M. revealed Resident #8's room window overlooked the facility parking area, and the window curtains were of a material which permitted observation from the parking lot into the resident's room. In addition, the window curtains were ripped and torn. There was no privacy curtain in the room even though privacy curtain tracking was in place. Interview on 02/20/25 at 12:50 P.M. with Housekeeping Director #341 confirmed the window curtains in Resident #8's room did not allow for visual privacy for the resident, and there was no privacy curtain in place in the resident's room. Review of the policy titled Resident Rights dated 2024 revealed the resident had a right to personal privacy in living accommodations.

Based on medical record review, observation, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected three (Residents #77, #8, #51) of four residents reviewed for MDS assessment accuracy. The facility census was 77 resident. Finding include: 1. Review of the medical record for Resident #77 revealed an admission on 07/25/24 with diagnoses including atherosclerosis, urinary tract infections, asthma, and diabetes mellitus. Review of the admission MDS assessment for Resident #77 dated 08/01/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the medical record for Resident #77 revealed an entry MDS assessment was completed on 07/25/24, a discharge return anticipated assessment was completed on 07/29/24, and a comprehensive assessment with an assessment reference date (ARD) of 08/01/24 was completed and transmitted. Interview on 02/19/25 at 2:17 P.M. with Minimum Data Coordinator Registered Nurse (RN) #311 confirmed the comprehensive MDS assessment was dated 08/01/24 after Resident #77 had discharged from the facility. RN #311 confirmed the discharge MDS should have been changed to reflect a five-day assessment, and the nurse would deactivate the inaccurate MDS that was submitted for Resident #77 on 08/01/24. 2. Review of the medical record for Resident #8 revealed an admission on 08/03/18 with diagnoses including dementia with behavioral disturbances and psychotic disorders with delusions. Review of the annual MDS assessment for Resident #8 revealed the resident was cognitively impaired and required set up with ADLs. Review of the plan of care for Resident #8 revealed resident was admitted to hospice services on 01/29/24. Interventions include assess advance directive upon admission, quarterly annually and with significant change. Review of the physician's orders for Resident #8 revealed an order dated 01/29/24 for the resident to be admitted to hospice. Review of the fall investigation for Resident #8 dated 03/19/24 revealed the resident was found in the room on the floor after an attempted self-transfer without injury. Review of the MDS assessment for Resident #8 dated 04/30/24 revealed the assessment did not reflect the resident's fall on 03/19/24 and did not reflect the resident's admission to hospice. Review of the MDS assessment for Resident #8 dated 07/31/24 revealed the assessment did not reflect the resident's admission to hospice. Interview on 02/20/25 at 2:45 P.M. with Registered Nurse (RN) #311 confirmed the MDS assessment for Resident #8 dated 04/30/24 was not accurate as it did not include the fall that occurred on 03/19/24 or that the resident was receiving hospice services. RN #311 confirmed the MDS assessment for Resident #8 dated 07/31/24 was not accurate as it was not coded to reflect the hospice services provided for the resident. 49771 3. Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including cerebral infarction with non-dominant (left) side hemiplegia and hemiparesis, diabetes mellitus type two, chronic kidney disease, and depression. Review of the MDS assessment for Resident #51 dated 02/09/25 revealed the resident moderately cognitively impaired and required staff assistances with ADLs. The assessment did not reflect contractures or limitations in the resident's range of motion. Observation on 02/18/25 at 10:33 A.M. revealed Resident #51's left hand was contracted. Observation on 02/20/25 at 3:57 P.M. with Rehab Director (RD) #363 revealed RD #363 found a left-hand splint in the resident's belongings on the sink counter. Interview on 02/20/25 at 3:57 P.M. with RD #363 confirmed she had been unaware Resident #51 had a contracture of his left hand. Interview on 02/20/25 at 4:00 P.M. with RN #311 confirmed the MDS assessment for Resident #51 dated 02/09/25 was inaccurate as it did not reflect contractures or limitations in the resident's range of motion. Interview on 02/20/25 at 4:10 P.M. with RD #363 confirmed Resident #51 had received therapy treatment for a left-hand contracture in September 2024.

Based on medical record review and staff interview, the facility failed to ensure completion of significant change Preadmission Screening and Resident Reviews (PASARRs.) This affected one (Resident #28) of two residents reviewed for PASARR status. The facility census was 77 residents. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, congestive heart failure, unspecified dementia, and schizophrenia. Review of the physician's orders for Resident #28 revealed an order dated 07/18/24 for admission to hospice. Review of the medical record for Resident #28 revealed the facility completed a significant change Minimum Data Set (MDS) assessment for the resident due to admission to hospice on 07/18/24. Review of the medical record for Resident #28 revealed the facility did not complete an update PASARR for the resident following the resident's hospice admission. Interview on 02/20/25 at 11:11 A.M. with Social Services Director (SSD) #353 confirmed the facility had not completed an updated PASARR for Resident #28 following the resident's admission to hospice and the facility should have completed a new PASARR on 07/18/24 when the resident received the new order to admit to hospice services.

Based on medical record review and staff interview, the facility failed to ensure care plans were updated to accurately reflect resident health care status. This affected one (Resident #72) of three residents reviewed for care plans. The facility census was 77 residents. Findings include: Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses including schizophrenia, subdural hemorrhage, traumatic brain injury, gastrostomy (g-tube) status and dislocation of right acromioclavicular joint. Review of the physician's orders for Resident #72 revealed orders dated 09/25/24 to flush the g-tube with thirty cubic centimeters (cc) of water every shift to maintain patency and orders for a regular diet, regular texture with thin liquids. Review of the plan of care for Resident #72 dated 09/26/24 revealed the resident required tube feeding related to dysphagia with interventions including the following: assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications, check for tube placement and gastric contents/residual volume per facility protocol and record, hold feed if greater than 100-200 cubic centimeters (cc) aspirate, discuss with resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications, does not like food related activities as it is upsetting to see others eating, head of bed elevated 45 degrees during and thirty minutes after tube feed, medication administration: may cocktail medications and administer via g-tube, monitor intake and output every shift, monitor lung sounds every shift and as needed, monitor for coughing, shortness of breath , choking, labored respirations, monitor/document/report to physician as needed tube dysfunction or malfunction, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and needs assistance/supervision/cueing with tube feeding and water flushes, registered dietician to monitor caloric intake, estimate needs, make recommendations for changes to tube feeding as needed. Review of the progress note for Resident #72 dated 12/02/24 per Nurse Practitioner (NP) #505 revealed the resident was no longer using the g-tube and the NP recommended discontinuation of the tube. Review of the progress note for Resident #72 dated 01/02/25 per NP #500 revealed the resident requested to have the g-tube removed and was scheduled for an outpatient procedure to remove the tube. Review of the Minimum Data Set (MDS) assessment for Resident dated 01/02/25 for Resident #72 revealed resident had impaired cognition and was independent in eating, toileting, bed mobility and transfers. Dietary administration via g-tube was not coded during the assessment period. Interview on 02/19/25 at 4:38 P.M. with Registered Nurse (RN) #311 confirmed Resident #72's care plan was not updated with the removal of the g-tube and Resident #72's care plan was not accurate as the resident never used the g-tube for nutritional support. RN #311 confirmed Resident #72 was on a regular diet and able to consume meals orally. Interview on 02/20/25 at 2:46 P.M. with NP #505 confirmed the g-tube for Resident #72 was never used for nutritional support.

