Every finding on record at Newark Nursing & Rehab

Based on observation, medical record review, resident interview, resident family interview, staff interview, and policy review, the facility failed to ensure pressure ulcer treatments supplies were handled in a manner to prevent contamination in order to promote healing of pressure ulcers. This affected one (#99) of three residents reviewed for pressure ulcers. The facility census was 121. Findings include:Review of the medical record for Resident #99 revealed an admission date of 06/12/26 and diagnoses including cerebral infarction, protein/calorie malnutrition, diabetes, and morbid obesity. The resident received dialysis treatments. Review of the MDS assessment completed 07/08/26 revealed Resident #99 was assessed with moderately impaired cognition and was dependent on staff for turning and transfers. The MDS assessment indicated the resident was admitted with a stage III pressure ulcer (full-thickness skin loss).Review of Resident #99's wound evaluation on 07/14/26 indicated the resident had a stage II pressure ulcer (partial-thickness loss of skin with exposed dermis) on the buttocks measuring 9.0 centimeters cm wide by 5.0 cm long by 0.2 cm deep with 80% granulation and 20% slough. The peri-wound was described as yeast and the wound was noted to be improving. Review of Resident #99's physician's order dated 07/16/26 revealed for staff to cleanse the buttocks with normal saline, pat dry, apply Medihoney or Manuka honey and calcium alginate to the wound bed, and cover with a padded dressing daily on day shift. Zinc barrier cream was to be applied to the peri-wound. Observation of the treatment to Resident #99's buttocks, and interview, on 07/16/26 at 3:15 P.M. revealed RN #255 completed the dressing change with RN #158 assisting. RN #255 entered the room with the dressing change supplies and placed the supplies in Resident #99's bed on the bottom sheet behind the resident's buttocks. The supplies included a box of gloves, a tube of skin ointment, a box containing a tube of Manuka honey, a bottle of normal saline, and the packages of dressing supplies. RN #255 then picked up the supplies from the bed and placed them on a bedside dresser which had not been cleaned prior to placing the item on and without a clean barrier. RN #158 then placed a towel over the overbed table and the dressing change supplies were then moved to the towel. RN #255 stated she needed to provide incontinence care as the resident was incontinent of stool. She then cleansed the resident's inner buttocks with soap and water. RN #255 proceeded to complete the treatment by applying the Manuka honey and calcium alginate to the wound bed, applied zinc cream to the peri-wound, and placed a padded dressing up against the wound. No tape was used to secure the dressing. During the treatment, a fly was noted to frequently land on Resident #99's bed linens near the open wound. RN #255 kept waving her hand to get the fly to leave and fly away. RN #158 stated the fly actually landed on the clean padded dressing while it was laying on the overbed table waiting to be applied, so a new dressing had to be obtained from the treatment cart. RN #255 stated tape was not applied to secure the dressing as the resident was allergic to tape. Resident #99's husband was in the room and stated the fly had been in the room for several days. Interview with RN #158 on 07/16/26 at 4:00 P.M. confirmed the dressing change supplies should not have been placed in the resident's bed on the dirty sheets. Review of the undated facility policy titled, Dressing Change- Clean, revealed for staff to clean the bedside stand and establish a clean field. Further review revealed for staff to then place the equipment on the bedside stand. This deficiency represents non-compliance investigated under Complaint Number 3072600 and continued non-compliance from the survey dated 06/16/26.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident had the right to choose schedules consistent with their interests. This affected one (#37) of three residents reviewed for activities of daily living choices. The facility census was 121. Findings include:Review of the medical record for Resident #37 revealed an admission date of 02/08/25 and diagnoses including acute respiratory failure, morbid obesity, diabetes, chronic kidney disease, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment completed 07/10/26 revealed Resident #37 was assessed with intact cognition and was dependent upon staff for transfers from bed to chair. Review of a physician's order on 06/25/26 revealed Resident #37 required the use of a mechanical lift for transfers. Interview with Resident #37 on 07/16/26 at 9:35 A.M. revealed she asked to get up out of bed at 4:30 A.M. that morning but staff did not get her up until 9:00 A.M. She stated the night shift aide told her the staff were doing rounds and would be back, but never came back. Resident #37 stated night shift ended at 7:00 A.M. Resident #37 stated day shift staff eventually got her up when the nurse was available to help, and stated day shift began at 7:00 A.M. The resident stated she was upset over how long it took to get up after she asked. Interview with Certified Nurse Aide (CNA) #242 on 07/16/26 at 4:15 P.M. revealed she worked the night shift on Resident #37's hall on the night the resident asked to get up. She stated it was 5:30 A.M. when Resident #37 asked to get up; however, she stated her and the other nurse aide on the hall were in the middle of doing rounds for other residents and could not get to her before they left at 7:00 A.M. CNA #242 stated she told day shift staff at 7:00 A.M. that Resident #37 wanted to get up from bed. Interview with Licensed Practical Nurse (LPN) #189 on 07/16/26 at 9:50 A.M. revealed she was aware when she came on duty at 7:00 A.M. that morning that Resident #37 wanted to get up. She confirmed the night shift staff did not get her up, the day shift staff were too busy with breakfast, and she had to give insulin to other residents. LPN #189 stated there were two nurse aides on duty for day shift for that hall and Resident #37 required two staff members to get up due to use of the mechanical lift. LPN #189 stated, however, Resident #37 did not like one of the nurse aides on duty on day shift so they had to wait until LPN #189 was free to assist the other nurse aide in getting the resident up. LPN #189 stated she did not know why night shift staff could not have gotten Resident #37 up when she asked, and confirmed they did not attempt to get the resident up earlier using other staff in the building from another unit. LPN #189 stated Resident #189 was gotten up at around 8:45 A.M.Review of the facility policy titled, Resident Rights, dated 2001 and revised December 2023, revealed residents have the right to self-determination (the ability and right to make your own choices and control the course of your life).This deficiency represents non-compliance investigated under Master Complaint Number 3093594.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident who was prescribed antipsychotic medications had appropriate documented indications for use of the medication. This affected one (#47) of one residents reviewed for medications. The facility census was 121. Findings include:Review of the medical record for Resident #47 revealed an admission date of 07/06/26 and diagnoses including Alzheimer's disease, dementia, and diabetes. Review of an admission Minimum Data Set (MDS) assessment completed 07/13/26 indicated Resident #47 was unable to complete a brief interview for mental status and had long and short-term memory issues. Further review revealed the resident was receiving antipsychotic medication on a routine basis and the physician had not documented a gradual dose reduction was contraindicated. Review of Resident #47's physician's orders revealed an order on 07/06/26 for an antipsychotic medication, risperidone, one (1) milligram (mg) three times daily for dementia. Review of Resident #47's July 2027 medication administration record (MAR) revealed the risperidone was given as ordered. Review of a psychotropic evaluation completed 07/07/26 revealed Resident #47 was receiving antipsychotic medication with no non-pharmacologic approaches used prior to medication. Further review indicated a physician review of the medication had not been completed. Review of Resident #47's physician orders revealed and order dated 07/07/26 for a psychiatric consultation. Further review of the medical record revealed no evidence the consultation had been completed. Interview with the Administrator on 07/20/26 at 7:45 A.M. revealed the psychiatric consult for Resident #47 had not yet been completed. Further review of Resident #47's medical record revealed no evidence that the resident had a specific condition which required the use of antipsychotic medications. There was no evidence the medication had been evaluated by the physician or that the physician documented the rationale for the antipsychotic medication. Interview with the Director of Nursing (DON) on 07/20/26 at 11:00 A.M. confirmed there was not a specific condition documented for the use of the antipsychotic medication for Resident #47. The DON confirmed the resident had diagnoses to include dementia and Alzheimer's disease, and the medication had not been evaluated by a physician for the continued need. Review of the facility policy titled, Antipsychotic Medication Use, dated 2001 and revised December 2024, revealed residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the residents and others. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will re-evaluate the use of the antipsychotic medications at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record: schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, mood disorders (bi-polar disorder), psychosis in the absence of dementia, medical illnesses with psychotic symptoms, Tourette's disorder, Huntington's disease, hiccups, or nausea/vomiting associated with cancer or chemotherapy. This deficiency represents an incidental finding discovered during the course of the complaint investigation.

Based on observations, review of the medical record, review of the ambulatory wound clinic notes, review of the pharmacy delivery slips, review of the facility policy, review of facility emails, and interviews with staff, the facility failed to ensure a comprehensive initial wound assessment for a new wound was completed, wound treatments were completed as ordered, the physician was notified of absent dressings, wound interventions were in place and initiated timely, the wound was adequately assessed for appropriate wound staging, imaging services were completed as ordered, and infection control was maintained during wound care, to prevent the in-house development and/or worsening of a pressure ulcer to the coccyx of Resident #01. Actual harm occurred on 02/21/26 when Resident #01, who was assessed to be at risk for developing pressure ulcers, had moderately impaired cognition, was dependent on staff for all activities of daily living including turning and repositioning, and was non-ambulatory, was identified to have a blister to the left buttock. The wound was initially identified as Moisture Associated Skin Damage (MASD) to the coccyx and deteriorated to Stage IV pressure ulcer (full thickness tissue loss with exposed underlying muscles, tendons and bones). This affected one resident (Resident #01) of three reviewed for pressure ulcers. The facility census was 114.Findings Include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included fractured right neck of the femur, antineoplastic chemotherapy pancytopenia, dementia, atherosclerotic heart disease, depression, cardiac defibrillator, ischemic cardiomyopathy, hypertension, edema, malignant neoplasm of the anus and urinary incontinence. Review of the Braden score dated 01/07/26 revealed Resident #01 was assessed to be at low risk for pressure injuries. Review of the physician's orders revealed Resident #01 had an order for a pressure-reducing mattress and cushion dated 01/20/26. Review of the nursing note dated 02/21/26 at 10:02 A.M. (recorded as a late entry on 02/22/26 at 5:37 P.M.) revealed the nursing assistant informed the nurse that Resident #01 had a new skin sore on her buttocks and upon observation the left buttock had a blister-like area that was starting to open. The area was cleaned with normal saline (NS) and zinc was applied. The residents' power of attorney (POA) and physician were notified. There was no further assessment or measurement of the wound. Review of the Telehealth Visit note by Physician #400 dated 02/22/26 at 5:34 P.M. revealed Resident #01 had a blister-like skin issue to the left buttock, it was cleaned with NS and zinc was applied. Review of the February 2026 physician's orders and Treatment Administration Record (TAR) from 02/19/26 through 02/24/26 revealed Resident #01 did not have a treatment ordered or administered for the left buttock. Review of the nursing note dated 02/25/26 at 10:40 A.M. (recorded as a late entry on 02/26/26 at 10:47 A.M.) revealed during wound rounds the Nurse Practitioner noted Moisture Associated Skin Damage (MASD) to the coccyx of Resident #01. A new order was received to cleanse the area with wound cleanser, assess and treat with zinc oxide cream twice daily. The resident's POA was notified. Review of the Wound Skin Note dated 02/25/26 at 8:50 P.M. revealed Resident #01 had MASD to the coccyx which measured 1.3 centimeters (cm) by 1.0 cm by 0.1 in depth. It was house acquired, and the peri-wound was pink. The resident's POA was notified. Review of the physician's orders dated 02/25/26 revealed Resident #01 had a new order for wound care to the MASD to the coccyx, cleanse with NS or wound cleaner, pat dry, apply zinc oxide every shift. Review of the Braden Scale dated 02/27/26 revealed Resident #01 was at moderate risk for pressure injuries. Review of the nursing note dated 02/27/26 at 1:19 P.M. revealed Resident #01 had a new skin alteration noted to the coccyx. A new order was obtained. The resident resided on the dementia unit and attempted to toilet herself independently. Resident #01 needed assistance with toileting and showering but did not always tell or allow staff to assist her with her toileting needs. Staff were to continue to encourage the resident to allow staff to assist, a new order in place and implemented per order. Would continue to monitor area for improvement until resolved. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 had moderately impaired cognition, was dependent upon staff for all activities of daily living, was incontinent with bladder and bowel, and had no pressure injuries or MASD. Review of the Wound Skin note dated 03/05/26 at 12:16 P.M. revealed Resident #01 had MASD to the coccyx which measured 1.0 cm by 1.0 cm by 0.1 cm in depth. It was house acquired, and the peri-wound was pink. The resident's POA was notified. Review of the Wound Skin note dated 03/10/26 at 12:16 P.M. revealed Resident #01 had an unstageable (full thickness skin loss but the depth was unknown due to the wound bed being covered with dead tissue) pressure ulcer to the coccyx which measured 1.27 cm by 2.3 cm by 0.0 cm in depth with 90 percent slough (dead tissue). There was a moderate amount of serosanguineous drainage. It was house acquired and the residents POA was notified. Review of the physician's order dated 03/10/26 revealed Resident #01 had an order to clean the coccyx with NS, apply Medi-honey and calcium alginate, and cover with a foam dressing every day shift and as needed if soiled/dislodged. Review of the physician's order dated 03/11/26 revealed Resident #01 had an order for a low air loss mattress for wound care and a Roho cushion (air filled medical cushion to help distribute body weight evenly to promote proper blood flow) in the wheelchair at all times. Review of the Administration note dated 03/11/26 at 7:42 P.M. revealed the nurse was informed by the Former Director of Nursing #215 to hold off on the air mattress for safety reasons. Review of the email dated 03/12/26 at 10:48 A.M. revealed Central Supply #302 was asking Purchasing Director #401 and Therapy Director #500 if they could order a couple Roho cushions because they had a resident who needed one. Review of the email dated 03/12/26 at 3:39 P.M. from Purchasing Director #401 to Central Supply #302 and Therapy Director #500 revealed the Roho Cushion had been ordered. Review of the physician's order dated 03/16/26 revealed Resident #01 had a new order for Pro-Heal protein supplement 30 milliliters twice daily for wound healing. Review of the Wound Skin note dated 03/17/26 at 6:26 P.M. revealed Resident #01 had an unstageable pressure ulcer to the coccyx which measured 1.27 cm by 1.63 cm by 0.0 in depth with 80 percent slough. There was a moderate amount of serosanguineous drainage. The resident's pain was one out of 10 (on a scale of zero to 10, zero being no pain and 10 being the worst). It noted it was in-house acquired and to continue with the same treatment order. The resident's POA was notified. Review of the Wound Skin note dated 03/24/26 at 4:02 P.M. revealed Resident #01 had a Stage III pressure ulcer (a full thickness skin loss with visible subcutaneous fat but no exposed muscle, tendon or bone) to the coccyx which measured 2.13 cm by 1.73 cm by 1.0 cm in depth with 70 percent slough. There was a moderate amount of serosanguineous drainage. It was house acquired. The resident's pain was zero out of 10, the POA was notified and there were new treatment orders. Review of the physician's orders dated 03/24/26 revealed Resident #01 had a new order to cleanse the wound with NS or wound cleanser, apply Santyl (topical debridement) to the wound bed, and cover with calcium alginate and superabsorbent dressing to the Stage III pressure ulcer daily and as needed until resolved. Review of the Wound Skin note dated 03/31/26 at 11:51 A.M. revealed Resident #01 had an unchanged Stage III pressure ulcer to the coccyx which measured 2.6 cm by 1.5 cm by 1.6 cm in depth with 70 percent slough. There was a small amount of serosanguineous drainage and there were no odors or signs of infection. It was house acquired. The resident's pain was zero out of 10, the POA was notified and there were no new treatment orders. Review of the documented weights in Point Click Care revealed on 04/06/26, which was the last weight documented for Resident #01, revealed she weighed 112 pounds. Review of the Wound Skin note dated 04/07/26 at 5:37 P.M. revealed Resident #01 had an unchanged Stage III pressure ulcer to the coccyx which measured 2.72 cm by 2.08 cm by 1.1 in depth with 70 percent slough. There was tunneling at the 11 to 12 o'clock location at 2.0 cm in depth. There was a moderate amount of serosanguineous drainage. It was house acquired. The residents' pain was zero out of 10, the POA was notified and there was new treatment orders added. Review of the physician's orders dated 04/07/26 revealed Resident #01 had a new order to cleanse the coccyx with NS, apply Santyl to the wound bed, pack with Dakin's half strength moistened gauze and cover with a superabsorbent dressing daily and as needed until resolved. Review of the April Medication Administration Record (MAR) revealed Resident #01 was being treated with Oxycodone 5.0 milligrams every six hours as needed for breakthrough pain on 04/10/26 at 5:58 A.M for a pain level of six out of 10 which was effective and on 04/10/26 at 11:59 A.M. for a pain level 10 out of 10 which was ineffective. Review of the nursing note dated 04/10/26 at 2:38 P.M. revealed Resident #01 appeared uncomfortable this shift, refused breakfast, her temperature was 100.2 degrees Fahrenheit (F), and she was screaming with any movement. She was medicated with as needed Oxycodone with minimal relief. A call was placed to the physician, and new orders were received to send her to the emergency department (ED) for evaluation. Review of the nursing note dated 04/10/26 at 3:21 P.M. revealed the transport arrived and three people lifted Resident #01 to the gurney and she was screaming out for someone to help her with tears noted, attempts to reposition her on the gurney were ineffective. Review of the nursing note dated 04/10/26 at 9:01 P.M. revealed Resident #01 returned to the facility with a new order for Augmentin (antibiotic) 875 mg every 12 hours for seven days for the coccyx wound. Review of the nursing note dated 04/10/26 at 9:32 P.M. revealed Resident #01 was to follow up with the hospital's ambulatory wound clinic and her POA stated she preferred for the resident to go to the ambulatory wound clinic. Review of the physician's orders dated 04/10/26 revealed Resident #01 had a new order for Augmentin 125-31.25 mg in 5.0 milliliters (ml), with instructions to give 7.0 ml every 12 hours for wound infection for seven days. This order was discontinued on 04/11/26 as the pharmacy did not have the dosage for distribution. Further review revealed Resident #01 had an order for imaging to the sacrum and coccyx dated 04/10/26 to rule out osteomyelitis, however there was no documentation this was ever completed. Review of the physician's order dated 04/11/26 revealed Resident #01 had a new order for Amoxicillin-Potassium Clavulanate Suspension 250-62.5 mg in 5.0 ml, with instructions to give 3.5 ml every 12 hours for wound infection for seven days. This order was discontinued on 04/13/26 to accommodate the dosage the pharmacy carried. Review of the physician's order dated 04/13/26 revealed Resident #01 had a new order for Augmentin Clavulanate Suspension 400-57 mg in 5.0 ml, with instructions to give 10 ml twice daily for wound infection for seven days. This order was completed on 04/21/26. Review of the Wound Skin note dated 04/14/26 at 3:49 P.M. revealed Resident #01 had Stage III pressure ulcer to the coccyx which measured 1.91 cm by 1.69 cm by 1.0 in depth with 100 percent granulation (healthy tissue). There was tunneling at the 11 to 12 o'clock location at 2.0 cm in depth. There was a moderate amount of serosanguineous drainage, and the note stated the wound was improving. It was house acquired, her pain was two out of 10, and a new treatment was ordered for Omeza (fish collagen for wound healing) applied to the wound bed and it was to stay in place for two days. The resident's POA was notified. Review of the physician's order dated 04/17/26 revealed Resident #01 had an order to cleanse the coccyx with NS or wound cleaner, apply calcium alginate, cover with a superabsorbent dressing daily and as needed until resolved. Review of the email dated 04/21/26 at 4:31 P.M. to Purchasing Director #401 and the Administrator revealed Therapy Director #500 was asking if anyone knew if they ever received the Roho cushion for Resident #01 because the wound nurse was asking for a new cushion. Review of the email dated 04/21/26 at 5:08 P.M. from the medical supply company revealed the order was being held and to reach out to the facilities representative for billing inquiries. Review of the email dated 04/22/26 at 3:09 P.M. from Purchasing Director #401 to the medical supply company revealed the facility was current [indicating they were up to date on all payments] and there were some outstanding [bills] from the previous ownership. It asked if the supply company could please look into this as the facility needed the item as soon as possible. Review of the care plan updated on 04/22/26 from the original date of 12/03/25 revealed Resident #01 had the potential for pressure ulcer development related to requiring activities of daily living assistance, dementia, delayed wound healing related to inadequate fluid and nutritional intake. It stated Resident #01 had a Stage III pressure wound to the coccyx. Interventions dated 12/03/25 were to administer medication as ordered, avoid prolonged skin to skin contact, therapy and dietitian consult as needed, educate the resident and family as to the cause of skin breakdown including transfers, positioning requirements, good nutrition and frequent repositioning, to follow facility procedure and protocol for prevention and treatment of skin breakdown, monitor nutritional status, obtain and monitor laboratory tests as ordered, provide incontinence care after each incontinent episode, and weekly skin review. Interventions dated 04/22/26 was an air mattress to the bed. Review of the physician's orders revealed Resident #01 received an order for an air mattress to the bed dated 04/22/26. Review of the email dated 04/23/26 at 4:11 P.M. from the medical supply company to Purchasing Director #410 revealed they did not have any updated credit information for the facility and the only thing they showed were four outstanding bills from last year which had never been paid for the products that were shipped to the address. It noted if there had been a recent change of ownership, they did not have that information documented. The email asked for the exact date of the change of ownership and attached was an application for credit because they would need to assign a line of credit. Review of the email dated 04/24/26 at 5:14 P.M. from the medical supply company revealed the order had been released and the tracking indicated it would be delivered to the facility on [DATE]. Review of the physician's orders dated 04/24/26 revealed Resident #01 received a new order for Amoxicillin-Potassium Clavulanate Suspension 400-57 mg in 5.0 ml, with instructions to give 10 ml twice daily for coccyx wound infection for 14 days. The order was completed on 05/08/26. Review of the email dated 04/27/26 at 10:12 A.M. from the medical supply company revealed they put a rush order in [for the Roho cushion], and they confirmed it was shipped on 04/27/26. Review of the Treatment Administration record from 03/12/26 through 04/27/26 revealed the staff were signing off the Roho cushion as being on the wheelchair of Resident #01. Review of the ambulatory wound clinic note dated 05/06/26 revealed Resident #01 present to the hospital last month for, what the family thought, was an infected decubitus ulcer and the resident was started on an antibiotic at that time. The family stated she had had the ulcer for approximately four months and the facility had been changing her dressings at the facility, but they had not been very aggressive with her rotation (repositioning) schedule. The resident had a Stage IV sacral pressure ulcer with some fibrinous exudate at the base. There was no exposed bone but there was minimal tissue left before the bone would be exposed, there was no surrounding cellulitis or erythema, and a moderate amount of serosanguineous drainage without odor. The wound culture revealed two plus Streptococcus Agalactiae Group B (indicating a moderate presence of the bacteria) and two plus normal cutaneous flora B (indicating a moderate presence of bacteria and fungi that live on healthy skin). The resident's wound was not recurrent and did not show signs of infection. The plan was to begin Santyl, Durafiber (Aquacel AG) and a foam dressing to be changed every two to three days, aggressive offloading on an every two-hour rotation schedule, no sitting for more than two hours at a time, nutritional supplements and to follow up in one month. Review of the medical record for Resident #01 revealed the wound was never updated to reflect the ambulatory wound clinics assessment of the wound staging as a Stage IV and not a Stage III and there was no new order entered for the resident to have aggressive offloading every two hours or no sitting for more than two hours at a time. Review of the physician's orders dated 05/06/26 revealed Resident #01 received orders to cleanse the coccyx with NS or wound cleanser, apply Santyl nickel thick to the wound bed, apply Aquacel AG, and cover with superabsorbent dressing three times weekly on night shift every Monday, Wednesday, and Friday and as needed for pressure wound. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 had moderately impaired cognition, was dependent upon staff for all activities of daily living, was incontinent of bladder and bowel, and had a Stage III pressure ulcer that was not present upon admission. Review of the May 2026 MAR/TARs revealed discrepancies as to whether or not the resident's treatments were completed on 05/22/26 and 05/25/26 as ordered due to duplicate orders for separate parts of the treatments. The Aquacel AG foam/sacral pad silver apply to the coccyx every night shift on Monday, Wednesday and Friday for open area to be used with Santyl ointment with superabsorbent dressing was coded as not completed on 05/22/26 and 05/25/26. The Santyl with instructions to apply to the coccyx topically every night shift Monday, Wednesday and Friday for pressure wound was documented as not completed on 05/05/26. Additionally, the order to cleanse the coccyx with NS or wound cleanser, apply Santyl a nickel thick to the wound bed, apply Aquacel AG and cover with a superabsorbent dressing three times weekly and as needed on Monday, Wednesday and Friday for pressure wound was not documented as not completed on 05/15/26, 05/20/26 and 05/22/26. Review of the Wound Skin note dated 05/19/26 at 8:35 P.M. revealed the unchanged Stage III coccyx pressure ulcer measured 3.8 cm by 2.15 cm by 1.0 cm in depth. There was tunneling at the 10 to 2 o'clock location at 1.5 cm in depth with 10 percent slough. There was a small amount of serosanguineous drainage, and the peri-wound appeared macerated but was intact. It noted this was an in-house acquired pressure ulcer, her pain was zero out of 10, and her POA was notified. She was seen by the wound clinic and was to continue her treatment orders. Review of the Administration note dated 05/21/26 at 2:19 A.M. revealed the facility was waiting for the Aquacel AG dressing and the Assistant Director of Nursing (ADON) #220 was aware of the need for the dressing, and they were using a wet to dry dressing with Santyl at this time. There was no documented evidence of an order for a wet to dry dressing or evidence the physician was notified that the Aquacel AG dressing was unavailable. Review of the nursing note dated 05/21/26 at 2:36 A.M. revealed the pharmacy phone operator stated the Aquacel AG dressing could be supplied by the pharmacy, she also stated an order needed entered to show that it could be a pharmacy order fill, therefore the order was entered in under pharmacy order with a note for the pharmacy to fill. Review of the Administration note dated 05/22/26 at 1:24 A.M. revealed the nurse spoke to the pharmacy regarding the Aquacel AG dressing for Resident #01 not arriving and the pharmacy stated they would send the order through again to be processed and delivered with the next delivery. Review of the nursing note dated 05/23/26 at 1:46 A.M. revealed the nurse spoke with pharmacy regarding the dressing for Resident #01 not coming with tonight's medications and they stated the dressing cost over $200 and needed the Former Director of Nursing #215's approval. The nurse messaged the Former Director of Nursing to inform her of the need for the dressing and the approval to have it sent though the pharmacy. Review of the Administration note dated 05/23/26 at 2:27 A.M. revealed the Aquacel AG dressing for Resident #01 was not available, a wet to dry dressing with Santyl was applied, the Assistant Director of Nursing #220 and the Former Director of Nursing #215 were aware the Aquacel AG was not available. Review of the nursing note dated 05/23/26 at 6:40 A.M. revealed the Former Director of Nursing #215 responded back and approved the Aquacel AG dressing for Resident #01, the pharmacy was notified and stated they would make a note of the approval. Review of the nursing note dated 05/24/26 at 2:53 A.M. revealed the pharmacy was called concerning Aquacel AG and indicated it was on back order and they did not know when it would be available to send, but they would send it when it came in. Review of the nursing note dated 05/24/26 at 5:09 P.M. revealed a low supply of Aquacel was found in the back-up supply and they were still waiting to hear from the pharmacy. Review of the concern log revealed the family of Resident #01 had a concern on 05/26/26 regarding the resident not being changed out of her pajamas, the infected wound, her not being turned every two hours, a possible urinary tract infection, a screening for therapy services, and a possible hospice consult. The action taken was to educate the staff, the resident was followed by an outside wound physician, and the physician was notified and started the resident on an antibiotic. The log did not state what the staff education was about. Review of the Wound Skin note dated 05/26/26 at 9:35 P.M. revealed the Stage III coccyx community-acquired pressure ulcer measured 5.0 cm by 3.0 cm by 1.5 cm in depth. There was tunneling at the 10 to 2 o'clock location at 1.5 cm in depth with 10 percent slough. There was a small amount of serosanguineous drainage, and the peri-wound appeared macerated but intact, and the note indicated