Based on medical record review observations, staff interviews and policy review, the facility failed to ensure timely suture removal. This affected one Resident (#73) of the one resident reviewed for facial lacerations. The facility census was 77. Findings included: Review of the medical record for Resident #73 revealed an admitted [DATE] with diagnoses including but not limited to history of physical injury and trauma, traumatic brain injury and altered mental status. Review of the plan of care for Resident #73 revealed resident at risk for falls related to balance problems, poor communication and comprehensive, and traumatic brain injury. Interventions include to anticipate and meet needs, follow facility fall protocol and notify physician and power of attorney (POA) of falls. Review of the most recent Minimum Data Set (MDS) assessment for Resident #73 revealed the resident was cognitively impaired. Review of the hospital discharge summary dated 01/24/25 revealed Resident #73 fell while at the hospital due to gastrostomy (g-tube) displacement sustaining a two-centimeter laceration to the right eyebrow. The discharge summary revealed no orders for suture removal. Review of the physician's orders for Resident #73 revealed an order dated 01/24/24 to monitor sutures to right eyebrow two times a day and there was no additional order for the sutures to be removed. Observation of Resident #73 on 02/18/25 at 10:45 A.M., revealed resident lying in bed. Observation of sutures to area of right eyebrow without sign or symptoms of infections. Interview with Resident #73 at the same time revealed she received the suture from a fall. Resident #73 was unable to provide date of fall or additional details of fall. Interview with Licensed Practical Nurse (LPN) #359 on 02/19/25 at 10:00 A.M., verified Resident #73 went to the hospital after she pulled her g-tube out. LPN #359 stated the resident fell from a stretcher while she was in the emergency room and returned with sutures in place. LPN #359 verified the resident had sutures still in place over her right eyebrow and verified there was not an order for the resident's sutures to be removed. Interview with Assistant Director of Nursing (ADON) #316 on 02/19/25 at 10:57 A.M., revealed the Wound Nurse Practitioner (WNP) was following Resident #73 for a sacral wound but was not following the resident for the wound with sutures. ADON #316 stated sutures should be removed after seven to ten days. ADON #316 verified Resident #73 had sutures in place and the facility did not have any orders to remove them.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure residents received care and services for management of contractures and impaired mobility. This affected three (Residents #9, #72, #51) of three residents reviewed for range of motion services. The facility census was 77 residents. Findings include: 1. Review of the medical record for Resident #9 revealed an admission on 03/18/16 with diagnosis including peripheral vascular disease, diabetes mellitus, traumatic brain injury, and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 12/25/24 for Resident #9 revealed the resident had impaired cognition and required supervision with activities of daily living (ADLs). Review of the care plan for Resident #9 dated 11/22/22 revealed the resident had an ADL self-care performance deficit related to cardiovascular disease. Interventions included staff to apply a left-hand resting hand orthotic as ordered. Review of the physician's orders for Resident #9 revealed an order dated 04/05/22 for the resident to wear left resting hand orthotic for six to eight hours as tolerated in order to promote skin joint integrity. The order also included instructions for staff to monitor skin integrity and document refusals every shift. Observation on 02/18/25 at 10:51 A.M. revealed Resident #9 was lying in bed without a brace on left hand. Observation on 02/19/25 at 10:10 A.M. revealed Resident #9 was lying in bed without a brace on left hand. Interview on 02/20/25 at 12:20 P.M. with Certified Nursing Assistant (CNA) # 323 and CNA #325 confirmed Resident #9 had not had a brace on all day. CNA #325 confirmed she had never placed a brace to Resident #9 's left hand. CNA #323 and CNA #325 confirmed they were unable to locate a brace for Resident #9. Interview on 02/20/25 at 12:40 P.M. with the Administrator confirmed Resident #9 was resting in bed and did not have the brace applied as ordered to left hand. Administrator further the nurse had documented Resident #9's skin was checked as ordered on 02/20/25. Interview on 02/20/25 at 12:40 P.M. with Resident #9 revealed the resident shook her head in a yes motion when asked if she wanted to have the splint applied. 2. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses including traumatic subdural hemorrhage, traumatic brain injury, cervical fracture, dislocation of right acromioclavicular joint and injury in motor vehicle accident. Review of the MDS assessment for Resident #72 dated 01/02/25 revealed the resident had moderately impaired cognition, required supervision with ADLs, and was coded as having no functional limitation to the bilateral upper extremities. Review of the plan of care for Resident #72 revealed the resident had an alteration in musculoskeletal status related to fractures from a motor vehicle accident. Interventions included the following: anticipate needs, encourage gentle range of motion daily two times a day morning and evening, see physical treatment plan. Review of the physician's progress note for Resident #72 dated 11/07/24 revealed the resident complained about soreness to his right shoulder and was currently working with physical therapy. The physician referred Resident #72 to orthopedics for a right shoulder evaluation. Review of the physician's orders for Resident #72 revealed an order dated 11/22/24 for staff to encourage the resident to apply a sling to his right arm and shoulder every shift. Review of the physician's progress note for Resident #72 dated 12/02/24 revealed the resident continued to complain about discomfort to his right shoulder and was working with physical therapy. Review of the physical therapy evaluation for Resident #72 dated 12/05/24 revealed the resident's right upper extremity range of motion was impaired and the resident presented with limited strength and range of motion needed for safe mobility. Review of the Medication Administration (MAR) for Resident #72 dated February 2025 revealed facility nurses initialed the order to encourage resident to apply sling to right arm and shoulder every shift with no documented refusals. Observation on 02/18/25 at 11:40 A.M. revealed Resident #72 was ambulating in his room and was not wearing a sling. Observation on 02/19/25 at 9:40 A.M. of revealed Resident #72 was ambulating in his room and was not wearing a sling. Observation on 02/20/25 at 10:19 A.M. revealed Resident #72 was sitting in his room and was not wearing a sling. Observation on 02/20/25 at 10:22 A.M. with CNA #323 revealed the aide searched for Resident #72's sling but was unable to locate it. Interview on 02/20/25 at 10:22 A.M. with CNA #323 confirmed she had never seen Resident #72 wear a sling and she routinely cared for the resident. CNA #323 further confirmed Resident #72 went out of the facility with a family member and did not wear a sling. Interview on 02/20/25 at 11:45 A.M. with CNA #329 confirmed Resident #72 did not have a sling present in his room and the aide could not remember when the resident was seen wearing a sling. Interview on 02/20/25 at 12:10 P.M. with Licensed Practical Nurse (LPN) #303 confirmed Resident #72 did not have a sling on when he left with his family member, and staff were unable to locate a sling in the resident's room. Interview on 02/20/25 at 12:50 P.M. with the Administrator confirmed Resident #72 did have a sling at one point but staff were unable to locate it. 49771 3. Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including cerebral infarction with non-dominant (left) side hemiplegia and hemiparesis, diabetes mellitus type two, chronic kidney disease, and depression. Review of the MDS assessment for Resident #51 dated 02/09/25 revealed the resident moderately cognitively impaired and required staff assistance with ADLs. The assessment did not reflect contractures or limitations in the resident's range of motion. Review of the medical record for Resident #51 revealed neither the resident's care plan nor the diagnosis list included contractures. Observation on 02/18/25 at 10:33 A.M. revealed Resident #51's left hand was contracted. Observation on 02/20/25 at 3:57 P.M. with Rehab Director (RD) #363 revealed RD #363 found a left-hand splint in the resident's belongings on the sink counter. Interview on 02/20/25 at 3:57 P.M. with RD #363 confirmed she had been unaware Resident #51 had a contracture of his left hand. Interview on 02/20/25 at 4:00 P.M. with RN #311 confirmed the MDS assessment for Resident #51 dated 02/09/25 was inaccurate as it did not reflect contractures or limitations in the resident's range of motion. Interview on 02/20/25 at 4:10 P.M. with RD #363 confirmed Resident #51 had received therapy treatment for a left-hand contracture in September 2024.

Based on medical record review, observation and staff interviews, the facility failed to ensure residents had fluids available at bedside. This affected one Resident (#08) reviewed for hydration. The facility census was 77. Findings include Medical record for Resident #08 revealed an admission on 08/03/18 with diagnoses including but not limited to dementia with behavioral disturbances and psychotic disorders with delusions. Review of the plan of care for Resident #08 revealed the resident is currently on hospice with diagnoses of moderate protein-calorie malnutrition. Interventions include to provide and serve diet as ordered, monitor and report any signs and symptoms of pocketing, drooling, multiple attempts with swallowing and refusing to eat. Resident #08 received a mechanically altered diet with regular liquids. Review of the physician order for Resident #08 dated 08/02/23 revealed an order for regular diet, mechanical soft texture and thin liquids consistency. Review of the nutritional assessment for Resident #08 dated 06/21/24 revealed no swallowing concerns. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #08 revealed an impaired cognition. Resident #08 is set up assistance for eating, toileting, transfers and bed mobility. Resident #08 was coded with incontinence of the bowel and bladder. Observation of Resident #08 on 02/18/25 at 11:09 A.M., revealed the resident lying in bed with family at bedside. No water pitcher or cup with water at bedside. Additional observation of surrounding area revealed fluids in her room for consumption. Observation of Resident #08 on 02/19/25 at 7:35 A.M., revealed the resident lying in bed with bedside table next to bed. No fluids were available for Resident #08. Interview with Certified Nursing Assistant (CNA) #329 on 02/20/25 at 9:59 A.M., revealed Resident #08 did not have water pitcher in her room because she has a history of throwing it at staff or taking it to other resident's rooms. CNA #329 stated Resident #329 was able to drink independently. Observation of Resident #08's room on 02/20/25 at 11:00 A.M. with Director of Nursing (DON) revealed Resident #08 did not have any fluids available for consumption and she should have. Interview with Resident #08 on 02/20/25 at 11:00 A.M. with Director of Nursing (DON), revealed the resident was lying in bed without any fluids available to drink. Resident #08 was questioned if she was thirsty and if she would like something to drink and the resident responded yes, what do you have. Interview with Administrator on 02/20/25 at 11:42 A.M, verified Resident #08 should have water available in her room at all times. The Administrator stated she was unaware staff was not providing fluids for Resident #08 related to behaviors Interview on 02/20/25 at 3:15 P.M. with Nurse Practitioner (NP) #500 stated there was no medical reason for Resident #08 to not have water at the bedside. NP #500 verified Resident #08 was currently on regular liquids and no laboratory tests were obtained regarding hydration due to hospice services in place. Request for policy related to hydration was requested during the survey and not provided for review.