the wound was improving. The resident's pain was zero out of 10, she was seen by the wound clinic, and the resident was to continue current treatment orders. The resident's POA was notified. Review of the Pharmacy delivery Slip dated 05/27/26 at 2:00 A.M. revealed Resident #01 received 10 Aquacel AG advantage dressings. Review of the Concern Form dated 06/01/26 revealed the Family of Resident #01 had another concern regarding her treatment not being completed on 05/31/26 (Sunday) and 06/01/26 (Monday). The action taken was her dressing was to be completed Monday, Wednesday, and Friday. It noted the treatment needed completed as soon as possible, to have the Nurse Practitioner round on the resident, and the nurse to assess the wound. Review of the nursing note dated 06/01/26 at 10:20 A.M. revealed the nurse was asked to assess Resident #01's current wound treatment by the POA due to her concerns that the dressing had not been changed on 05/31/26 or 06/01/26. The nurse explained to the POA that the current treatment order was only to be completed on Monday, Wednesday, and Friday. The POA informed the nurse, who was new to the facility, the resident was also followed by an outside wound physician and request the outside wound physician be called due to the increase wound drainage and odor. The wound nurse was notified and would update the physician regarding the POA's concerns of increased drainage and odor. There was no further evidence of documentation related to the drainage, odor, or physician notification/response. Review of the Wound Skin note dated 06/02/26 at 2:00 P.M. revealed the Stage III coccyx community-acquired pressure ulcer measured 5.0 cm by 3.0 cm by 1.5 cm in depth. There was tunneling at the 10 to 2 o'clock location at 1.5 cm in depth with 10 percent slough. There was a small amount of serosanguineous drainage, no odor, and the wound was documented as unchanged. The residents' pain was zero out of 10. The resident was seen by the wound clinic and was to continue current treatment orders. The resident's POA was notified. Review of the ambulatory wound clinic note (which the facility did not have in the medical record, obtained by the hospital on [DATE]) dated 06/03/26 revealed Resident #01 presented to the hospital last month for a, what the family thought, was an infected decubitus ulcer and the resident was started on an antibiotic at that time. The family stated she had the ulcer for approximately four months and the dressing changes had resulted in cleaning of the wound well, but they were still reporting significant pain, and the resident was not being turned or not allowing herself to be turned on a regular basis. It noted that this would result in poor to no healing and worsening of the wound. The resident had a Stage IV sacral pressure ulcer that was cleaned up quite a bit with the Santyl with better tissue at the base, there was no surrounding cellulitis or erythema, and a moderate amount of serosanguineous drainage without odor. The plan was to start Durafiber with foam as the Santyl was not needed anymore. Once again, the family was told that if the rotation schedule was not employed, the wound would not get better, and her pain would not improve either as it was causing ischemia (restricted blood flow) to the tissues. The resident was ordered to be on an every two-hour rotation schedule, offloading, nutritional supplements and to follow up in one month. Review of the wound after-visit summary dated 06/03/26 revealed Resident #01 was to start sulfamethoxazole-trimethoprim (Bactrim DS) (antibiotic) one tablet twice daily for 14 days, follow up in month, a treatment was ordered to clean with NS, Durafiber AG, foam dressing, and Allevyn three times a week, offloading, and every two-hour rotation. Review of the nursing note dated 06/03/26 revealed Resident #01 returned from the wound clinic appointment. A wound assessment completed, indicating a worsening wound with tunneling. New orders received to discontinue the Santyl and to start Resident #01 on Bactrim DS for 14 days. The Physician refused to change the frequency of the dressing change and wished to remain on a three-times a week schedule using the same material except the Santyl, the physician stated they need to let the treatment do its job. The POA was aware of the treatment frequency and was agreeable. Resident #01 was to return in one month in which the POA was aware. Review of the physician's orders dated 06/03/26 revealed Resident #01 had an order for Bactrim DS Oral Tablet 800-160 MG one tablet twice daily for 14 days for wound infection, cleanse the coccyx with NS or wound cleanser, pat dry, apply Aquacel AG, and cover with superabsorbent dressing three times weekly and as needed until resolved, resident only up for one to two hours at a time, and turn and reposition ever two to three hours. Observation on 06/12/26 at 8:30 A.M. revealed the air mattress for Resident #01 was set for a resident who weighed 220 pounds. Observation of wound care for Resident #1 on 06/12/26 at 1:25 P.M. with Licensed Practical Nurse #100 and Assistant Director of Nursing (ADON) #220 revealed the ADON placed the clean dressing supplies directly on the bedside table without cleaning/sanitizing the bedside table prior to laying them down, she retrieved four paper towels from the bathroom dispenser and placed them on the bedside table for a barrier however she never placed the dressing on the barrier. LPN #100 cleaned the wound with no concerns, however when she went to initial the foam dressing, the ADON moved LPN #100's isolation gown out of the way, LPN #100 grabbed the black marker out of her right front pocket, wrote the date on the foam dressing, placed the black marker on to the bedside table, proceeded to pick up the piece of Aquacel AG with her now contaminated gloved hands and started to tear the dressing in half until the surveyor intervened. An interview at 1:43 P.M. with LPN #100 verified she had touched the contaminated black marker prior to touching the clean Aquacel AG and she should have washed her hands and changed her gloves before she touched the dressing. An interview at 1:45 P.M. with the ADON revealed the facility did not have any more Aquacel AG so they would have to call the physician for a new order. She further verified LPN #100 had contaminated the clean field when she touched the soiled black marker however she stated she had cleaned the bedside table prior to them coming into the room to do the dressing change. On 06/12/26 at 2:40 P.M. an interview and observation with Registered Nurse (RN) #110 revealed the air mattress for Resident #01 was set for a resident who weighed 220 pounds and Resident #01 did not weigh 220 pounds. RN #110 stated she would find out why it was set at 220 pounds. On 06/12/26 at 3:10 P.M. an interview with ADON #220 revealed the facility had issues receiving the Roho cushion for Resident #01. She verified it was ordered on 03/11/26 but it had not been received until after 04/27/26 due to issues with nonpayment of bills. She indicated she did not know when the facility actually received the Roho cushion. She verified the nursing staff was incorrectly charting Resident #01 had the Roho cushion to her wheelchair from 03/11/26 until around 04/27/26 when she did not have it. She also stated they removed the low air loss mattress to the bed on 03/11/26 due to fear of her falling out of bed, but she verified Resident #01 had never fallen out of bed due to an air mattress and they had not put any other new interventions in its place. She verified there was no order for a treatment from 02/21/26 until 02/24/26. She indicated she believed the imaging ordered for 04/10/26 of the sacrum and coccyx was completed at the hospital but verified there was no documented evidence that the imaging was completed as ordered. On 06/12/26 at 4:30 P.M. an interview with the Administrator verified there was no order for a wet to dry dressing and no physician notification that the dressing was not available from 05/21/26 to 05/24/26. On 06/13/26 at 1:30 P.M. a review with the Interim Director of Nursing (IDON) of all the concerns related to Resident #01 wounds revealed she verified there was no assessment and no order written on 02/21/26 when the blister-like area was found to the left buttock, there was no other interventions were put into place upon finding the wound, the wound declined from 03/05/26 to 03/10/25 and went from MASD to unstageable on 03/10/26, she verified the air mattress should not have been discontinued on 03/11/26 without another intervention put into place, she verified the facility did not obtain the Roho cushion for Resident #01 in a timely manner, and the wound had further declined from 03/17/26 to 03/24/26 and should not have been changed from an

Based on observation, review of facility water temperature logs, review of the facility policy, and interview, the facility failed to maintain appropriate water temperatures on the hallway with rooms including Room Numbers 100, 101, 102, 103, 104, 105, 107, 473, 474, 475, and 476. This affected four residents (#22, #38, #57, and #61) out of four residents reviewed for environment, and had the potential to affect all 10 residents (#3, #9, #12 #22, #36, #38, #49, #57, #61, and #87) on the 100 and 400 hallway. Findings Include: Review of the weekly tap water temperature logs from 03/07/26 through 06/13/26 revealed no temperature or room number were documented it just indicated the temperatures were checked and were within normal limits.Observation on 06/13/26 at 8:50 A.M. revealed the public restrooms tap water appeared to be hot and the surveyor was unable to hold hands under the water safely.Observation on 06/13/26 from 9:00 A.M. through 9:10 A.M. of water temperatures on the 100 and 400 hallway, which was one continuous hallway, revealed room [ROOM NUMBER] (Resident #57's room) revealed the tap water temperature was 138 degrees Fahrenheit (F), the tap water temperature of room [ROOM NUMBER] (Resident #22's room) was 140 degrees F, the tap water temperature in room [ROOM NUMBER] (Resident #61's room) was 140 degrees F, and the tap water temperature in room [ROOM NUMBER] (Resident #38's room) was 138 degrees F. Observations on 06/13/26 at 9:20 A.M. of tap water temperatures, with Maintenance #200 using the facility thermometer, revealed the tap water temperature in room [ROOM NUMBER] (Resident #61's room) was 140 degrees F and the tap water temperature of room [ROOM NUMBER] (Resident #22's room) was 140 degrees F. An interview at this time with Maintenance #200 revealed the whole hall would be that temperature because it was on the same loop. He stated the boiler was set at 120 degrees F, so he did not understand why the water in the rooms were higher than the boiler temperature. He stated would have to look into what was going on. On 06/13/26 at 10:55 A.M. an interview with the Administrator revealed the facility had not had any resident burns. On 06/13/26 at 12:36 P.M. an interview with the Administrator revealed the tap water temperature logs did not indicate the actual water temperatures or what rooms were tested they just indicated the water was within normal range. She verified she was unable to indicate what the last temperatures were reading for Rooms 103, 105, 107 and 474.Review of the facility policy titled, Water Temperatures, Safety of, dated 12/09 revealed tap water in the facility should be kept within a temperature range to prevent scalding of residents. Step 1 of the policy indicated water heaters that serviced resident rooms, bathrooms, common areas and shower/tub areas should be set to a temperature of no more than 120 degrees F or the maximum allowable temperature per state regulations. Step 2 of the policy indicated the maintenance staff was responsible for checking thermostats and temperature control in the facility and recording these checks in the maintenance log. Step 3 of the policy indicated the maintenance staff should conduct periodic tap water temperatures and record the water temperature in a safety log.This deficiency is based on an incidental finding discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to implement behavioral management interventions for dementia residents. This affected one (Resident #116) of three residents reviewed for behavior management. The facility census was 115 residents.Findings include:Review of the medical record for Resident #116 revealed an admission date of 03/19/26 with diagnoses including Alzheimer's disease, chronic kidney disease, and mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #116 dated 04/13/26 revealed the resident had severe cognitive impairment, was dependent on staff assistance with activities of daily living (ADLs), received antianxiety and antidepressant medications, and exhibited verbal and physical behavioral symptoms. Review of the care plan for Resident #116 revealed the resident had behavior problems related to Alzheimer's disease which included wandering and physical and verbal aggression towards other residents. Interventions included staff should administer psychotropic medications as ordered and observe for effectiveness of the medications. Review of the physician's orders for Resident #116 revealed orders dated 03/20/26 for Ativan 0.5 milligrams (mg) every eight hours as needed for agitation for 14 days and for hydroxyzine 25 mg every 6 hours as needed for agitation for 14 days. Review of the progress note for Resident #116 dated 03/23/26 at 07:56 A.M. revealed the resident had been up and was wandering the hallways. Staff tried to redirect the resident to not enter other resident rooms and to take breaks, but the resident refused and continued to pace the hallways. Review of the progress note for Resident #116 dated 03/23/26 at 1:56 P.M. revealed the resident was rocking back and forth in front of a female resident and her visitor. Staff placed the resident on 15-minute checks. Review of the Medication Administration Record (MAR) for Resident #116 dated March 2026 revealed on 03/23/26 the resident was documented as having no behaviors and did not receive as needed Ativan or hydroxyzine. Review of the Medical Director note for Resident #116 dated 03/25/26 revealed the resident was calm and cooperative and staff should continue to administer Ativan as needed for anxiety. Review of the progress note for Resident #116 dated 03/29/26 at 6:29 A.M. revealed the resident was combative with aides during care. There was no documentation of staff interventions related to the resident's behavior. Review of the MAR for Resident #116 dated March 2026 revealed 03/29/26 the resident was documented as having no behaviors and did not receive as needed Ativan or hydroxyzine. Review of the progress note for Resident #116 dated 03/31/26 at 2:10 P.M. revealed the resident was involved in an altercation with another resident where he pulled the other resident's hair. There was no documentation of staff interventions related to the resident's behavior. Review of the MAR for Resident #116 dated March 2026 revealed the resident was documented as having no behaviors on day shift. Interview on 05/12/26 at 9:59 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #116 had behaviors on 03/23/26 and the resident may have been agitated. The ADON verified Resident #116 did not receive as needed Ativan or hydroxyzine on 03/23/26 and no behaviors were documented on the MAR. ADON stated she did not think Resident #116's medication management for his behaviors was appropriate during the time frame of 03/19/26 to 04/13/26. Interview on 05/13/26 at 12:36 P.M. Regional Director of Clinical Services (RDCS) # 187 confirmed Resident #116's behavioral medications could have been better managed. Interview on 05/13/26 at 1:42 P.M. with Nurse Practitioner (NP) #185 verified he did not see Resident #116 during 03/19/26 to 04/13/26 and was not notified of any behaviors for the resident. Interview on 05/13/26 at 3:52 P.M. with the Medical Director verified she saw Resident #116 on 03/25/26 but was not notified of any of his behaviors during 03/19/26 to 04/13/26. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring dated March 2019 revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The interdisciplinary team would evaluate behavioral symptoms in residents to determine the degrees of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies would be implemented immediately if necessary to protect the resident and others from harm. This deficiency represents noncompliance investigated under Complaint Number 2982628.

Based on medical record review, observation staff interview, and review of the facility policy, the facility failed to ensure staff practiced proper hand hygiene during care. This affected two residents (Resident #58 and #74) of the three residents reviewed for wounds and incontinence care. The facility census was 115 residents.Findings include: 1.Review of the medical record for Resident #58 revealed an admission date of 04/28/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 04/07/26 revealed the resident was cognitively intact, was frequently incontinent of bowel and bladder, and required staff assistance with toiletingReview of the physician's order for Resident #58 revealed an order dated 05/02/26 for wound care to the left lower extremity to cleanse with normal saline or wound cleanser, apply adaptic to the wound bed, cover with two abdominal (ABD) pads, wrap with Kerlix and secure with tape daily and as needed until resolved.Observation on 05/12/26 at 2:25 P.M. of incontinence care provided for Resident #58 per Certified Nursing Assistant (CNA) #180 revealed the aide donned gloves, entered the resident's room, set up for incontinence care, and then provided incontinence care for the resident. At no time did the CNA perform hand hygiene.Interview on 05/12/26 at 2:35 P.M. with CNA #180 confirmed she did not change gloves or perform hand hygiene once she entered Resident #58's room and verified she had touched multiple items before performing incontinence care for the resident.Observation on 05/12/26 at 2:38 P.M. of wound care for Resident #58 per by Licensed Practical Nurse (LPN) # 130 and Registered Nurse (RN) # 375 revealed LPN #130 removed the old dressing from the resident's left lower leg and then removed her gloves and donned a new pair of gloves. RN # 375 wore cleansed the wound with wound cleanser. LPN #130 then applied adaptic to the resident's left lower leg, covered the adaptic with an ABD, wrapped the leg with Kerlix, and secured the dressing with tape. Interview on 05/12/26 at 2:46 P.M. with LPN #130 verified she had changed gloves after removing the old dressing from Resident #58's left lower leg and did not wash her hands or use hand sanitizer before putting on a new pair of gloves prior to applying dressing to Resident #58's left lower leg. 3.Review of the medical record for Resident #74 revealed an admission date of 01/28/26 with diagnoses including pressure ulcer of right buttock, anxiety disorder, and paraplegia. Review of the MDS assessment for Resident #74 dated 05/06/26 revealed the resident was cognitively intact and was dependent on staff for all activities of daily living (ADLs.) Review of the care plan for Resident #74 revealed the resident required enhanced barrier precautions (EBP) related to risk for multi-drug-resistant organism (MDRO) infections related to indwelling device, gastrostomy (g-tube).Review of the physician's orders for Resident #74 dated May 2026 revealed an order to cleanse the g-tube site with soap and water, pat dry, and leave open to air every day.Observation on 05/12/26 at 11:20 A.M. of g-tube care for Resident #74 per LPN # 186 revealed the nurse did not a gown prior to entering the resident's room. LPN #186 donned gloves but did not wash her hands or use hand sanitizer and then removed the soiled dressing from the resident's g-tube, cleansed the tube site with soap and water, changed gloves, and applied a new g-tube dressing. Interview on 05/12/26 at 11:29 A.M. with LPN #186 verified Resident #74 was on EBP and she had not donned a gown prior to entering the resident's room. LPN #186 confirmed she did not wash her hands or use hand sanitizer when entering the room and when she changed her gloves. Review of the facility policy titled Handwashing/Hand Hygiene dated August 2024 revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Staff should perform hand hygiene in the the following situations: before and after direct contact with residents, before and after handling an invasive device, before handling clean or soiled dressings, gauze pads, before moving from a contaminated body site to a clean body site during resident care, after contact with objects in the immediate vicinity of the resident, after removing gloves, before and after entering isolation precaution settings.Review of the facility policy titled Enhanced Barrier Precautions undated revealed staff should don a gown and gloves during high contact resident care activities for residents on EBP. This deficiency represents noncompliance investigated under Complaint Number 2808594.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to provide resident and resident representatives with written notice of discharge. This affected one (Resident #116) of three residents reviewed for resident rights. The facility census was 115 residents. Findings include:Review of the medical record for Resident #116 revealed an admission date of 03/19/26 with diagnoses including Alzheimer's disease, chronic kidney disease, and mood disorder and a discharge date of 04/13/26. Review of the Minimum Data Set (MDS) assessment for Resident #116 dated 03/25/26 revealed the resident had severe cognitive impairment. Review of the discharge not anticipated MDS assessment for Resident #116 dated 04/13/26 revealed the resident was discharged from the facility. Review of the hospice note for Resident #116 dated 03/18/26 revealed the resident was being admitted to the facility for permanent placement. Review of the hospice note for Resident #116 dated 04/07/26 revealed Resident #116's wife had called hospice saying the facility stated Resident #116 had to be discharged to a psychiatric facility due to his behaviors. Review of an email from hospice Licensed Social Worker (LSW) #182 to the facility Administrator dated 04/08/26 revealed Resident #116's wife had notified hospice of the facility's intent to discharge the resident to a psychiatric facility. LSW #182 indicated the facility had not issued a 30-day discharge notice to the resident's wife. Interview on 05/12/26 at 1:56 P.M. with the Administrator confirmed the facility verbally notified Resident #116's wife the facility wanted to discharge the resident to a psychiatric facility due to his behaviors, but the facility had not issued a written 30-day discharge notice. Interview on 05/12/26 at 2:51 P.M. with LSW #219 stated Resident #116 had been to the facility prior for respite stays but had come to the facility 03/19/26 for a permanent placement. LSW #219 stated the Administrator told her Resident #116 needed to be discharged from the facility but she was unsure why the resident needed to be discharged . LSW #219 stated she did send a packet of information to hospice because they were looking for placement for Resident #116. Interview on 05/13/26 at 12:36 P.M. with Regional Director of Clinical Services (RDCS) # 187 confirmed Resident #116 needed to be discharged from the facility because the resident had been involved in four resident to resident altercations without resident injury. RDCS #187 stated there was concern that Resident #116 might possibly injure another resident in the future if he were permitted to stay. Interview on 05/13/26 at 3:52 P.M. with Medical Director # 188 verified she saw Resident #116 on 03/25/26 and was not notified of any problem behaviors from 03/19/26 to 04/13/26. Review of the facility policy titled Transfer or discharge date d December 2016 revealed the facility would provide a resident and/or the resident's representative (sponsor) with a thirty (30) day written notice of impending discharge.Review of the facility Admissions Packet undated revealed the facility would notify the resident and resident's representative in writing in advance of any proposed transfer or discharge from the facility. The facility would also send a copy of the notice to the Ohio Department of Health and the state long-term care ombudsman. This deficiency represents noncompliance investigated under Complaint Number 2982628.

Based on observations, staff interviews, and review of facility policies, the facility did not provide a safe, clean, and homelike environment by maintaining the building in good repair. This had the potential to affect all 120 residents living in the facility. The facility census was 120. Observation of the facility on 03/02/26 at 8:37A.M. to 9:39 A.M. revealed the following: -Observation of the 600-unit resident shower room revealed there was cracked tiles along the wall directly adjoining the floor. The cracked tiles were on the far wall from the desk area and around the toilet. There was a black and brown substance on eleven tiles to the left of the toilet and two cracked tiles, one cracked tile which was the fifth tile up the wall next to the inoperable shower which had equipment in it and rust on the facet handles. The shower room sink was leaking water and did not turn off. The shower nearest to the door had black and brown substances in the grout nearest the floor and cracked tiles adjoining the floor. There was cracked flooring at the door to enter the shower room. There was a hole in the floor of the hallway near the recreation room by the 600-unit nurse station. -In the hallway floor between room [ROOM NUMBER] and room [ROOM NUMBER] there was a round metal plumbing cover as big as the bottom of a one half gallon milk jug raised one inch above the rest of the flooring in the middle of the hallway. The 400-unit shower floor had a black substance on all four sides of the shower between the wall and the floor and around under the sink. The wall in the 400-unit shower room had the paint pulled off the wall by the sharps box, both the wooden cabinets in the 400-unit shower room had water damage to the bottoms with damage going up the wood cabinets about twelve inches and breaking off near the floor with wood dust and chips lying in the floor. -The 300-unit shower room had a black substance all around the showers between the floor and the wall in both showers, cracks in the tiles in the showers, cracks in the tiles near the door entrance. -On the memory care unit, the wall nearest the 300-unit behind the television had black streaks and parts of the drywall were chipped, the drywall was chipped at the corner near the double doors, and the trim was separating from the wall. The trim under the air conditioner in the common area with the small television was separated from the wall. There was paint chipping off the corner wall near the single external door and piano. There was paint off the drywall on the nurse's desk wall on all three sides facing into the common area. There was a black substance along the floor corners near the kitchenette on the memory care unit and trim was coming off the wall near the kitchenette. On the memory care unit, rooms 230, 229, 228, 227, 226, 225, 224, 223, 221, 220, 119, 117, 116, 115, 114, 113, 112, 109 had door frames which were separated from wall near the floor. On the memory care unit, the shower room had cracked tiles around the toilet and a black substance around the tile under the sink and under the window. -In the 700-unit shower room, the wall corner on the right of the door frame had two- and one-half tiles broken and a black substance in the shower floor and around the toilet. -The carpet in all six nurse stations had black areas where the carpet had worn down to the floor underneath. Interview on 03/02/26 at 9:22 A.M. with Housekeeper #207 who stated a lot of the housekeepers think they shouldn't have to clean the floors, because the floor technician should do it. Housekeeper #207 stated there had been issues with the floor machine and it was not working currently. Interview on 03/02/26 at 3:38 P.M. with Housekeeping Supervisor #425 who stated the common areas, the nurses' stations, and each resident's room on the unit is cleaned daily. The Housekeeping Supervisor stated the floor machine is broken right now. Interview on 03/02/26 at 2:39 P.M. to 3:21 P.M. with Maintenance #530 who verified and confirmed the 600-unit resident shower room which had cracked tiles along the wall directly adjoining the floor. The cracked tiles were on the far wall from the desk area and around the toilet. There was a black and brown substance on eleven tiles to the left of the toilet and two cracked tiles, one cracked tile which was the fifth tile up the wall next to the inoperable shower which had equipment in it and rust on the facet handles. The shower room sink was leaking water and did not turn off. The shower nearest to the door had black and brown substances in the grout nearest the floor and cracked tiles adjoining the floor. There was cracked flooring at the door to enter the shower room. There was a hole in the floor of the hallway near the recreation room by the 600-unit nurse station. Observation of 03/04/26 at 8:35 A.M. on the memory care unit common area of the two love seats with multi-colored circles and two chairs with multi-colored circles have black stains on the arms of the chairs and black stains throughout the seat cushions. Licensed Practical Nurse (LPN) #281 verified the black stains at the time of the observation stated the two love seats with multi-colored circles and two chairs with multi-colored circles had been on the memory care for at least five years with these stains and the stains were getting worse. Review of the facility policy, Maintenance Service, dated revised 12/2009 revealed maintenance shall be provided to all areas of the buildings, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. Functions of the maintenance personnel include, but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintaining the building in good repair, maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order, and providing routinely scheduled maintenance service. This deficiency represents non-compliance found under Complaint Numbers 2712669 and 2722594.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had two medication errors of 34 opportunities for an error rate of 5.8%. This affected two Residents (#50 and #545) of three residents observed for medication administration. The facility census was 120 residents. Findings include:1.Review of the medical record for Resident #50 revealed an admission date of 08/20/19 with diagnoses to include but not limited to type two diabetes mellitus with hyperglycemia, muscle weakness, diastolic heart failure, chronic pancreatitis, toxic liver disease, cardiomyopathy, hyperlipidemia, hypertension, spinal stenosis, need for assistance with personal care, vascular disease, hypotension, gastro-esophageal reflux disease, and atrial fibrillation.Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #50 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. Further review of the quarterly MDS dated [DATE] revealed Resident #50 had no psychosis, no verbal or physical behaviors, and no rejection of care.Review of the care plan for Resident #50 dated 02/15/21 revealed a focus which stated resident has an impaired metabolic status related to diabetes and morbid obesity with interventions to include administer medications/insulins and treatments as indicated by physician orders.Review of an order for Resident #50 revealed Lantus subcutaneous solution 100 unit/milliliter (mL) (Insulin Glargine) inject 18 unit subcutaneously in the morning for diabetes mellitus type two.Observation on 03/03/26 at 8:58 A.M. of Licensed Practical Nurse (LPN) #268 administering Resident #50's morning medications revealed LPN #268 gave Resident #50 eye drops and oral medications but held the morning dose of Lantus. Interview on 03/03/26 at 5:06 P.M. with LPN #268 who verified she held Resident #50's morning dose of Lantus on 03/03/26 and stated Resident#50 did not refuse the Lantus injection. LPN #50 confirmed there are no parameters to hold the Lantus. LPN #268 stated she did not call the provider and Resident #50's blood sugar was 97 on the morning of 03/03/26.Review of the facility Administering Medications policy dated revised 04/2019 revealed if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having a potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's medical Director to discuss the concerns.2.Review of the medical record for Resident #545 revealed an admission date of 05/22/24 with diagnoses included but not limited to acute respiratory failure with hypoxia, depression, dementia, muscle weakness, hypertension, type two diabetes mellitus, bipolar disorder, anxiety disorders, hypothyroidism, hyperlipidemia, chronic obstructive pulmonary disorder, and chronic kidney disease stage three.Review of the annual MDS dated [DATE] for Resident #545 revealed a BIMS of 12 which indicated moderate cognitive impairment. Further review of the annual MDS dated [DATE] revealed Resident #545 had no psychosis, no verbal or physical behaviors, and no rejection of care.Review of the care plan dated 10/22/24 for Resident #545 revealed a focus which stated potential risk for hyper/hypoglycemia due to diagnosis of diabetes mellitus daily insulin with an intervention of administer medications as ordered.Review of an order for Resident #545 revealed Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/mL (Insulin Glargine) inject 10 unit subcutaneously in the morning related to type two diabetes mellitus without complications.Observation 03/03/26 at 7:44 A.M. of RN #310 administering medications for Resident #545. RN #310 removed the Lantus pen for Resident #545 from the medication drawer and placed a needle on the end of the pen. Then RN #310 dialed the Lantus pen to 10 units of insulin without priming the insulin pen. RN #310 administered the Lantus to Resident #545 in the lower left abdomen.Interview on 03/03/26 at 7:27 A.M. with RN #310 who stated she checked the Lantus insulin pen for air bubbles before she gave the insulin. RN #310 stated she did not know any other way of priming the Lantus pen.Review of the Lantus Solostar Pen instruction leaflet under step three states Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that the pen and needle work properly and removing air bubbles. Select a dose of two units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way n. Check of insulin comes out of the needle tip. Check the dose window shows 0 following the safety test.This deficiency represents non-compliance investigated under Complaint Number 2722159.