Based on medical record review, staff interview and policy review, the facility failed to ensure timely monitoring of adverse side effects of psychoactive medications. This affected three Residents (#08, #72, and #06) of the five resident reviewed for unnecessary medications. The facility census was 77. Findings include 1) Medical record for Resident #08 revealed an admission on 08/03/18 with diagnoses including but not limited to dementia with behavioral disturbances and psychotic disorders with delusions. Review of the plan of care dated 08/15/18 for Resident #08, revealed the resident takes psychoactive medication related to psychotic disorder. Interventions include administering medication as ordered, monitoring, documenting and report adverse side effects of psychotropic medications. Review of the active physician orders for Resident #08 revealed an order dated 04/17/23 for Seroquel (antipsychotic) tablet 25 milligram (mg) by mouth three times a day. Review of the facility assessment tab in the electronic health record (EHR) for Resident #08 revealed an abnormal involuntary movement (AIMS) (a rating scale used to assess the severity of involuntary movements; particularly tardive dyskinesia) was last completed on 06/19/24. Additional review of assessment tab revealed only one AIMS assessment was completed in 2024 and no AIMS assessments were completed in January or February of 2025. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #08 revealed an impaired cognition. Resident #08 was coded as receiving antipsychotic and antidepressants medications during the assessment period. Interview on 02/20/25 at 3:30 P.M. with MDS Coordinator #316, verified the AIMS assessment should be completed with the annual and quarterly assessments. MDS Coordinator #316 verified the assessments were not completed for the MDS completed on 04/30/25, 07/31/25, 10/31/25 and 01/29/25 and they should have been. 2) Medical record review for Resident #72 revealed an admission on 09/25/24 with diagnoses including schizophrenia, subdural hemorrhage, traumatic brain injury and fracture of cervical vertebra. Review of the Medication administration record (MAR) for Resident #72, revealed an order for Invega Sustenna (atypical antipsychotic) Intramuscular Suspension Prefilled Syringe 117 MG/0.75 milliliter (ml) Inject one dose intramuscularly one time a day every 30 days dated 10/10/2024. Review of the quarterly MDS assessment dated [DATE] for Resident #72, revealed the resident had an impaired cognition. Resident #72 was independent in eating, toileting, bed mobility and transfers Review of the plan of care for Resident #72, revealed the resident is at risk for adverse effects and complications related to the use of psychotropic medications. Interventions include administering medications as ordered, monitoring and document for side effects and effectiveness, completing an AIMS every six months and as warranted and consulting with pharmacy, physician to consider dosage reduction when clinically appropriate. Review of the facility assessment tab in the electronic health record for Resident #72, revealed no documented evidence of any assessment for AIMS completed for the resident. Interview on 02/20/25 at 3:25 P.M. with the Director of Nursing (DON) verified the AIMS test was not completed on admission and should have been. 42731 3) Review of the medical record of Resident #06 revealed an admitted [DATE]. Diagnoses included dementia with agitation, memory deficit following cerebrovascular disease, type 1 diabetes, history of traumatic brain injury, post-traumatic stress disorder, unspecified convulsions, anxiety, depression, violent behavior, and mood disorder. Review of the physician orders for Resident #06 revealed an order dated 12/23/24 to check laboratory results (labs), including a Depakote level. The frequency of the need for the labs was not specified. Further review of physician orders revealed orders dated 01/07/22 for Depakote tablet Delayed Release (DR) 500 milligrams (mg) twice per day for unspecified convulsions and 08/01/24 for Rexulti (atypical antipsychotic) Oral Tablet two mg one time a day for dementia with agitation. Review of the quarterly MDS assessment for Resident #06 dated 01/24/25, revealed the resident had intact cognition. The resident required set-up assistance with eating, supervision for oral hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the medical record for Resident #06, revealed no documented evidence of a Depakote level (or valproic acid level) being obtained as ordered. Review of the medical record for Resident #06, revealed the most recent AIMS was completed on 06/28/24. Interview on 02/20/25 at 2:00 P.M., Licensed Practical Nurse (LPN) #359 verified the most recent AIMS completed for Resident #06 was on 06/28/24. LPN #359 stated AIMS should be completed quarterly for residents taking antipsychotic medications. LPN #359 further verified there was no evidence in the medical record of a Depakote/valproic acid level being obtained as ordered. Interview on 02/20/25 at 2:05 P.M., LPN #303 revealed she called the lab and there were no Depakote/valproic acid results available at any time for Resident #06. Interview on 02/20/25 at 2:35 P.M., the Director of Nursing (DON) verified Resident #06 did not have any Depakote/valproic acid results completed in the facility since Resident #06 started taking the medication 01/07/22. The DON stated Depakote/valproic acid levels should be checked every six months and stated the facility did not have a policy regarding the use of Depakote. Interview on 02/20/25 at 2:42 P.M., Nurse Practitioner (NP) #505 stated, when a resident takes Depakote, he expected Depakote/valproic acid levels to be monitored twice per year. Review of the facility policy titled, Use of Psychotropic Medication, dated 03/2025), revealed the resident's response to the medications should be monitored and documented. Residents who receive antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, and as needed.

Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure a safe, clean and homelike environment. This affected one (Residents #59) of four residents reviewed for physician environment and had the potential to affect two (Residents #27 and #238) of seven residents residing on the Heritage nursing unit. The facility census was 77 residents. Findings include: 1. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including lupus, epilepsy, and hypertension Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 01/07/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Observation on 02/18/25 at 10:25 A.M. revealed the wall by Resident #59's bathroom door had a missing section of cove base. The sink in the room was not properly secured and was able to be moved in all directions. There was a wide gap with no grout between the countertop and backsplash. The wall between the closet and sink had exposed drywall and needed to be patched and painted. There was an extra cable wire laying on the floor by the door. Interview on 02/18/25 at 10:25 A.M. with Resident #59 confirmed he was not pleased with the missing cove base, the condition of the sink and countertop area, and the extra cable wire on the floor in his room. Resident #59 was unable to recall if he had reported these concerns. Interview on 02/20/25 from 12:55 P.M. with Housekeeping Director (HD) #341 confirmed the physical environment concerns in Resident #59's room. 2. Observation of the shower room on the Heritage nursing unit revealed the shower room ceiling had damaged drywall that was peeling and in need of repair/replacement and painting. Interview on 02/20/25 at 1:09 P.M. with HD #341 confirmed the Heritage nursing unit shower room ceiling had damaged drywall that was peeling and in need of repair/replacement and painting. Interview on 02/20/25 at 1:20 P.M. with Registered Nurse (RN) #316 confirmed Residents #27 and #238 were the only resident of the seven residents residing on the Heritage nursing unit who had the ability to use the shower room. Review of the policy titled Resident Rights dated 2024 revealed the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely.

Based on medical record review, staff interview, review of hospice plan of care and hospice contract, the facility failed to jointly collaborate to develop a comprehensive plan of care that identified services to be provided by both providers. This affected one Resident (#08) of two reviewed for hospice services. The facility census was 77. Findings include: Medical record for Resident #08 revealed an admission on 08/03/18 with diagnoses including but not limited to dementia with behavioral disturbances and psychotic disorders with delusions. Review of the plan of care for Resident #08 revealed resident has an advanced directive do not resuscitate comfort care (DNR-CC) order dated 02/02/2020 with a revision date of 01/30/2024. Resident #08 is currently on hospice with diagnoses of moderate protein-calorie malnutrition. Interventions included to provide and serve diet as ordered, monitor and report any signs and symptoms of pocketing, drooling, multiple attempts with swallowing and refusing to eat. Resident #08 received a mechanically altered diet with regular liquids. Review of the facility and hospice agency contract dated 01/17/2024, revealed under coordination of services facility will ensure resident's written plan of care includes the most recent hospice plan of care with descriptions of services provided by both parties. Review of the hospice agency plan of care for Resident #08 dated 11/24/24, revealed hospice services would include skilled nursing visits one to two times a week for nine weeks, an aide two times a week for nine weeks, a Chaplin and a Licensed Social Worker (LSW) as needed. Additionally, the hospice agency would provide a bedside table, hospital bed, pressure relieving mattress with bolsters, and side rails. The hospice plan of care did not indicate any collaboration with facility staff in determining services to be provided. Review of the Care Conference Form dated 12/20/24 for Resident #08 revealed no documentation of hospice staff participating in the care conference meeting. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #08, revealed an impaired cognition. Resident #08 received hospice services during the assessment period. Observation on 02/18/25 at 11:09 A.M. of Resident #08 revealed resident lying in bed with family at bedside. Interview on 02/20/25 at 9:59 A.M. with Certified Nursing Assistant (CNA) #329 stated Resident #08 has a hospice aide at times, but there is not a schedule for the facility staff to know when they will be here and what care they will provide to the resident. Interview on 02/20/25 at 11:42 A.M with the Administrator, verified the facility has attempted to contact the hospice agency for schedule of hospice staff and services without success. The Administrator verified multiple messages have been left for the hospice agency without return contact. Interview on 02/20/25 at 12:05 P.M. with Facility's Social Service Director (SSD) #353, verified there has not been any collaboration between the facility and the hospice agency in the development of the care plan for Resident #08. SSD #353 verified a recent care conference was held on 12/20/24 and hospice staff did not participate. SSD #353 stated they were notified of the planned meeting via phone message. Interview on 02/20/25 at 2:45 P.M. with MDS Coordinator / Registered Nurse (RN) #311, verified the facility plan of care did not contain information related services hospice would be providing for Resident #08. RN #311 verified the participating hospice agency did not participate in the development of a plan of care. A request for a policy related to the development of the plan of care was requested during the survey and not provided for review.

Based on medical record review, observation and staff interviews, the facility failed to ensure medications were stored in accordance with professional standards. This affected one Resident (#237) of four resident reviewed for medication administration. The facility was 77. Findings include: Review of the medical record revealed Resident #237 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, tracheostomy, metabolic encephalopathy, diabetes mellitus type II, schizophrenia, bipolar disorder, opioid dependence and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment for Resident #237 dated 02/18/25 was not completed at the time of the survey. Review of the plan of care for Resident #237 was incomplete due to recent admission. Review of the physician orders for the month of February 2025 for Resident #237 revealed an order dated 02/12/25 for Lidocaine external patch 5 percent apply to affected area topically in the evening for pain. Review of the Medication Administration Record (MAR) for February 2025 for Resident #237 revealed the lidocaine patch was applied as ordered on 02/19/25 at 6:00 P.M. Observation on 02/20/25 at 9:01 A.M. of medication administration for Resident #237 with Licensed Practical Nurse (LPN) #303 and Assistant Director of Nursing (ADON) #316 revealed LPN #303 entered the resident's room with the prepared medications. Resident #237 requested LPN #303 to apply a Lidocaine patch that was observed laying on her bedside table. The Lidocaine patch was not dated and still had the protective backing adhered to one side (adhesive side) of the patch. Resident #237 stated the nurse came into her room last night (02/19/25) and did not apply the patch to her lower back as ordered. LPN #303 verified Resident #237 did not have the patch on as ordered and patch should not have been left in the room unsupervised. A request for a facility policy related to medication administration was made during the survey and not provided for review.

Based on observation, family interview, and staff interview, the facility failed to ensure residents had a safe, clean, comfortable environment. This affected one (Resident #8608) and eight additional residents (#29, #30, #4, #5, #10,#11, #14 and #15) of nine residents' rooms observed. The facility census was 81. Findings include: Review of the medical record revealed Resident #8608 was admitted on [DATE] with diagnoses of paranoid schizophrenia, cerebral infarction with right sided hemiplegia and hemiparesis, anemia and congestive heart failure. The resident discharged to the hospital on 07/31/24 and bed hold was discontinued on 08/04/24. Review of the Minimum Data Set (MDS) discharge return anticipated assessment dated [DATE] revealed Resident #8608 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating and was dependent for all other activities of daily living which included oral and personal hygiene, toileting, bathing, dressing bed mobility and transfers. Review of the August 2024 Grievance/Concern Log revealed on 08/01/24, the family of Resident #8608 registered a concern about an area of exposed drywall potentially harboring mold and creating an unsafe living environment. Observation during the initial tour on 08/12/24 from 9:10 A.M. to 10:35 A.M. revealed the following concerns: In Resident #8608's room there was wallpaper above the Heating, Ventilation and Air Conditioning (HVAC) unit and below the window peeled back exposing dry wall which was black in color. In Resident #29 and Resident #30's room the privacy curtain for the bed near the window was torn and not hanging properly. In unoccupied room [ROOM NUMBER] the wallpaper seams were peeling and ceiling tile was missing in the toilet stall. In Resident #4 and #5's room there was brown material resembling feces all over the toilet bowl. In Resident #10 and #11's room the bathroom ceiling tile had a large brown ring stain. In Resident #14 and #15's room the wallpaper was peeling in the bathroom. Interview on 08/12/24 at 10:20 A.M. with State tested Nursing Assistant (STNA) #500 confirmed the discolored drywall in Resident #8608's room above the HVAC unit and below the window and stated it had been in this condition for approximately two weeks. Interview on 08/12/24 at 1:00 P.M. with Administrator #100 verified the above observations. This deficiency represents non-compliance investigated under Complaint Number OH00156431 and OH00155848.

Based on record review, hospital record review, staff interview, and policy review, revealed the facility failed to ensure residents medications were ordered and administered following a hospital discharge resulting in a significant medication error. This affected one (#11) of three Residents (#11, #12, and #13) reviewed of use of anti-coagulants. The facility census was 83. Findings include: Review of Resident #11's closed medical record revealed the resident was admitted to the facility on [DATE] Diagnoses included myocardial infarction (heart attack) with cardiac and vascular implants (stents), history of transient ischemic attacks (TIAs), human immunodeficiency virus (HIV), and cerebrovascular disease. Resident #11 was discharged to a local hospital on 06/01/24. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had cognitive deficits and required set up assistance with activities of daily living (ADLs). Review of Resident #11's Hospital After Visit Summary (AVS) dated 05/21/24, revealed the resident was ordered to start taking the following new medications: Ticagrelor 90 milligrams (mgs) (anti-coagulant) twice daily. ferrous sulfate 325 mgs (iron supplement) daily, and metoprolol succinate 25 mgs Extended Release (ER) (anti-hypertensive) daily. Review of Resident #11's progress note dated 05/21/24 and authored by Licensed Practical Nurse (LPN) #42, revealed the resident returned to the facility from the hospital at 3:05 P.M. Resident #11's vital signs were within normal limits (WNL) with no concerns at this time. Resident #11's family was notified of the residents returning to the facility. Review of Resident #11's May and June 2024 Medication Administration Record (MAR) revealed the ferrous sulfate 325 mg, metoprolol 25 mg ER, and Ticagrelor 90mg were not listed on the MAR as being administered. Review of Resident #11's May and June 2024 physician orders, revealed ferrous sulfate 325 mg, metoprolol 25 mg extended release, and ticagrelor 90mg were never ordered upon readmission to the facility on [DATE]. Review of Resident #11's progress note dated 06/01/24, revealed the resident was complaining of shortness of breath and vitals were as follows: blood pressure (BP) 134/65 millimeters of mercury (mm/Hg), temperature 98.1 degrees Fahrenheit, pulse 177 beats per minute, and respirations 24 breaths per minute. Resident #11 was placed on a non-breather oxygen mask and 10 Liters Per Minute (LPM) of oxygen was administered. The pulse oxygen saturation increased to 85 percent (%) (normal 95-100 %). Nine-one-one (911) was called to transfer the resident to the hospital. The Medical Director (MD) and Power-of-Attorney (POA) were notified. Review of a Nursing Policy/Procedure Manual Medication Incident Report, dated 06/02/24, revealed Resident #11 had medications that were not implemented from a hospital discharge on 05/21/24. Review of Employee Progressive Disciplinary Report, dated 06/03/24 ,revealed LPN #24 was terminated for substandard work including failing to audit hospital paperwork that resulted in a medication error. Interview on 06/11/24 at 10:57 A.M. with the Director of Nursing (DON) verified former LPN #42 did not check the physician orders for Resident #11 when he returned from the hospital on 05/21/24 and the resident's ferrous sulfate 325 mg, metoprolol ER 25 mg, and Ticagrelor 90mg was never started. The DON stated the LPN #42 was disciplined and ultimately terminated due to failure to do a proper readmission for Resident #11 that resulted in the significant medication error. Interview on 06/12/24 at 10:15 A.M. Medical Director (MD) #35 reported he was never informed of the medication error involving Resident #11 because he was on vacation when it happened. MD #35 stated Resident #11 was declining in health due to strokes, non-compliance with care and had suffered cognitive decline causing him to be on the memory care locked unit. MD #35 indicated that he was not aware that Resident #11 had been readmitted to the hospital on 06/01/24 because he was still on vacation. An additional interview on 06/12/24 at 10:30 A.M. with the DON, reveled the Assisted Director of Nursing (ADON) #34 called her on 06/02/24 to inform her that Registered Nurse (RN) #31 and LPN #32 received a call from the hospital to reconcile the resident's current medications and to question why ferrous sulfate 325 mg, metoprolol ER 25 mg, and Ticagrelor were not listed on the transfer list of medications. The DON stated that is when the facility discovered the medication error had occurred. Interview on 06/12/24 at 10:38 A.M. with ADON #34, revealed she received a phone call on 06/02/24 from RN #31 stating the hospital called her to reconcile the resident's medications when she discovered orders for Resident #11 were never transcribed upon being readmitted on [DATE]. ADON #34 stated she informed the DON, and an investigation was initiated. Interview on 06/12/24 at 10:45 A.M. with LPN #32, revealed after Resident #11 was admitted to the hospital, an unknown staff member called the facility to find out if Resident #11 was taking the Ticagrelor, metoprolol and ferrous sulfate which was ordered when he was discharged on [DATE] since it was not listed on his current medication list sent with the resident to the hospital. LPN #32 stated she pulled Resident #11's chart and there were no hospital discharge orders or physician orders for the Ticagrelor, metoprolol 25 mg, and iron and no pharmacy records which showed the medications had been ordered. LPN #32 stated she and RN #31 looked around the nurse's station for the 05/21/24 discharge orders and they were found between a bunch of folders and paperwork on the nurse's desk. Interview on 06/12/24 at 11:20 A.M. with RN #31, revealed the hospital called when Resident #11 was admitted reconciling the resident's medications. RN #31 stated the Ticagrelor, metoprolol and ferrous sulfate were not on the physician order sheet. RN #31 stated the nurse never transcribed the new orders from the hospital discharge when Resident #11 was readmitted to the facility on [DATE]. RN #31 stated after learning of the medications not being started, she started searching the nurse's station and found the envelope with the orders between folders and other paperwork where no one would have thought to look. Review of the undated facility policy titled Administering Medications, revealed medications must be administered in accordance with the physician orders, including any required time frames. This deficiency represents non-compliance investigated under Complaint Number OH00154602.