Based on observation, interview, and record review, the facility failed to prevent significant medication errors when staff did not administer insulin as ordered and did not prime insulin prior to administration. This affected two (Residents #50 and #545) of three residents reviewed for medication administration. The facility census was 120.1.Review of the medical record for Resident #50 revealed an admission date of 08/20/19 with diagnoses to include but not limited to type two diabetes mellitus with hyperglycemia, muscle weakness, diastolic heart failure, chronic pancreatitis, toxic liver disease, cardiomyopathy, hyperlipidemia, hypertension, spinal stenosis, need for assistance with personal care, vascular disease, hypotension, gastro-esophageal reflux disease, and atrial fibrillation.Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #50 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. Further review of the quarterly MDS dated [DATE] revealed Resident #50 had no psychosis, no verbal or physical behaviors, and no rejection of care.Review of the care plan for Resident #50 dated 02/15/21 revealed a focus which stated resident has an impaired metabolic status related to diabetes and morbid obesity with interventions to include administer medications/insulins and treatments as indicated by physician orders.Review of an order for Resident #50 revealed Lantus subcutaneous solution 100 unit/milliliter (mL) (Insulin Glargine) inject 18 unit subcutaneously in the morning for diabetes mellitus type two.Observation on 03/03/26 at 8:58 A.M. of Licensed Practical Nurse (LPN) #268 administering Resident #50's morning medications revealed LPN #268 gave Resident #50 eye drops and oral medications but held the morning dose of Lantus. Interview on 03/03/26 at 5:06 P.M. with LPN #268 who verified she held Resident #50's morning dose of Lantus on 03/03/26 and stated Resident#50 did not refuse the Lantus injection. LPN #50 confirmed there are no parameters to hold the Lantus. LPN #268 stated she did not call the provider and Resident #50's blood sugar was 97 on the morning of 03/03/26.Review of the facility Administering Medications policy dated revised 04/2019 revealed if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having a potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's medical Director to discuss the concerns.2.Review of the medical record for Resident #545 revealed an admission date of 05/22/24 with diagnoses included but not limited to acute respiratory failure with hypoxia, depression, dementia, muscle weakness, hypertension, type two diabetes mellitus, bipolar disorder, anxiety disorders, hypothyroidism, hyperlipidemia, chronic obstructive pulmonary disorder, and chronic kidney disease stage three.Review of the annual MDS dated [DATE] for Resident #545 revealed a BIMS of 12 which indicated moderate cognitive impairment. Further review of the annual MDS dated [DATE] revealed Resident #545 had no psychosis, no verbal or physical behaviors, and no rejection of care.Review of the care plan dated 10/22/24 for Resident #545 revealed a focus which stated potential risk for hyper/hypoglycemia due to diagnosis of diabetes mellitus daily insulin with an intervention of administer medications as ordered.Review of an order for Resident #545 revealed Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/mL (Insulin Glargine) inject 10 unit subcutaneously in the morning related to type two diabetes mellitus without complications.Observation 03/03/26 at 7:44 A.M. of RN #310 administering medications for Resident #545. RN #310 removed the Lantus pen for Resident #545 from the medication drawer and placed a needle on the end of the pen. Then RN #310 dialed the Lantus pen to 10 units of insulin without priming the insulin pen. RN #310 administered the Lantus to Resident #545 in the lower left abdomen.Interview on 03/03/26 at 7:27 A.M. with RN #310 who stated she checked the Lantus insulin pen for air bubbles before she gave the insulin. RN #310 stated she did not know any other way of priming the Lantus pen.Review of the Lantus Solostar Pen instruction leaflet under step three states always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that the pen and needle work properly and removing air bubbles. Select a dose of two units by turning the dosage selector. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way n. Check of insulin comes out of the needle tip. Check the dose window shows 0 following the safety test.This deficiency represents non-compliance investigated under Complaint Number 2722159.

Based on record review, observation, and interviews, the facility failed to ensure appropriate incontinence care was provided for one Resident # 910. This affected one (Resident #910) of the three residents reviewed for incontinence care. Additionally, the facility failed to ensure staff handled medication in a sanitary way. This affected one (Resident #205) of three residents observed for medication administration. The facility census was 120.Findings include:1.Review of the medical record for Resident #910 revealed an admission date of 12/24/25 with diagnoses to include, but not limited to cerebral infarction, hypertension, dementia, anorexia, abnormalities of gait and mobility, and urinary incontinence.Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #910 revealed a Brief Interview for Mental Status (BIMS) of six which indicated severe cognitive impairment. Resident #910 required supervision with toileting hygiene and was occasionally incontinent with bladder and always incontinent of bowel.Review of the care plan dated 12/24/25 for Resident #910 revealed a focus which stated the resident has potential for impairment of skin integrity with an intervention of check and change approximately every two to three hours and as needed for incontinence.Observation on 03/03/26 at 10:07 A.M. of Certified Nursing Assistant (CNA) #164 and CNA #348 proving incontinence care for Resident #910. Licensed Practical Nurse (LPN) #209 was in Resident #910's room during the observation. CNA #164 went into Resident #910's room and washed his hands, then he put on gloves. While wearing gloves, CNA #910 opened bags of clean linen, then put a clean towel on Resident #910's bedside table. LPN #209 left Resident #910's room to retrieve wash basins for incontinence care. LPN #209 brought two wash basins which were not covered into Resident #910's room. CNA #164 took the basins from LPN #209, then put water in each one and placed it on the towel on Resident #910's bedside table. Then CNA #164 placed clean wash cloths into the wash basins. While wearing the same gloves, CNA #164 pulled Resident #910's bedside table closer to the bed and without changing gloves performed peri-care on Resident #910. After completing peri-care, CNA #164 removed his gloves and washed his hands, then CNA #164 put on new gloves, placed an incontinence brief on Resident #910 and pulled up her pants. Afterwards, CNA #164 removed his gloves and washed his hands.Interview on 03/03/26 at 10:36 A.M. with CNA #164 and LPN #209 revealed CNA #164 confirmed he washed his hands and put on gloves, then touched items such as the basins and bedside. CNA #164 confirmed he performed peri-care without removing the dirty gloves and washing his hands. LPN #209 verified CNA #164 did not change his gloves after touching multiple items before he performed peri-care for Resident #910.Review of the facility Handwashing/Hand Hygiene policy dated revised 08/2019 revealed all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Use an alcohol-based and rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents.Review of the facility Policies and Practices-Infection Control dated revised 10/2020 revealed this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and mange transmission of diseases and infections.2.Review of the medical record for Resident #205 revealed an admission date of 07/16/25 with diagnoses to include but not limited to spinal stenosis, anxiety disorder, mild cognitive impairment, need for assistance with personal care, muscle weakness, cognitive communication deficit, dysarthria and anarthria, asthma, dementia, hypertension, hyperlipidemia, and anemia osteoarthritis.Review of the quarterly MDS dated [DATE] for Resident #205 revealed a BIMS of eleven which indicated moderate cognitive impairment. Further review of the quarterly MDS dated [DATE] revealed Resident #205 had no psychosis, no verbal or physical behaviors, and no rejection of care.Review of the care plan dated 07/24/25 for Resident #205 revealed a focus which stated the resident has a slight impaired cognitive function/dementia with impaired communication due to BIMS of 13 and hearing impairment, uses hearing aids with an intervention to include administer medication as ordered.Review of an order for Resident #205 revealed Losartan Potassium oral tablet 50 milligrams (mg) give one tablet by mouth in the morning for hypertension.Observation on 03/03/26 at 7:27 A.M. of Registered Nurse (RN) # 310 preparing medications for Resident #205. The medications were in prefilled single containers within a bag which had all the medications listed on the outside of the bag. RN #310 removed the Losartan pill from its individual container by popping the back of the container. The Losartan pill fell out of its container onto the medication cart. RN #310 picked up the Losartan pill with her bare fingers and placed it in the medication cup with Resident #205's other oral medications. RN #310 then gave Resident #205 all the oral medications in the medication cup and Resident #205 swallowed them.Interview on 03/03/26 at 7:57 A.M. with RN #310 who verified she picked up Resident #205's Losartan with bare fingers and put it in the medication cup. RN #310 stated she should have put on a glove to pick up the pill.Review of the facility Administering Medications policy dated revised 04/2019 revealed staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on interview, record review, hospital record review, facility policy review, review of Centers for Disease Control (CDC) Stimulant Guide, and review of SAMHSA (Substance Abuse and Mental Health Services Administration) guidelines, the facility failed to ensure a resident with history of substance use received the appropriate care to manage his condition or attain the highest practicable mental and psychosocial well-being. This affected one resident (Resident #82) of three residents reviewed for neglect.Findings Include:Review of the medical record for Resident #82 revealed an admission date of [DATE]. The facility listed diagnoses as of [DATE] that included paraplegia, anxiety disorder, insomnia, depression, chronic pain syndrome, and peripheral vascular disease unspecified. The diagnosis list did not include substance use disorder or a drug abuse diagnosis.Review of hospital referral records dated [DATE] revealed Resident #82 had diagnosis of drug abuse, had reported current drug use of marijuana, methamphetamines and cocaine. The hospital report also stated Resident #82 had an order for naloxone (Narcan) (used for opioid overdoses). The hospital report noted Resident #82 had been paraplegic since an industrial accident in the late 1980's. Per the hospital report, Resident #82 was evicted from his apartment on [DATE] and had been living on the streets because he had a service dog that homeless shelters wouldn't allow.Review of the progress notes for Resident #82 from [DATE] revealed an incident in which Resident #82 had overnight visitors and reported himself to be so high. He was examined by nurses and found to have dilated pupils, abnormal mental status and was lethargic. He refused a search of his room. The CNP was notified and ordered his narcotic medications to be held and a drug test. The resident refused a drug test at that time but later consented. Results were unavailable at time of survey.Review of the outside counseling referral form dated [DATE] for Resident #82 completed by the facility social worker noted he was being referred for adjustment difficulties, anger problems, emotional outbursts and problem behaviors. History of or current substance use/abuse behaviors was not circled or indicated on the form in any way.Review of the care plan entry revised [DATE] revealed Resident #82 had an alteration in behavior and would have abusive attacks on staff and/or other residents. Interventions included: administer medications as ordered and monitor side effects; inform the Medical Director (MD)/Certified Nurse Practitioner (CNP) of worsening behavior; intervene as needed to protect the rights and safety of others, approach/speak in calm manner, divert attention, remove from situation and take to another location as needed.Review of the care plan entry for Resident #82, revised [DATE], revealed a focus that Resident #82 was at risk for episodes of anxiety due to a history of mood changes and anger outbursts. Interventions suggested included: address reasons for anxiety, social withdraw/crying, absence of family/friends; administer medications as ordered and monitor for side effects and effectiveness.A plan of care focus for Resident #82 revised on [DATE] indicated the resident had potential to demonstrate verbally abusive behaviors due to ineffective coping skills, mental/emotional illness and poor impulse control. Interventions included: analyze key times, places, circumstances, triggers and what de-escalates behaviors and document; assess the resident's coping skills and support system; assess the resident's understanding of the situation, allow time for the resident to express self and feelings to the situation; assess risks when the resident makes manipulative statements; evaluate for side effects of medications; monitor/document observed behaviors and attempted interventions in behavior log.Review of the care plan focus for Resident #82, revised [DATE], revealed that Resident #82 was assessed to have the potential for a mood problem displayed as anxiety or restlessness due to depression and anxiety. Suggested interventions included: assess/evaluate resident's behavior and cognition systematically and continually throughout the day and night as appropriate; discuss possibility of changes in mental status, agitation, confusion and restlessness with responsible party/family member; monitor for possibility of changes in mental status, agitation, confusion and restlessness; report to practitioner mood patterns of acute agitation, anxiety and/or restlessness; and to use the counseling source.Review of previous PHQ Questionnaire completed with Resident #82 on [DATE] revealed Resident #82 scored a 12 at that time, which indicated moderate depression.Review of the trauma evaluation completed on [DATE] for Resident #82 indicated trauma of forklift accident and triggers were nightmares. There was a 'no' selected for the question of whether the resident had any new trauma or issues related to old trauma. There was no other information on this documentation regarding Resident #82's behaviors or triggers that would lead him to seek maladaptive coping strategies such as substance use. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #82 had intact cognition. Resident #82 required setup or cleanup assistance for eating and oral hygiene. Resident #82 required partial/moderate assistance for upper body dressing, rolling left to right, and moving from sitting to lying position. Resident #82 was dependent on staff for toileting, showering/bathing, lower body dressing, putting on/taking off footwear, personal hygiene, chair to chair transfers and tub transfers. Resident #82 used a motorized wheelchair and was independent for wheeling 150 feet.Review of the plan of care for Resident #82, last reviewed by the facility on [DATE], revealed no mention of Resident #82's history of substance use, current substance use or previous homelessness. While the care plan mentioned that he was paraplegic, it was in the context of noting he had potential risk for falls. There was no mention in the care plan of trauma history related to the life-changing industrial accident or the death of both parents which eventually led to his homelessness. There was no mention in the care plan of his history of leaving the facility without signing out. Subsequently, there was no documentation of triggers that might lead Resident #82 to want to pursue illicit substance use. Additionally, there was no suggestion of actions to take in order to keep the resident safe when Resident #82 returned to the facility with an altered mental status and was presumed to be high. Review of physician orders for [DATE] for Resident #82 revealed no orders for Narcan and no orders for monitoring Resident #82 for potential adverse effects from any incidents of illicit substance use.Review of the nursing progress note from [DATE] at 8:11 P.M. revealed Resident #82 had left the building at 7:00 A.M. in his mechanical wheelchair and did not sign out in the leave of absence (LOA) book or tell anyone where he was going. Per the note, he returned at 11:30 A.M. with a known drug addict and appeared to be not acting normal. The nurse and the Administrator spoke with the resident and requested a urinalysis (drug screen). They also notified the CNP who put the resident's narcotics on hold and wrote the order for urinalysis. The resident agreed to the drug test but said he wanted to go with his friend and would be back in an hour. The note went on to say that he had not returned by 8:11 P.M.Review of the nursing progress note from [DATE] at 5:44 A.M. noted Resident #82 returned to the building at 5:30 A.M.Review of the nursing progress note from [DATE] at 12:27 A.M. revealed Resident #82 and a visitor friend of his were following the Certified Nursing Assistants (CNA) around the building and making them uncomfortable. The note indicated the resident attempted to follow the aide into the bathroom and sat outside the door attempting to talk to the aide while the aide was using the restroom. The note went on to say that Resident #82 was acting erratically and listening to music loudly which upset other residents. The Administrator was notified and per the nursing note, suggested they ask the visitor to leave the building.Review of the nursing progress note from [DATE] at 1:21 P.M. revealed Resident #82 continued to refuse drug testing and continued with altered mental status. There was a new order to discontinue the resident's Oxycodone order. Review of the Medication Administration Report for [DATE] for Resident #82 revealed his order for Oxycodone 10 milligrams by mouth every 6 hours was held on [DATE] and [DATE] and discontinued on [DATE].Review of the nursing progress note from [DATE] at 1:53 P.M. revealed Resident #82 was sliding out of his chair, continued with altered mental status, slurred speech and his eyes were closed. Staff used a Hoyer lift to get the resident back in bed.Review of the nursing progress note from [DATE] at 2:03 P.M. revealed that while staff were preparing a bed for resident, they found weapons and tetrahydrocannabinol (THC) (a psychoactive compound found in the leaves and flowers of the cannabis plant) gummies and removed them from the residents area.Review of the nursing progress note from [DATE] at 6:07 P.M. revealed Resident #82 had been yelling out, was incoherent and mumbling. The nurse asked if he wanted dinner but was unable to understand his speech and left the resident in bed with call light in reach.Review of the nursing progress notes for Resident #82 for [DATE] at 8:20 P.M. revealed Resident #82 was reported to be not acting right and was noted to be yelling, screaming and exhibiting incoherent speech. The note indicated he had history of suspected substance use, and the resident refused a urine sample. He had low oxygen saturation at 58% (normal ranges from 92 to 100%) and appeared disoriented. With oxygen at 2 liters, they were able to increase his oxygen saturation to 67%. Facility staff called 911 due to his low oxygen levels and altered behavior. Emergency medical services (EMS) arrived and noted the resident to be alert and oriented and therefore they could not transport resident as he refused to go. The CNP was notified.Review of the physician progress note for Resident #82 posted [DATE] at 12:00 A.M. noted the purpose of the visit was a regulatory visit to address chronic conditions including chronic pain, insomnia, edema and leukocytosis. The progress note attributed Resident #82's insomnia to Resident #82 drinking several caffeinated beverages throughout the day and recommended for him to not have caffeine after 4:00 P.M. The note had no mention of the events of the previous week, how methamphetamines would contribute to insomnia, and there was no mention of the resident's history of substance use. Review of the CNP progress note from [DATE] at 11:02 A.M. revealed the CNP was seeing him for a follow up visit for cellulitis Resident #82 had in July that was since resolved with a 10 day course of cephalexin. The note indicated Resident #82 had increased bilateral lower extremity (BLE) edema and community acquired pneumonia (CAP), but had refused treatment. Per the note, on that day, Resident #82 told the CNP to go away because he didn't feel good. There was no mention in the note regarding the recent incident where the staff believed the resident to have used illicit substances in the past week or Resident #82's substance use history.Review of progress note dated [DATE] at 1:20 P.M. revealed a nurse had completed a Patient Health Questionnaire (PHQ) (screening tool for depression) evaluation for Resident #82 with a resulting score of 21, which indicated severe depression and a nine-point increase from the last assessment in [DATE]. No new interventions were in place after this noted increase in depression.Review of nursing progress note from [DATE] at 4:15 P.M. revealed an aide notified the nurse that Resident #82 was acting abnormal. The nurse noted the resident appeared anxious, but unable to express full thought process to the nurse and was only responding with one or two words. The note indicated his verbal speech and responses were noted to be confused. The note indicated the resident said he was scared and wanted to go to the hospital, but was afraid to be alone. He was noted to be shaking. The nurse called the squad, administered oxygen for shortness of breath and anxiety. Review of hospital emergency department (ED) note dated [DATE] at 4:32 P.M. revealed Resident #82 presented to the emergency room (ER) due to concern worsening shortness of breath. The note indicated the residents history was limited. Resident #82 was found to be hypoxic (inadequate supply of oxygen) requiring a nonrebreather (device that delivers high concentration of oxygen). There was no mention in the ER note regarding recent suspected drug use. He was given new diagnoses of acute respiratory failure with hypoxia and hypercapnia, and pneumonia of both lungs due to infectious organism in an unspecified part of lung. Review of the hospital toxicology (drug) screen collected [DATE] for Resident #82 revealed only three substances were tested: acetaminophen (Tylenol), salicylate (such as aspirin) and ethanol (alcohol). Resident #82 tested negative for the alcohol.Review of the hospital physician documentation from [DATE] at 9:57 A.M. revealed while Resident #82 was in hospital, he had chronic hypoxemia on 3 liters of oxygen and the physician noted he previously did not have a pulmonary diagnosis. The physician attributed Resident #82's condition to his history of smoking and history of drug use and wrote that his status had worsened and therefore he needed to be intubated.Interview on [DATE] at 3:25 P.M. with Licensed Practical Nurse (LPN) #201 revealed she had seen rolled up dollar bills (drug paraphernalia typically used by drug users to snort powdered drugs) in Resident #82's room and that he had a couple of visitors who would come in at two or three in the morning and drop things off and he would act differently afterwards. She lamented that management wouldn't do anything and would state that the facility had a 24-hour visitation policy. She said a co-worker of hers had seen a crack pipe (drug paraphernalia used to heat and smoke crack cocaine) in the room and had written it up and the previous Director of Nursing (DON) made her friend change the writeup. LPN #201 cried as she shared that some of the staff were in recovery and would get nervous going into his room because you would never know what you would find. She said they would double glove for fear of fentanyl residue. Interview on [DATE] at 8:15 A.M. with Resident #75 revealed that Resident #82 would scream and yell and made her and her daughter uncomfortable. She said he played rap music really loud and she didn't like the language in the music. She said sometimes she would get her medication late or aides wouldn't be available to help her because they were taking care of [Resident #82]. Interview on [DATE] at 8:27 A.M. with Resident #68 revealed she kept her distance from [Resident #82] because he was cruel to her when he asked her to help him in his room. A couple of times he came into her room and asked her to rub his arm and she said he told her it soothed him. She did that twice but chose not to do it again because she didn't want it to be a habit. She said he was verbally abusive to staff and other residents. She said she hadn't had many conversations with him because she remembered him telling her about what he had done to somebody and how he got even, though Resident #68 did not elaborate as to what Resident #82 had done. She said she stayed away from him after hearing that. Interview on [DATE] at 8:51 A.M. with Certified Nursing Assistant #209 revealed she was close with Resident #82, but noted he was obnoxious with his music. She said his playing loud music would be during his moments when he was really high. She said his drug use was really bad the past four months. She said she never saw the drugs herself, but she could tell when he was high. She expressed sadness for him and noted he had depression from his accident. She said she was working one of the times when he came back to the facility from being out and he was really high, and he had a female friend and they were picking stuff up off the ground that weren't there. She said the night he came back at 5:30 A.M. he asked staff to lie for him but they didn't want to. She expressed sadness for the pain that he had in the days leading up to going to the hospital. She said she didn't think he was high then because he was moaning and groaning and he didn't do that when he was high.Interview on [DATE] at 9:08 A.M. with Certified Nursing Assistant #208 revealed she knew Resident #82 before he moved to the facility. She shared that he started using recreational drugs after his accident. She said she didn't believe his recreational drug use to be for pain control but rather for coping. She said before his accident he was young and fit and took pride in himself and after the accident he just didn't seem to care anymore. She shared that he had been living with his parents and then when they both died, he became homeless. She said she had seen some of the visitors that have come in were pretty [NAME]. She said she didn't know of any attempts to supervise visits. She said she saw a rolled up dollar bill in his room and heard about the other items that were removed from the room. She said she thought his hospitalization might be related to his drug use because his drug of choice was methamphetamine (meth) and his route of choice was smoking it. Interview on [DATE] at 9:54 A.M. with CNP #206 revealed he did not know why they didn't retain the diagnosis of drug abuse from when Resident #82 first moved to the facility. He said they should have left that on there. He said he believed the use of meth to be intermittent, although noted it had been a problem the past couple of years off and on. He noted he received a lot of calls from staff over the years. He said they would say that Resident #82 was confused, up all night and/or wired. In regards to the absence of a Narcan order, CNP #206 noted it may have been there when Resident #82 first came to facility and it would have been removed if it wasn't used. He said the facility had Narcan on site though. He confirmed he did not have a specific order for observations when Resident #82 would return high and that he would tell staff to keep an eye on the patient. He said that in the past, Resident #82 did test positive for meth which coincided with the insomnia. He discussed the challenge of pain management when Resident #82 would refuse a drug screen. He said he would have to take Resident #82 off of the opioids because they didn't want interactions. He said he would have conversations with Resident #82 about formal substance use disorder treatment any time he had to take Resident #82 off of his narcotics, however, Resident #82 would decline because Resident #82 feared losing access to his pain medicine. CNP #206 said he didn't know if he had documented these conversations. CNP #206 shared that they just recently made an appointment for Resident #82 to go to a pain clinic and that was the suggestion of the new Director of Nursing. He lamented that they probably should have done that a long time ago. He said he did not know that Resident #82 smoked his meth and thought that it could have a connection to his breathing issues. CNP #206 said he was not aware of how or when Resident #82 had his accident and that he didn't know that both parents were deceased . He had not noticed that the two significant incidents documented were the same week a year apart and didn't know if the month of October had any significance to Resident #82. He said knowing these type of things about Resident #82's past may have helped them provide better care.Interview on [DATE] at 1:34 P.M. with the Director of Nursing (DON) confirmed there was no update to the care plan after the PHQ results for Resident #82 went from a 12 to a 21 and indicated severe depression. She said he wasn't in his right state of mind for them to follow up. She did not know if he had seen a counselor more recently than [DATE]. She said the last few weeks she had heard about odd behaviors. The DON said she did not know or notice that the occurrences when Resident #82 returned to the facility with altered mental status were during the same week of October in 2024 and [DATE]. She said he never did agree to take a urine test when it was ordered earlier this [DATE]. Interview on [DATE] at 1:36 P.M. with Housekeeping Supervisor #211 revealed Resident #82 would frequently complain about not being able to sleep and other people would tell her that it was because he was high. Interview on [DATE] at 1:45 P.M. with Housekeeper #212 revealed that when they were cleaning Resident #82's room they found a pipe that you smoke out of, lighters and vapes.Interview on [DATE] at 1:47 P.M. with Hospital Representative #265 revealed the hospital would only do an abbreviated toxicology screen unless they knew they needed to run a full one. She noted the emergency department notes did not have reports of recent meth use.Review of Substance Abuse and Mental Health Services Administration publication, Treatment of Stimulant Use Disorders noted long term use of cocaine and methamphetamines can cause mood fluctuations, anxiety and depression, even when not using the drugs. A strong evidenced-based treatment for stimulant use disorder is the use of contingency management that incentivizes positive behaviors with small prizes or privileges.Review of Centers for Disease Control publication A Stimulant Guide, dated 2022 revealed signs and symptoms of a stimulant overdose included dilated pupils, dizziness, tremors, irritability, confusion, mood swings, panic, or extreme anxiety. Overdoses from stimulants such as methamphetamines may not result in loss of consciousness. The effects of stimulant use may cause someone to panic and act impulsively out of fear or self-defense. People who have used stimulants may experience sleep deprivation or paranoia leading to energetic or loud physical behaviors that could be interpreted as aggressive. Review of facility policy, Visitation, dated 2017, revealed the facility provides 24-hour access to all individuals visiting with the consent of the resident. Some visitation may be subject to reasonable restrictions as outlined in licensure and/or that protect the security of the facility's residents such as: Limiting or supervising visits from persons who are known or suspected to be abusive or exploitative to a resident; denying access to individuals who are found to have been committing criminal acts; and denying access to visitors who are inebriated or disruptive.Review of the undated facility policy, Abuse, Neglect, Exploration and Misappropriation of Resident's Property and Injuries of Unknown Sources, revealed the definition of neglect to be recklessly failing to provide a resident with any treatment, care, goods or services necessary to maintain the health or safety of the resident when the failure results in serious physical harm to the resident. Residents that may be at increased risk include behaviorally disturbed residents-aggressive, agitated. The policy further stated that the facility will strive to identify, correct and intervene in situations in which abuse, neglect more likely to occur, including: the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or totally dependent on staff.This deficiency represents non-compliance investigated under Complaint Number 2654456.