Based on observations, review of medical record reviews, interviews with resident and facility staff, and review of facility policy, the facility failed to ensure staff provided adequate supervision to prevent a resident, who had been previously assessed as being at high risk of elopement, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#26) was placed at potential risk for serious life-threatening harm and/or injury when he eloped from the facility without staff knowledge. Resident #26 was missing for an unknown amount of time and was found by an off-duty employee approximately 0.1 miles from the facility ambulating with a wheeled walker in the middle of a busy, heavily trafficked street, and cars were having to swerve around the resident to avoid hitting him. This affected one (#26) of three residents reviewed for risk of elopement. The facility identified 16 current residents (#03, #04, #05, #06, #07, #08, #11, #12, #13, #14, #16, #19, #21, #22, #23 and #26) at risk for elopement. Additionally, the facility failed to provide adequate supervision and ensure residents smoked only in the designated smoking areas which placed residents at risk for the potential for more than minimal harm that was not Immediate Jeopardy. This affected four (#32, #33, #40, and #68) of four residents reviewed for smoking. The facility identified 44 residents who smoke. The facility census was 88. On 05/14/24 at 12:07 P.M., Director of Operations (DOO) #01, DOO #02, the Administrator, and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/20/24 at an undocumented time when Resident #26 exited the facility without staff knowledge. Resident #26 was previously assessed as being at high risk for elopement on 08/30/23 and 09/14/23. The facility did not have a care plan in place for the resident being at a high risk for elopement nor interventions in place to prevent elopement. On 04/20/24 at an undocumented time, Resident # 26 was found by Housekeeper #970 who was driving near the facility and was not working at the time and identified the individual as a resident of the facility. Resident #26 was located about one-tenth of a mile from the facility and was walking in the street with his walker and cars were having to swerve around the resident to avoid hitting him. The facility staff were unaware Resident #26 was missing until Housekeeper #970 notified them that the resident was outside in the middle of the street. Resident #26 was returned to the facility by an unknown staff member with no physical injuries observed. The facility did not document in the medical record Resident #26's elopement on 04/20/24 and did not complete an investigation into Resident #26's elopement because the facility did not consider this incident an elopement. On 04/22/24, Resident #26 was moved into the secured unit of the facility. The Immediate Jeopardy was removed on 05/15/24 when the facility implemented the following corrective actions: On 04/20/24 at approximately 8:00 P.M., Resident #26 was redirected by an employee to return to the facility after leaving the facility to go to the local gas station. Facility staff assisted Resident #26 to return to the facility with no indication of negative effects. On 04/22/24, Certified Nurse Practitioner (CNP) #91 assessed Resident #26 with no negative findings. On 04/22/24, the DON completed the Secured Unit Screening and Resident #26 was moved to the secured unit. On 05/13/24, DOO #01 educated the DON and Administrator on the definition of elopement. On 05/13/24, the Administrator and DON completed elopement in-services to all staff in-person, by telephone, and by text notification. Education included whom to notify and how to identify if an elopement had occurred. Agency staff will be provided with a copy of the education, and it will be in the assignment binder that the agency staff report to for each shift. On 05/13/24, the Administrator began investigating Resident #26's elopement on 04/20/24. It was discovered that Resident #26 met qualifications for placement on the secured unit on 09/14/23 when Resident #26 was assessed to be at a high risk of elopement, but the resident was not moved to the unit until 04/22/24. Root cause analysis indicates the system failure was an Elopement Risk Assessment was completed with no follow up action. On 05/13/24, the DON and designee completed audits of all 88 residents for Elopement Risk with no negative findings. No additional residents were impacted by the Elopement Risk Assessments. All 16 high-risk residents were appropriately located on the secured unit. All high-risk residents had care plans reviewed to ensure elopement risk was included. Care plans were revised to reflect changes for Residents #04, #13, #14, #21, and #26. On 05/13/24, the Administrator provided verbal education to the DON, and two unit managers [Registered Nurse (RN) #345 and Licensed Practical Nurse (LPN) #165] on identifying high elopement risk residents and the appropriate placement of exit-seeking individuals onto the secured unit as applicable. On 05/13/24, Minimum Data Set (MDS) Nurse #340 initiated a care plan for Resident #26. The care plan included that Resident #26 was an elopement risk/wanderer with an intervention of placement on a secured unit. Other interventions included identifying the pattern of wandering: divert as needed and intervene as appropriate. On 05/14/24, the facility held an ad hoc Quality Assurance Performance Improvement (QAPI) meeting with Medical Director #90, the Administrator, DOO #01, DOO #02, and the DON. The long-term care Ombudsman was also notified of the Immediate Jeopardy situation involving Resident #26. On 05/15/24, the DON or designee completed education to the nursing staff regarding Elopement Risk assessments and their completion/accuracy to ensure all nursing staff are knowledgeable. Beginning 05/15/24, the Administrator or designee will complete weekly audits for four weeks for elopement risk assessments for all admissions, readmissions, and any resident with a change in condition. Although the Immediate Jeopardy was removed on 05/15/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #26 revealed an initial admitted [DATE]. Resident #26 had diagnoses including dementia, altered mental status, cognitive communication deficits, and high blood pressure. Review of the elopement risk assessment, dated 07/12/23, revealed Resident #26 had an incomplete elopement risk assessment upon admission to the facility. Review of the elopement risk assessment completed on 08/30/23 and 09/14/23 reflected a score of 11, indicating the resident was at a high risk for elopement. Both assessments reflected Resident #26 had poor decision-making skills and poor safety awareness. Review of the quarterly MDS assessment, dated 04/01/24, revealed Resident #26 had moderate cognitive impairment, and required supervision from staff with ambulation and personal care. Review of the care plan, dated 07/12/23 through 05/13/24, revealed there was no care plan in place for Resident #26 for elopement or interventions to prevent elopement. Review of the nursing notes revealed no recollection or documentation providing information on the events of 04/20/24. Review of the census record revealed Resident #26 was transferred to the secured memory care unit on 04/22/24. Review of CNP #91's assessment dated [DATE] revealed no negative findings as a result of Resident #26's elopement. Review of the Secured Unit Screening dated 04/22/24 revealed Resident #26 was assessed to be appropriate for the secured locked unit. Review of the social service progress notes from 05/02/24 revealed a late entry note was created for 04/22/24 which documented Social Services Director #200 called to speak with the niece of Resident #26 to discuss future placement of the resident on the secure unit. The niece agreed and will come to the facility to visit. Resident #26 was made aware of future placement in the secured unit; agrees and presents with excitement regarding possible change. A request to review the facility's investigation on 05/13/24 revealed the facility did not complete an investigation following Resident #26's elopement on 04/20/24. On 05/13/24 at 12:45 P.M., an observation and interview with Resident #26 revealed the resident was walking up and down the hallway on the secured unit. Resident #26 was self-ambulating with the use of a wheeled walker. Resident #26 stated that he knew he messed up when he went outside a few weeks ago to go to the store, which he thought was around 04/20/24. Resident #26 stated he was now completely locked up because of it. On 05/13/24 at 1:20 P.M., an interview with the Administrator and the DON verified Resident #26 often left the facility prior to 04/20/24 without incident. The Administrator and DON verified the resident was at risk for elopement per the elopement risk assessments completed on 08/30/23 and 09/14/23 and would often exit the front doors to sit outside. The Administrator and DON verified Resident #26 had walked away from the facility on 04/20/24, without staff knowledge, and stated he was trying to go to the store. The DON stated has never eloped from the facility and was placed on the locked unit after an agreement with the guardian. The DON stated Resident #26 was trying to go to the store which he had never done before. The DON verified the facility did not complete an investigation into Resident #26's elopement and explained the facility did not consider it an elopement. The DON verified Resident #26 had impaired cognition, was off the facility property, and found in the middle of the road. On 05/13/24 at 2:15 P.M., an interview with Social Services Director #140 revealed Resident #26 was identified by another staff member walking into oncoming traffic near a four-way intersection on 04/20/24. She verified Resident #26 was placed on the secured unit on 04/22/24 following the incident two days earlier. She verified the niece of the resident was notified of the move on 04/22/24. On 05/13/24 at 2:30 P.M., telephone interview with Housekeeper #970 revealed he had identified Resident #26 as he was ambulating on the main road in front of the facility with his wheeled walker. Housekeeper #970 stated the resident was about 0.1 miles from the facility walking in the middle of the road with vehicles swerving around him. Housekeeper #970 stated he had yelled at the resident to get out of the road and drove to the facility to alert nursing staff that the resident had left the facility grounds. On 05/14/24 at 9:45 A.M., an interview with LPN #79 revealed she was working on the first floor and was not assigned to provide care to Resident #26 on 04/20/24. LPN #79 stated Housekeeper #970 had entered the building on 04/20/24 and reported Resident #26 was ambulating in the middle of the road into oncoming traffic. LPN #79 stated she went up to the second floor where the resident resided and the staff were not aware Resident #26 had even left the floor. LPN #79 verified this was not a very safe situation for this resident. LPN #79 stated an unknown staff member brought Resident #26 back to the facility and escorted him to the second floor. She then stated the resident was placed on the secured unit on 04/22/24 following these events. On 05/14/24 at 10:00 A.M., an interview with the DON verified she was not sure who the nurse on duty was for Resident #26 on 04/20/24. She verified there has been no elopement care plan since the resident was identified as an elopement risk on 08/30/23 and 09/14/23. The DON also verified the facility did not have any type of policy to define or prevent elopement. 42728 2) Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] and had diagnoses including epilepsy, hemiplegia affecting the right dominant side, dementia, and tobacco use. Review of the quarterly MDS assessment, dated 04/26/24, revealed the resident was assessed to have moderately impaired cognition. Review of the care plan, most recently revised on 02/15/24, revealed Resident #40 had the potential for injury related to smoking and was non-compliant with supervised smoking. Interventions included providing smoking aprons for use during supervised smoking. Review of the facility's Smoking-Safety Screen, dated 01/18/24, revealed Resident #40 was assessed to be safe to smoke with supervision. Observation on 05/15/24 at 10:35 A.M. revealed Resident #40 was sitting in a chair less than 10 feet away from the facility entrance smoking a cigarette. Hanging above the resident's head was a sign which read No Smoking. The resident was observed to finish his cigarette and throw the cigarette butt onto the ground in front of him as there was not a cigarette butt receptacle available to throw it into. The resident was not wearing a smoking apron and no staff had been outside monitoring the resident. Interview with the DON at the time of the observation on 05/15/24 at 10:35 A.M. verified Resident #40 was sitting outside smoking a cigarette without staff supervision and was not wearing a smoking apron. The DON additionally verified the area was not a designated smoking area. 3) Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, chronic obstructive pulmonary disorder, and tobacco use. Review of the admission MDS assessment, dated 04/18/24, revealed Resident #32 was assessed to have intact cognition. Review of the care plan, dated 04/15/24, revealed Resident #32 had a potential for injury related to smoking and could smoke with supervision. Interventions included assessing and monitoring the resident's ability to smoke safely. Review of the assessments for Resident #32 revealed a safe smoking assessment had not been completed. Observation on 05/14/24 at 4:00 P.M. revealed Resident #32, Resident #33, and Resident #68 were sitting less than 10 feet away from the facility entrance smoking a cigarette. Hanging above the residents' heads was a sign which read No Smoking. The residents were observed to finish their cigarettes and throw the cigarette butts onto the ground in front of them as there was not a cigarette butt receptacle available to throw them into. No staff were outside monitoring the residents while they were smoking. Observation on 05/15/24 at 8:15 A.M. revealed Resident #32 was sitting in a wheelchair less than 10 feet away from the facility entrance smoking a cigarette. Hanging above the resident's head was a sign which read No Smoking. The resident was observed to finish his cigarette and throw the cigarette butt onto the ground in front of him as there was not a cigarette butt receptacle available to throw it into. No staff were outside monitoring the resident while he was smoking. Interview with the DON on 05/15/24 at 10:35 A.M. verified Resident #32 and several other residents frequently sat outside within 10 feet of the facility smoking cigarettes without staff supervision. The DON additionally verified the area was not a designated smoking area. 4) Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] and had diagnoses including angina, chronic obstructive pulmonary disease, and nicotine dependence. Review of the quarterly MDS assessment, dated 02/28/24, revealed the resident was assessed to have mildly impaired cognition. Review of the care plan, most recently revised on 10/30/23, revealed Resident #68 was a smoker. Interventions included to notify the charge nurse immediately if it was suspected the resident had violated the smoking policy. Review of the facility's Smoking-Safety Screen, dated 01/24/24, revealed Resident #68 could smoke with staff supervision. Observation on 05/14/24 at 4:00 P.M. revealed Resident #32, Resident #33, and Resident #68 were sitting less than 10 feet away from the facility entrance smoking a cigarette. Hanging above the residents' heads was a sign which read No Smoking. The residents were observed to finish their cigarettes and throw the cigarette butts onto the ground in front of them as there was not a cigarette butt receptacle available to throw them into. No staff were outside monitoring the residents while they were smoking. Interview with the DON on 05/15/24 at 10:35 A.M. verified Resident #68 and several other residents frequently sat outside within 10 feet of the facility smoking cigarettes without staff supervision. The DON additionally verified the area was not a designated smoking area. 5) Record review for Resident #33 revealed the resident was admitted to the facility on [DATE] and had diagnoses including weakness, glaucoma, and peripheral vascular disease. Review of the admission MDS assessment, dated 03/15/24, revealed the resident was assessed to have intact cognition. Review of the care plan, dated 03/11/24, revealed Resident #33 had a history of smoking in the community and was an independent smoker. Interventions included to complete the smoking evaluation and encourage compliance. Review of the assessments for Resident #33 revealed a safe smoking assessment had not been completed. Observation on 05/14/24 at 4:00 P.M. revealed Resident #32, Resident #33, and Resident #68 were sitting less than 10 feet away from the facility entrance smoking a cigarette. Hanging above the residents' heads was a sign which read No Smoking. The residents were observed to finish their cigarettes and throw the cigarette butts onto the ground in front of them as there was not a cigarette butt receptacle available to throw them into. No staff were outside monitoring the residents while they were smoking. Interview with the DON on 05/15/24 at 10:35 A.M. verified Resident #33 and several other residents frequently sat outside within 10 feet of the facility smoking cigarettes without staff supervision. The DON additionally verified the area was not a designated smoking area. Review of the facility policy titled Smoking, revised 01/02/24, revealed residents will be evaluated upon admission and routinely to determine if he or she is able to smoke safely with or without supervision (per smoking assessment). Residents who require supervision shall always have the supervision of a staff member, family member, visitor, or volunteer worker while smoking. Designated smoking times will be provided for residents that require supervision. Smoking is only permitted in designated smoking areas. Appropriate containers and receptacles must be available in smoking areas. Residents who do not require supervision with smoking do not have to adhere to designated smoking times but must smoke in designated areas only. This deficiency represents non-compliance investigated under Complaint Number OH00153627.