Based on observation, record review, facility policy review, and interviews, the facility failed to ensure an adequate stock of controlled substances were on-hand to adequately treat pain. This affected two residents, Resident #46 and Resident #65.Actual Harm occurred when the facility failed to ensure scheduled pain medication was reordered timely and available for Resident #65 and Resident #46. Resident #65's pain medication was not documented as administered on 08/09/25, 08/10/25, 08/11/25, and 08/12/25 leading to Resident #65 reporting pain, rating the pain a ten on a one to ten scale, with 10 being the worst pain ever experienced. Resident #65's pain medication was not documented as administered and on 08/11/25 at 10:43 A.M. and 12:01 P.M., Resident #46 reported constant and intense pain in the legs where an amputation had been performed. Resident #46 rated his pain at a level of 1000 out of ten on the numeric pain scale and complained he could not get out of bed. Resident #46 resident reported the nurse was aware of his severe pain and was working on obtaining his ordered medication. This affected two (Residents #46 and #65) of four residents reviewed for pain. The facility census was 105. Findings include:1. Review of the medical record for Resident #65 revealed an initial admission date of 05/05/18 and a re-entry date of 11/01/18. Medical diagnoses included rheumatoid arthritis, osteoarthritis, and right temporomandibular joint disorder. Review of the undated care plan for Resident #65 revealed the resident had complaints of pain related to inconsistent bowel pattern, rheumatoid arthritis, osteoarthritis, temporomandibular joint dysfunction and gout with multiple comorbidities. Interventions noted for the care plan included administering medications as ordered by the physician and to notify the physician if the current pain medication regimen was ineffective. Review of the physician orders for Resident #65 revealed an order dated 04/11/24 for Methadone (opioid) Hydrochloride (HCL), 10 milligram (mg) tablet, give one tablet in the morning for pain management. Resident #65 had an order dated 09/07/24 for Oxycodone HCL 10 mg, give one tablet by mouth every four hours as needed for moderate to severe pain. Review of Resident #65's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making. Resident #65 had impairment to the bilateral lower extremities and was receiving opioid pain medication daily. Review of the Medication Administration Record (MAR) for August 2025 for Resident #65 revealed the scheduled Methadone HCL 10 mg tablet was not administered on 08/09/25, 08/10/25, 08/11/25, or 08/12/25. This medication was not administered again until 08/13/25, where Resident #65 reported a pain level of a 10 on a one to ten scale. Review of a nursing progress note dated 08/11/25 at 1:37 P.M. revealed Resident #65 was out of her ordered Methadone 10 mg tablets. The pharmacy was called and stated the resident needed a new prescription. The nurse recorded that the oncoming nurse would be notified in the morning. Review of a nursing progress note dated 08/12/25 at 10:00 A.M. revealed the Licensed Practical Nurse (LPN) #403 contacted the unnamed Certified Nurse Practitioner (CNP) due to the resident not having ordered Methadone available and communicated a new prescription was needed. The nurse further communicated that the resident had been out of the medication since Saturday 08/09/25. The CNP stated to utilize the resident’s as-needed Oxycodone if needed until the Methadone arrived from the pharmacy. A new prescription was sent to the pharmacy from CNP. LPN #403 verified the pharmacy received the prescription from CNP and the pharmacy stated the Methadone would be in that evening’s pharmacy delivery. Review of Resident #65's MAR for August 2025 confirmed this resident did already have an as-needed order for Oxycodone HCL 10 mg tablet which was to be given every 4 hours as needed for moderate to severe pain. This medication was already being administered prior to the Methadone not being available, and the MAR documented the as-needed Oxycodone was ineffective at times. During an interview on 08/12/25 at 9:00 A.M., Resident #65 stated she was very upset because she had been out of her pain medication for days and was experiencing pain. Resident #65 rated her pain a 10 on a one to ten scale. During an interview on 08/12/25 at 9:10 A.M., LPN #915 confirmed Resident #65 was out of her ordered Methadone and confirmed the resident had not received her scheduled doses since the morning of 08/08/25. 2. Review of the medical record for Resident #46 revealed an admission date of 01/22/25 with diagnoses including acquired absence of the left leg below the knee, displaced comminuted fracture of the shaft of the right tibia, and chronic pain syndrome. Review of the care plan dated 02/05/25 revealed Resident #46 had the potential for altered comfort related to decreased mobility, comorbidities, fracture of the right tibia, joint pain, and chronic pain. Interventions included attempting non-pharmacologic approaches before using medications, encouraging the resident to request pain medication before pain intensified, evaluating the effectiveness or need to adjust pain medications, monitoring pain every shift, and offering analgesics as ordered by the physician. Review of pain evaluation for cognitively intact individuals dated 04/29/25 revealed the resident reported past experiences of pain, with no diagnosis of opioid use disorder. Previous interventions included prescribed medications. An acceptable pain level was recorded at a four out of 10. The resident reported frequent pain, which did not interfere with sleep but did limit daily activities. Non-medication interventions used included relaxation techniques. Review of the MDS quarterly assessment dated [DATE] revealed Resident #46 was cognitively intact and received opioid medications for pain management. Record review revealed a physician order for Resident #46’s dated 08/01/25 for Oxycodone oral tablet 10 mg, one tablet by mouth every four hours for pain. Scheduled administration times were 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of the controlled drug receipt/record/disposition form dated 08/10/25 revealed the last dose of Resident #46’s Oxycodone 10 mg was recorded as administered on 08/10/25 at 4:30 A.M. Review of Resident #46’s progress notes dated 08/10/25 through 08/11/25 revealed multiple entries from staff documenting that the resident’s Oxycodone was not available and was awaiting delivery from the pharmacy. This included documentation on 08/10/25 at 8:21 A.M., 9:48 P.M., and 11:22 P.M., as well as on 08/11/25 at 5:05 A.M. On 08/11/25 at 12:30 P.M., the physician was notified the resident was out of her ordered Oxycodone. Review of Resident #46’s MAR from 08/10/25 at 8:00 A.M. through 08/11/25 at 12:00 P.M. revealed the resident’s Oxycodone was marked as not given or not available. On 08/11/25 at 8:00 A.M. and 12:00 P.M., pain levels were marked as not applicable. On 08/11/25 at 4:00 P.M., oxycodone was administered for pain rated at an eight out of 10. On 08/10/25 at 11:21 P.M. and on 08/11/25 at 5:05 A.M., Resident #46 was given doses of Acetaminophen (an over-the-counter mild pain reliever) oral tablet 325 mg, two tablets by mouth every four hours as needed for pain. The pain scale was recorded as zero out of 10. Prior to this administration, Resident #46 did not receive any as-needed doses between 08/01/25 and 08/09/25. Review of a pain level summary from 08/09/25 through 08/11/25 revealed Resident #46 reported pain of a zero out of ten. On 08/11/25 at 1:12 P.M., the resident reported his pain at two out of 10, and at 4:18 P.M. reported pain of an eight out of 10. During an observation on 08/11/25 at 10:43 A.M., Resident #46 was observed lying supine in bed with his arms covering his head. He had his fists clenched with minimal movement. He gave short responses, stating he had not received his prescribed narcotic pain medication since 08/10/25 at 8:00 A.M. He rated his pain as “1000 out of 10” and described phantom limb pain in his left lower leg from a previous amputation. He confirmed LPN #402 was aware he was out of pain medication and was working with the Unit Manager to resolve the issue. Due to severe pain, he reported being unable to get out of bed and declined to continue the conversation. During an interview on 08/11/25 at 10:48 A.M., LPN #402 confirmed Resident #46 had no remaining doses of his ordered Oxycodone for his scheduled 8:00 A.M. and 12:00 P.M. administrations. LPN #402 acknowledged the resident’s severe pain and indicated he received his scheduled Lyrica (a nerve pain medication) for some pain relief. She attempted to pull a dose of Oxycodone from the back-up stock box, but the resident’s current prescription did not match the available stock. LPN #402 confirmed the Unit Manager was coordinating with the pharmacy and physician to obtain the correct order for the resident. During an observation on 08/11/25 at 12:01 P.M., Resident #46 remained lying still in bed in the fetal position, with a blanket completely covering his body. He reported ongoing and severe pain, rating it a 10 out of 10 and confirmed he had still not received his prescribed narcotic pain medication, nor had he heard of any additional updates. Review of the controlled drug receipt/record/disposition form for Resident #46, dated 08/11/25, showed Oxycodone tablets 10 milligrams, quantity of 60, was delivered to the facility. The order called for the medication to be administered every four hours as needed for pain. The first recorded dose administered from the new supply was given to Resident #46 on 08/11/25 at 4:00 P.M. Review of the pharmacy delivery slip dated 08/11/25 at 4:14 P.M. for Resident #46 confirmed delivery of oxycodone tablets 10 milligrams. During an interview on 08/14/25 at 10:10 A.M., Unit Manager #240 confirmed licensed nursing staff did not place a medication reorder on 08/10/25 to the pharmacy for Resident #46’s scheduled Oxycodone. Unit Manager #240 stated the first request occurred on Monday morning, 08/11/25, around 8:00 A.M., when she arrived on site and was notified the resident was out of his medication by LPN #402. She attempted to obtain an emergency order to pull from the back-up stock box from the physician, but by the time the order was received, the replacement medication had already arrived. She confirmed Resident #46 went approximately 36 hours without his prescribed pain medication and Resident #46 missed eight scheduled doses: 08/10/25 at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., and 08/11/25 at 12:00 A.M., 4:00 A.M., 8:00 A.M., and 12:00 P.M. During an interview on 08/18/25 at 10:33 A.M., LPN #400 confirmed she was working with Resident #46 during the day shift on 08/10/25 when the resident was without his narcotic pain medication. She was informed by the night shift nurse that the facility had run out of Oxycodone and was awaiting delivery of the medication from the pharmacy. LPN #400 had not contacted the pharmacy to verify the refill request and had not received a delivery during her shift. During an interview on 08/21/25 at 11:38 A.M., Medical Director (MD) #900 confirmed an on-call physician was initially notified on 08/11/25 at approximately 12:00 A.M. via the facility’s non-urgent messaging system. As a result of the non-urgent alert, a voicemail was left, and the return call was not expected until the morning from an on-call physician. MD #900 was notified again on 08/11/25 at approximately 12:30 P.M. and was informed that Resident #46 had been without his prescribed pain medication and was experiencing increased pain. By that time, staff had already begun coordinating with the on-call physician and pharmacy to obtain a new prescription and arrange for delivery. MD #900 acknowledged that Resident #46 should not have gone without scheduled pain medication for such an extended period. MD #900 confirmed nursing staff often wait until medications are completely depleted before requesting refills, which prevents physicians and pharmacies from acting proactively. MD #900 stated that, ideally, refill requests should be submitted several days in advance to avoid any lapse in medication availability. Review of the facility policy titled, Pain-Clinical Protocol, dated March 2018 revealed, the physician and staff will identify individuals who have pain or who are at risk of having pain. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. This deficiency represents noncompliance investigated under Complaint Number 1263770 (OH00165823).