Based on observations, staff interviews, resident interviews, record review, and review of the facility policy, the facility failed to ensure the elevators were maintained in good working order and failed to ensure cigarette butts were disposed of in appropriate containers. This had the potential to affect all residents residing in the facility except the 27 residents who resided on the secured unit of the facility. The facility census was 89. Findings include: 1. Observation on 05/13/24 at 10:00 A.M. revealed there were numerous cigarette butts lying on the ground in front of the facility entrance doors. Observation on 05/14/24 at 8:00 A.M. revealed there continued to be numerous cigarette butts lying on the ground in front of the facility entrance doors, in the mulch across from the facility entrance doors, and in the rocks located beside the facility entrance doors. Observation on 05/14/24 at 4:00 P.M. revealed there were three residents sitting outside within ten feet of the facility entrance doors smoking cigarettes. When finished with the cigarettes, the residents disposed of the cigarette butts on the ground as there was not a receptacle to place them in. Numerous cigarette butts continued to be observed on the ground in front of the facility entrance doors, in the mulch across from the facility entrance doors, and in the rocks located by the facility entrance doors. Observation on 05/15/24 at 8:15 A.M. revealed one resident sitting outside within ten feet of the facility entrance doors smoking a cigarette. When finished with the cigarette, the resident disposed of the cigarette butt on the ground as there was not a receptacle to place it in. Numerous cigarette butts continued to be observed on the ground in front of the facility entrance doors, in the mulch across from the facility entrance doors, and in the rocks located by the facility entrance doors. Observation and interview with the Director of Nursing (DON) on 05/15/24 at 10:35 A.M. confirmed there were numerous cigarette butts located on the ground in front of the facility entrance doors, in the mulch across from the facility entrance doors, and in the rocks located by the facility entrance doors. The DON additionally confirmed the area was not a designated smoking area and contained a sign which read No Smoking but residents continued to sit outside smoking cigarettes and threw the cigarette butts on the ground. Review of the facility policy titled Smoking, revised 01/02/24, revealed smoking was only permitted in designated smoking areas and appropriate containers and receptacles must be available in smoking areas. 2. Observation on 05/13/24 at 11:10 A.M. revealed there were two elevators located next to each other inside the facility. The elevator on the right had a sign indicating the elevator was out of order. The elevator on the left was observed to be in service. Observation on 05/13/24 at 4:00 P.M. revealed the elevator on the right continued to have a sign indicating it was out of order. The button for the elevator on the left was pressed and the doors opened. After entering the elevator and pressing the button containing the number two the elevator proceeded to move up to the second floor but the doors would not open. After approximately 30 seconds, the elevator was felt to be moving back down and the doors opened to the first floor. Interview with State tested Nursing Assistant (STNA) #189 on 05/14/24 at 12:29 P.M. confirmed the elevators located in the facility were frequently out of order or not working properly. Interview with Resident #68 on 05/14/24 at 12:48 P.M. confirmed the elevators in the facility were frequently out of order or not working properly. Telephone interview with Ombudsman #500 on 05/14/24 at 3:39 P.M. confirmed the facility frequently had complaints regarding the elevators not functioning properly which included complaints made by the local Fire Chief. Interview with the DON on 05/14/24 at 4:30 P.M. confirmed one elevator was currently out of service and the second elevator did not always open on the second floor to allow people to get off prior to going back down to the first floor. Observation and interview with the DON on 05/15/24 at 10:45 A.M. confirmed while taking the elevator from the first floor up to the second floor the elevator stopped on the second floor but the doors would not open. The elevator then proceeded back to the first floor and the doors opened. Interview with the Administrator on 05/16/24 at 10:45 A.M. confirmed one elevator was out of order and the other elevator was not functioning properly despite multiple repairs being done. Interview with the DON on 05/16/24 at 11:05 A.M. confirmed the facility did not have a policy pertaining to elevator maintenance. Review of the Resident Council Meeting minutes, dated 04/25/24, revealed documented concerns of the elevators not being in good, working order. This deficiency represents non-compliance investigated under Master Complaint Number OH00153836, Complaint Number OH00153830, Complaint Number OH00153679, and Complaint Number OH00153493.

Based on closed medical record review, staff interviews and review of hospital records the facility failed to provide timely care for a resident who had a change in condition after the resident was found on the floor. This resulted in actual harm when the resident sustained [REDACTED]. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 94. Findings include: Review of the closed medical record revealed Resident #22 was originally admitted on [DATE]. The resident was readmitted on [DATE] after hospitalization and surgery for [REDACTED]. The resident was discharged back to the hospital on [DATE] for respiratory distress. Review of the residents' five day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene. He required the extensive assistance of one staff for transfers. The resident was frequently incontinent of bowel and bladder functions. The resident had demonstrated inattention and disorganized thinking. Review of fall assessment dated [DATE] revealed the resident was a moderate risk for falls. Review of a fall care plan dated 02/22/19 revealed the resident was a fall risk related to [DIAGNOSES REDACTED]. The intervention was to encourage the resident to use adaptive devices. Review of a risk management assessment dated [DATE] at 11:40 [NAME]M. revealed the resident sustained [REDACTED]. At this time the resident was also assessed to be at high risk for falls. Review of a risk management assessment dated [DATE] at 2:26 P.M. revealed the resident was found laying on the floor in his room with a blanket and pillow. He was awake and able to respond to questions. The resident complained of pain in his right leg, and he was unable to stand without assistance. The new intervention was a prompt sign in his room. The resident was sent to the hospital at 3:05 P.M. Review of the hospital emergency department records revealed the resident presented with complaints of back pain and right ankle pain. The final impression was a closed fracture of distal end of right fibula, initial encounter. The resident was referred to an orthopedist. The resident had a computed tomography (CT) scan completed of his head and cervical spine. The CT scan was negative. Review of a risk management assessment dated [DATE] at 6:56 P.M. revealed the resident was attempting to stand in the dining room when a State tested Nurse Aide (STNA) tried to redirect him to sit. The resident swung his cane at the STNA, lost his balance and fell . The immediate intervention was routine checks every 15 minutes. Neurological checks were initiated. The resident was oriented to person and situation and no injuries were observed post incident. Review of the Neurological Evaluation Flow Sheet initiated 06/22/19 revealed complete neurological evaluation with vital signs was completed initially, then every 30 minutes times four, then every hour times four, then every eight hours times nine (72 hours). The form indicated more frequent evaluations may be necessary. Complete episodic charting for at least 72 hours including any pertinent findings related to the neurological evaluation. Review the most recent evaluation on the medical record and notify the physician of any changes from previous evaluation. File completed flow sheets in the center specified area of the clinical record. Review of nursing note dated 06/25/19 at 5:30 P.M. revealed the resident attempted to stand up out of the wheelchair and fell on the dining room floor. The resident was assessed, vital signs were stable and the resident was assisted up by three nurses and transferred back into the wheelchair. No injuries or signs of distress was noted. The intervention for this fall was a non-skid pad in his wheelchair. Review of nursing note dated 06/26/19 at 7:30 [NAME]M. revealed an STNA was making rounds when she found the resident lying on the floor on his stomach with a blanket under his head. The resident reported he attempted to ambulate to the restroom unassisted. His clothing was wet, the resident denied pain and there were no apparent injuries noted. His blood pressure was 161/80, pulse 90, respiratory rate 18, his temperature was 98.4 degrees and his oxygen saturation was 96% on room air. The residents' spouse was called, but there was no response so a message was left on the voice mail to call the facility. Review of nursing note dated 06/26/19 at 12:30 P.M. revealed the resident appeared tired at lunch. He was able to respond when spoken to but was up at the table with his eyes closed. An STNA assisted the resident to bed. Review of nursing note dated 06/26/19 at 2:00 P.M. revealed an STNA notified the nurse that the resident was lying in bed resting with emesis noted on clothing and linen. The resident was not responding to staff. Audible breath sounds were noted. The nurse notified the Unit Manager and the Director of Nursing (DON) of the change of status. A call was placed to nine-one-one (911), the spouse was notified and aware of transport to the hospital. Review of hospital neurosurgery history and physical examination [REDACTED].M. revealed the physician documented the resident was intubated after a CT showed a large right sided subdural hematoma. The physician documented he had personally reviewed the CT of the head dated 06/26/19 demonstrating by his read, a large right sided subdural hematoma measuring two centimeters (cm) in maximum with 1.7 cm right to left midline shift with trapping of the left lateral ventricle with developing [DIAGNOSES REDACTED]. Review of the hospitals discharge summary dated 07/13/19 documented the resident had a subdural hemorrhage. The resident had a right hemicraniectomy (surgical removal of part of the skull) for evacuation of subdural hematoma. A [MEDICAL CONDITION] and a gastrostomy tube were placed. On 09/30/19 at 10:30 [NAME]M. a telephone interview was conducted with Licensed Practical Nurse (LPN) #23 who cared for the resident on 06/26/19. LPN #23 said she kept the resident with her during the day after his was found on the floor. The nurse stated she initially did vitals but was unable to provide an explanation as to why there was no documentation of neurological checks. She stated she could not remember if she did neuro checks after the resident was found on the floor. On 09/30/19 at 11:55 [NAME]M. a telephone interview was conducted with STNA #10 who cared for the resident on 06/26/19. STNA #10 said on 06/26/19 at lunch time the resident was unusually lethargic. STNA #10 said usually the resident was more aggressive, but he was groaning at lunch. STNA #10 said when she checked on him at 06/26/19 at 2:00 P.M. he was in bed, he had vomited and he was snoring. Follow up telephone interview with STNA #10 on 09/30/19 at 3:30 P.M. revealed on 06/26/19 around lunch time she told LPN #23 that the resident was more lethargic than usual. She said the nurse assessed the resident and instructed staff to put him to bed. Follow up telephone interview with LPN #23 on 09/30/19 at 4:00 P.M., LPN #23 denied on 06/26/19 that STNA #10 told her the resident was more lethargic than usual. This is an incidental citation discovered during the investigation of Complaint Number OH 666.

Based on review of closed and current medical records, review of a facility policy, review of a Death Certificate, interviews with staff, and review of personnel files, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) timely for one Resident (#80) who was a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #80 did not receive CPR or Emergency Medical Services and expired at the facility. This resulted in Immediate Jeopardy for one (#80) of three residents reviewed for an emergent change in condition. The facility identified a total of 68 residents residing in the facility designated with Full Code Status. The facility census was 78. On [DATE] at 5:00 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 12:00 A.M. when Resident #80 was found unresponsive without a pulse, respirations or blood pressure, and Licensed Practical Nurse (LPN) #105 and Registered Nurse (RN) #110 failed to initiate CPR or notify EMS. Resident #80 expired at the facility. The Immediate Jeopardy was removed on [DATE] at 8:30 A.M. after the facility implemented the following corrective actions: · On [DATE] at 6:30 A.M., the DON initiated an investigation related to the lack of CPR being initiated. · On [DATE] at 8:00 A.M., the DON assessed all residents in the building to ensure accurate code status was correct in the medical records. With the audit, a new brightly colored code sheet with the resident's code status was placed in the front of all charts as the first page, making it easier to identify resident's code status. To ensure all nursing staff could identify a resident's code status, the new colored sheets were also placed in care tracker, as well as on the Medication Administration Records (MAR). The DON found no concerns identified with the audits of all the residents ' medical records. · On [DATE] at 8:30 A.M., the DON began a process of monitoring all new admissions and all readmissions within one business day to verify code status was placed in the chart and accurate. The monitoring will continue until otherwise directed by the facility's QA process. The DON found no concerns with the four new admissions and two readmissions. · On [DATE], LPN #105 was put on suspension immediately pending the facility's investigation. · On [DATE] at 11:00 A.M., the Medical Director was notified by the former Administrator the resident did not receive CPR and had expired. · On [DATE] at 8:30 A.M. and [DATE] at 8:30 A.M., the DON provided education to 22 LPNs and 13 RNs on the CPR policy, the new code status sheets in each resident's medical records, code status on all MARs, in care tracker and to always verify a resident's code status even if the resident is on Hospice. · On [DATE], the DON provided Human Resources the information concerning locating a resident's code status and verifying a code status even if the resident is on Hospice, to be included in Orientation for all nursing staff. · On [DATE], LPN #105's employment was terminated. · On [DATE] from 11:00 A.M. to 2:20 P.M., interviews with State tested Nurse Aides (STNAs) #115, #117, #119, #120, #122, #124 and #125, verified they had knowledge of the facility's policy for CPR and where to locate a resident's code status. Interviews with RNs #103, #108, #110 and LPNs #100, #104 and #108 revealed knowledge of the facility's CPR policy, receiving education on locating and verifying code status as well as verifying the code status for residents on Hospice. · On [DATE], the DON verified CPR certifications were in place for licensed nursing staff completed by the American Heart Association. · Review of two additional closed medical records [REDACTED]. · The Quality Assurance Meeting has been scheduled for [DATE] to discuss all findings and the facility's new plan of correction concerning CPR and residents' code status. Monitoring will also be included in the meeting Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing the corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #80's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #80's [DATE] monthly physician orders revealed an order for [REDACTED].#80's medical record revealed Hospice services began on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #80 's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, required total assistance of two staff members with bed mobility and transfers, extensive assistance of one staff member for dressing, personal hygiene, eating, toileting and bathing. Resident #80 was assessed as always being incontinent of urine and bowel. Review of Resident #80's nursing progress notes revealed an entry dated [DATE] at 10:18 A.M. documenting Resident #80's heart rate was regular, lungs were clear and the resident had one plus [MEDICAL CONDITION] (indentation of two millimeters or less when the area is pressed) noted to the bilateral lower extremities. The resident was on room air and had no cough or shortness of breath. An entry on [DATE] at 9:30 P.M. documented the resident had no pressure or non-pressure skin areas and required one staff assistance with activities of daily living. The resident was alert to her name only and no difficulties were noted. There was no further documentation and/or change noted in Resident #80's condition until a progress note dated [DATE] at 12:00 A.M., written by LPN #105. The note indicated Resident #80 was noted without pulse, respiration and blood pressure. The note indicated the DON was notified at 12:05 A.M. Hospice was also notified and the Hospice nurse arrived around 12:15 A.M. Around 1:00 A.M., the Power of Attorney (POA) arrived with other family members. The resident was transported to the hospital. Upon arrival to the hospital emergency room , Resident #80 was verified to have expired. Further review of the progress notes verified no documentation of any CPR being provided or EMS being called for Resident #80. Review of Resident #80's Certificate of Death revealed the resident passed away on [DATE] at 12:50 A.M. with the immediate cause of death documented as [MEDICAL CONDITION]. Interview on [DATE] at 12:40 P.M. with Resident #80's POA revealed upon arrival to the facility she observed Resident #80 all cleaned up and deceased . The POA stated she questioned how the resident had died and she was not informed the resident had any change of condition. Interview on [DATE] at 11:05 A.M. with RN #110 verified he was working on [DATE] from 7:00 P.M. to 7:00 A.M. Around midnight, STNA #126 came to the nurse's station and stated Resident #80 was not responding to her. RN #110 was not assigned to Resident #80, but he immediately went to Resident #80's room to assess him. Resident #80 was non-responsive, LPN #110 (the resident's nurse) arrived and started to assess for vital signs and found there were none. As LPN #105 assessed the vital signs, RN #110 went to the nurse's station to check on the code status. RN #110 saw on the chart there was a sticker in the shape of a heart. The heart identified the resident as a patient of Hospice so he thought Resident #80 was a no code. RN #110 verified neither himself or LPN #105 checked the chart any further and no CPR was provided. RN #110 verified he had received an in-service from the DON. The in-service was even though a resident is on Hospice it does not mean they are not a full code. The facility has now changed the medical records to have a bright colored sheet in the front of every chart to show the resident's code status. The sheet must be checked each time a resident has an emergency. Interview on [DATE] at 1:15 P.M. with the DON verified Resident #80 was a Full Code status during his entire stay at the facility. The DON verified the resident was found without a pulse or respirations by LPN #105 and RN #110. The DON verified neither LPN #105 or RN #110 initiated CPR or called 911 per the facility policy. Further interview revealed on the night of [DATE] around 12:00 A.M., STNA #126 found Resident #80 to be non- responsive when she entered his room to provide care. She went out to the nurse's station and informed RN #110. RN #110 went to the resident's room and was assessing the resident, when LPN #105 entered the room. After not being able to obtain vital signs both nurses went out to the nurse's station to find Resident #80's code status. When they looked at the chart in the rack they saw the heart on the side (indicating a Hospice patient) of the chart and assumed the resident was a No Code since he was a patient of Hospice. During the interview the DON verified LPN #105 and RN#110 did not follow the facility CPR policy in regards to properly checking the resident's code status and initiating CPR if the resident was a Full Code. The DON verified licensed nurses are now required to check all residents' code status. Lastly, the DON stated the facility completed an internal investigation and determined LPN #105 did not implement the facility CPR policy for Resident #80 when he was found without a pulse. The LPN checked the outside of the resident's medical chart and assumed the resident was a No Code. The nurse did not verify the resident 's code status with the medical record and failed to initiate CPR. On [DATE], three attempts made to conduct a telephone interview with LPN #105 were unsuccessful. The facility terminated LPN #105's employment on [DATE]. Review of LPN #105's personnel file revealed a termination letter dated [DATE] to end employment for failure to meet job duties. Review of RN #110's personnel file revealed on [DATE] at 8:30 A.M., RN#110 was provided education by the Administrator on checking code status and verifying the code status even if a resident was on Hospice. Review of eleven LPNs' and five RNs' personnel files revealed evidence of current American Heart Association CPR training. Review of three current residents' (#55, #78 and #25) medical records revealed the code status in the physician orders and the colored code form used by the facility matched. Review of two additional residents' closed medical records [REDACTED]. There were no concerns identified. Review of the in-service sign-in-sheets from [DATE] and [DATE] revealed all nursing staff in the facility had received training on the CPR policy, the new code status sheets in each resident's medical records, code status on all MARs, in care tracker and to always verify a resident's code status even if the resident is on Hospice. Review of the facility policy titled, Cardio-pulmonary Resuscitation (CPR), revised [DATE], revealed the purpose was to restore and maintain respiration and circulation in a resident/patient whose heartbeat and breathing have stopped. When resident found unresponsive, check for advanced directive on the resident's chart. If the resident is a full code, dial 911 for emergency assistance. When a resident becomes unresponsive and not breathing the facility staff are to start compressions if resident is Full Code. This deficiency substantiates Complaint Number OH 150.

Based on medical record review, observations, interviews, and review of pressure ulcer healing chart, pressure ulcer tracking grid and pressure ulcer prevention policy the facility failed to complete routine assessments and failed to ensure a physcian was notified for treatment recommendations for an avoidable pressure ulcer. This resulted in actual harm to Resident #4 who developed an unstageable pressure ulcer with necrotic tissue. This affected one Resident (#4) of three reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 87. Findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 01/30/17 revealed Resident #4 had a pressure ulcer (history of) to the coccyx related to immobility. He also had excoriation to the left hip. Interventions included to administer treatments as ordered and monitor for effectiveness; assess, record, monitor wound healing and report declines to the medical doctor. Review of the admission minimum data set (MDS) comprehensive assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making, Resident #4 was totally dependent with transfers and toileting, extensive assistance was required with personal hygiene, and supervision with eating. Resident #4 didn't have any pressure ulcers. Medical record review revealed physician order [REDACTED]. Skin assessments were to be completed twice weekly on Tuesdays and Fridays. Review of the Medication Administration Record [REDACTED]. No skin assessments were completed. Further review revealed the resident was admitted to the hospital from 03/14/17 to 03/18/17 for a urinary tract infection and bacteremia. Review of the readmission screener assessment dated [DATE] revealed Resident #4 had a red sacrum and reddened right hip. Review of the nursing progress note dated 03/18/17 at 5:56 P.M. revealed Resident #4 was readmitted to the facility with reddened area to the coccyx and to the right hip. Review of a nursing note dated 03/29/17 at 8:42 P.M. revealed Resident #4 had an open area on the coccyx with drainage noted on the old dressing. The area was cleansed with normal saline and a new dry dressing was applied. The Director of Nursing (DON) was notified of the open area. Review of the pressure ulcer healing chart revealed an assessment was completed on 03/30/17 and revealed a stage II pressure ulcer which measured 0.7 centimeter (cm) by 0.6 cm by 0.1 cm area, [MEDICATION NAME] (new pink shiny skin) tissue, to Resident #4's coccyx. No other assessments of the coccyx pressure ulcer were in the medical record. Review of the progress note dated 03/30/17 at 6:39 A.M. revealed the dressing was changed to the left hip with a small amount of red drainage noted without odor. The dressing to the coccyx was changed and no drainage was noted. There wasn't any assessment of the appearance of the left hip and no notification made to the physician for changes of treatment. Review of the MAR for April 2017 revealed staff continued to change the [MEDICATION NAME], foam dressing, to the coccyx and left hip daily (on night shift) per physcian order. Observation on 04/18/17 at 2:44 P.M. revealed Resident #4 was appropriately positioned in bed on a low air loss mattress. Review of the facility pressure ulcer tracking grid provided by the DON on 04/18/17 revealed Resident #4 was not listed as having any pressure ulcers. An interview with the DON on 04/18/17 at 3:07 P.M. in reference to Resident #4 not being listed on the pressure ulcer grid revealed she was mistaken and Resident #4 did have a stage II pressure ulcer to his coccyx. The DON indicated the dressing to the left hip was only a preventative treatment and there weren't any open areas on the left hip. Observation on 04/18/17 at 3:15 P.M. of a dressing change by licensed practical nurse (LPN) #30 to Resident #4's coccyx revealed an open area about the size of a pencil eraser, pink skin, without drainage or odor. The area was cleansed with normal saline and a foam dressing was applied. Resident #4 was comfortable without signs of discomfort during the treatment. A foam dressing was observed to the left hip. LPN #30 reported the night shift nurses routinely completed the wound treatment to the left hip and the dressing was only for prevention. Resident #4 was positioned on his right side upon request and reported he was unable to be on his left side due to hip discomfort. During an observation on 04/19/17 at 2:17 P.M. of ostomy care to Resident #4 by LPN #32, Resident #4 again reported he was unable to be positioned on his left side due to hip pain. Upon request, LPN #32 peeled back the foam dressing, dated 04/19/17, to Resident #4's left hip which revealed a quarter sized unstageable pressure ulcer, 100 percent slough (yellow, tan, green, or brown dead tissue). The DON was immediately notified and assessed the wound. The DON reported the wound was unstageable, 100 percent slough, the center of the wound was brown with yellow around the outside, and there was moderate drainage. The wound measured 1.6 cm by 1.8 cm and the depth was unable to be determined. An interview with the DON on 04/19/17 at 3:27 P.M. reported the stage II pressure ulcer to the coccyx was discovered on 03/29/17 and initially assessed on 03/30/17. The wound had not been assessed again until this morning and measured 0.5 cm by 0.5 cm by 0.1 cm and was 100 percent [MEDICATION NAME] tissue. The DON reported she had never assessed the left hip as a preventative foam dressing was always in place which occluded the area from being seen. She further indicated the night nurses never informed anyone the area to the left hip had opened, they just kept placing the preventative foam dressing on the hip. The DON reported there wasn't any documented skin assessments in Resident #4's medical record since his readmission from the hospital on [DATE] except for a rash to the neck documented on 03/29/17. All skin assessments and skin abnormalities were to be documented in the nursing progress notes. Review of the Pressure Ulcer Prevention Policy revised April 2017 revealed skin assessments were to be completed weekly or more often if indicated. Direct care staff should observe the Residents skin during daily care and report changes immediately when identified. This deficiency substantiated Complaint Number OH 759.