Based on observation and interview, the facility failed to maintain a clean kitchen environment. This had the potential to affect all 105 residents residing in the facility who received meals from the facility kitchen. The facility census was 105.Findings include: An observation made on 08/11/25 at 9:00 A.M. during the initial kitchen tour revealed a large, uncovered commercial floor stand mixer with the mixing bowl in place. The mixer bowl was observed to have dust and small pieces of paper in the bottom of the bowl. Further observation revealed a free standing reach-in refrigerator in the prep area with the right hand side door handle covered with a sticky substance and a dried white substance (similar to dried batter) which dripped from above the door handle to below the door handle on the outside of the left door. Observation of the gas-powered cooktop revealed a thick, black, crusted, and greasy substance on the flat surfaces around the burners with a dried yellow substance observed on top of the thick, black, crusted, and greasy substance between the front edge of the cooktop and the front right burner.In an interview on 08/11/25 at 9:30 A.M., Dietary Director #195 verified the large commercial floor stand mixer was uncovered and the mixer bowl had dust and small pieces of paper in the bottom of the bowl. Dietary Director #195 also verified free standing reach-in refrigerator in the prep area had the right hand side door handle covered with a sticky substance and a dried white substance (similar to dried batter) which dripped from above the door handle to below the door handle on the outside of the left door. Dietary Director #195 further verified the gas powered cooktop had a thick, black, crusted, and greasy substance on the flat surfaces around the burners with a dried yellow substance observed on top of the thick, black, crusted, and greasy substance between the front edge of the cooktop and the front right burner.

Based on medical record review, controlled substance log review, staff interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors related to controlled medications. This affected six residents (#1, #3, #36, #62, #93, and #108) of seven residents reviewed for medication administration. The facility census was 105. Findings include: 1. Review of the medical record for Resident #1 revealed an initial admission date of 10/06/21 with a re-entry date of 03/09/25. Diagnoses included stage three chronic kidney disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of Resident #1's physician order dated 03/09/25 revealed an order for Oxycodone (narcotic pain medication) 5 milligram (mg) tablet, give two tablets by mouth every eight hours for pain. Review of the Controlled Drug Receipt/Record/Disposition form revealed on 08/12/25, Resident #1 received the scheduled pain medication at 5:16 A.M. and again at 9:00 P.M. Resident #1's 2:00 P.M. dose had not been administered or signed out on the log. On 08/16/25, Resident #1 was noted to receive the scheduled pain medication at 6:00 A.M. and again at 2:30 P.M. but had not received the 9:00 P.M. dose. Interview on 8/18/2025 at 10:00 A.M. with Licensed Practical Nurse (LPN) #403 confirmed Resident #1 was scheduled to receive Oxycodone every eight hours or three times a day and on a few of the noted days, the resident only received this medication twice. 2. Review of the medical record for Resident #36 revealed an admission date of 11/25/22. Diagnoses included cervical disc disorder, generalized anxiety, and mucopurulent chronic bronchitis. Review of Resident #36's physician order dated 12/13/23 revealed an order for Norco (a narcotic pain medication containing a combination of Hydrocodone and acetaminophen) oral tablet 5-325 mg, give one tablet by mouth three times a day for pain. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #36's Norco medication revealed on 08/12/25, this medication was recorded as being administered at 10:22 A.M., 2:26 P.M., 4:00 P.M., and 9:57 P.M. Interview on 08/18/25 at 10:00 A.M. with LPN #403 confirmed Resident #36 was supposed to receive the scheduled pain medication three times a day and received it four times on 08/12/25. 3. Review of the medical record for Resident #62 revealed an initial admission date of 08/07/24 and a re-entry date of 10/05/24. Diagnoses included alcoholic cirrhosis of the liver, osteoarthritis of the left hip, and hypertension. Review of Resident #62's physician order dated 06/25/25 revealed an order for Oxycodone HCL 5 mg tablet, give one tablet my mouth in the morning for moderate to severe pain. Review of the Controlled Drug Receipt/Record/Disposition form revealed Resident #62's scheduled pain medication was administered twice on 07/23/25, at 9:50 A.M. and at 8:35 P.M. This pain medication was also administered twice on 07/27/25 at 8:00 A.M. and again at 8:30 A.M. Interview on 08/18/25 at 10:00 A.M. with LPN #403 confirmed Resident #62 was supposed to get his scheduled pain medication one time a day in the morning and actually received two doses of this medication on 07/23/25 and 07/27/25. 4. Review of the medical record for Resident #93 revealed an initial admission date of 01/18/24 and a re-entry date of 06/04/25. Diagnosis included chronic obstructive pulmonary disease, chronic kidney disease, and respiratory failure. Review of Resident #93's physician order dated 06/04/25 revealed an order for Oxycodone HCL 20 mg tablet, give one tablet my mouth every 6 hours for chronic pain. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #93's pain medication revealed this medication was administered five times on 08/10/25 at 5:10 A.M., 8:00 A.M. 10:10 A.M, 12:00 P.M. and 6:00 P.M. On 08/12/25, only three doses were administered instead of the scheduled four at 5:30 A.M., 4:00 P.M. and 11:00 P.M. Continued review revealed Resident #93 only received three doses of this medication again on 08/14/25, at 12:11 P.M., 5:25 P.M. and 11:00 P.M. On 08/17/25, Resident #93 was noted to only receive three doses of this medication at 6:23 A.M., 2:08 P.M. and 11:17 P.M. Interview on 08/18/25 at 10:00 A.M. with LPN #403 confirmed Resident #93 received one dose too many on 08/10/25 and one dose less than what was ordered on 08/12/25, 08/14/25, and again on 08/17/25. 5. Review of the medical record for Resident #108 revealed an admission date of 08/04/25. Diagnoses included dementia, bipolar disorder, anxiety disorder, and insomnia. Review of Resident #108's physician order dated 08/04/25 revealed an order for Lorazepam (a controlled anti-anxiety medication) 1 mg tablet, give one tablet by mouth every eight hours for anxiety. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #108 revealed this medication was administered only two times on 08/09/25 at 5:22 A.M. and at 10:10 P.M. instead of three times that day. Interview on 08/18/2025 at 10:00 A.M. with LPN #403 confirmed a medication that was scheduled to be administered every eight hours would equal out to three times a day and that Resident #108 did not receive the correct amount of medication on 08/09/25. 6. Review of the medical record for Resident #3 revealed an admission date of 07/25/22 with diagnoses of chronic pulmonary edema, chronic obstructive pulmonary disease, acute diastolic heart failure, chronic respiratory failure with hypoxia, metabolic encephalopathy, chronic pain syndrome, rheumatoid arthritis, and a personal history of diabetic foot ulcer. Review of the care plan dated 01/19/24 revealed Resident #3 was at risk for pain related to chronic pain syndrome, rheumatoid arthritis, and comorbidities. Interventions include administering analgesia as per orders, anticipating need for pain relief, calling for assistance when in pain, evaluating the effectiveness of pain interventions, and monitoring for side effects pertaining to pain medication. Review of Resident #3's physician orders revealed an order dated 03/09/25 revealed Oxycodone HCl extended-release (ER) tablet 10 mg, give one tablet by mouth two times a day related to chronic pain syndrome. Continued review revealed an additional physician order dated 03/12/25 for Oxycodone HCl oral tablet 10 mg, give one tablet by mouth every six hours for pain. Review of Resident #3's Minimum Data Set (MDS) 3.0 annual assessment completed 07/13/25 revealed the resident was cognitively intact, received opioid medications, and had a scheduled pain medication regimen. Review of Resident #3's Medication Administration Record (MAR) from 07/01/25 through 07/31/25 revealed OxyContin (narcotic pain medication) 10 mg was scheduled to be administered at 7:00 A.M. and 7:00 P.M., and on 07/29/25 the medication was marked as given. Additionally, Oxycodone 10 mg was scheduled for administration on 07/29/25 at 5:00 A.M., 11:00 A.M., 5:00 P.M., and 11:00 P.M. On 07/29/25, an extra administration of Oxycodone 10 mg was not documented. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #3 dated 07/23/25 through 07/30/25 revealed on 07/29/25 at 10:00 A.M. and again at 12:00 P.M., the resident was administered Oxycodone 10 mg tablets. The form recorded five administrations of Oxycodone 10 mg tablets were given on 07/29/25, where the resident was scheduled to receive four doses per day. Review of the Controlled Drug Receipt/Record/Disposition form for Resident #3 dated 07/25/25 through 08/08/25 for Resident #3 revealed only one dose of OxyContin on 07/29/25 at 11:50 P.M. was logged and was noted as administered late. The form did not include indication that the scheduled 7:00 A.M. dose was administered on 07/29/25. Review of Resident #3's progress notes dated 07/29/25 revealed no documentation pertaining to a medication error. Additionally, there was no notification of physician notification of the error. Review of a medication error without harm report dated 08/18/25 revealed Resident #3 was noted to have received Oxycodone 10 mg on 07/29/25 at 10:00 A.M. instead of the scheduled OxyContin. An agency nurse was noted to have signed off the medication in the narcotic book. Resident #3 had no adverse effects. The report noted an unnamed Nurse Practitioner was notified. The medication error was recorded as being discussed with the resident. Interview on 08/13/25 at 11:39 A.M. with Resident #3 revealed concerns pertaining to the medication error. The resident stated an error had occurred a couple of weeks ago and that during the incident, she could not stay awake and believed she was overdosed on her pain medication. Interview on 08/18/25 at 1:18 P.M. with the Regional Director of Clinical Services (RDCS) #901 confirmed two doses of Oxycodone were given on 07/29/25 at 10:00 A.M. and 12:00 P.M. RDCS #901 confirmed the extra administration of Oxycodone was not documented on the MAR and prior to the surveyor's request for additional information, management was unaware of the documented medication error; therefore, an incident report was not completed on the day of the incident or around the event. Interview on 08/19/25 at 5:24 P.M. with Licensed Practical Nurse (LPN) #404 confirmed she worked with Resident #3 on 07/29/25. She denied knowledge of any medication error that day. However, she confirmed, based on the signature on the Controlled Drug Receipt/Record/Disposition form the resident's Oxycodone, that she administered the medication. LPN #404 denied notifying the physician, stating she was unaware that a medication error had occurred. Review of the policy Accidents and Incidents - Investigating and Reporting dated 07/2017 revealed all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator, additionally the nurse supervisor/charge nurse/supervisor shall promptly initiate and document investigation of the accident or incident. Review of the policy Controlled Substances revealed access to controlled medications remain locked at all times, and access is recorded. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on the premises. Upon administration, the nurse administering the medication is responsible for recording the name of the resident receiving the medication, the name, strength, and dose of the medication, time of administration, quantity remaining, and a signature of the nurse administering the medication. This deficiency represents noncompliance investigated under Complaint Number 1263770 (OH00165823).

Based on medical record review, and staff interview, this facility failed to ensure care plans had been revised to accurately reflect enhanced barrier precautions and fluid restrictions had been discontinued. This affected two residents (#24 and #66) of 30 residents reviewed for care planning. The facility census was 105.Findings include:1.Review of the medical record for Resident #24 revealed an initial admission date of 08/09/24 and a re-entry date of 07/11/25. Diagnoses included chronic systolic heart failure, peripheral vascular disease, and atrial fibrillation. Review of Resident #24's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Review of the undated care plan revealed Resident #24 required enhanced barrier precautions for infection prevention. Observations completed on 08/11/25 at 10:00 A.M. and again on 08/19/25 at 11:00 A.M. revealed Resident #24 did not have enhanced barrier precautions in place per the care plan. Interview on 08/14/25 at 12:47 P.M. with Regional Director of Clinical Services (RDCS) #997 revealed Resident #24 previously had a wound area that required enhanced barrier precautions which had since healed. RDCS #997 stated nursing staff must have forgotten to discontinue this in the care plan, but it was no longer required. 2.Review of the medical record for Resident #66 revealed an admission date of 06/03/14. Diagnosis included alcohol induced persisting dementia, hypertension, and hypokalemia. Review of the care plan dated 02/17/2021 revealed Resident #66 was at risk for fluid volume deficit related to cognitive impairment and fluid restriction. Interventions included to maintain a fluid restriction of 1800 milliliters (ml) in a 24-hour period Review of Resident #66's MDS 3.0 quarterly assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderately impaired cognition for daily decision-making abilities. Review of Resident #66's physician orders for August 2025 revealed no active fluid restrictions orders. Interview on 08/14/2025 at 12:27 P.M. with RDCS #997 confirmed Resident #66 did not have an order for a fluid restriction, but it was still in the care plan, most likely it was something that was missed and just needed to be removed.

Based on record review and interview, the facility failed to have resident funds available to the residents on the weekend. This affected one resident (#15) and had the potential to affect all residents with funds managed by the facility. The facility census was 105.Findings include: Review of Resident #15's medical record revealed an admission date of 03/10/23 and diagnoses including but not limited to diabetes, schizophrenia, other seizures, depression, bipolar disorder current episode mixed, severe, with psychotic features, anxiety disorder, hyperlipidemia, and hypertension. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Review of Resident #15's facility-managed funds account records dated June 2025 to August 2025 revealed there were no receipts for money released to Resident #15 from his facility-managed account on any weekend days. Interview on 08/12/25 at 10:00 A.M. with Resident #15 revealed he was unable to get money from his facility-managed account on the weekend because no one was in the facility's office on Saturdays or Sundays. Interview on 08/20/2025 at 2:01 P.M. with Business Office Manager (BOM) #102 confirmed no one is available in the facility to get funds for the residents on Saturdays or Sundays. BOM #102 further stated that the residents who frequently accessed their facility managed funds were aware that no one was available to access the facility-managed funds on Saturdays or Sundays and normally get their money for the weekend on Fridays.

Based on record review and interview, the facility failed to complete a baseline care plan for Resident #2 within 48 hours of admission as required. This affected one resident (#2) of four residents reviewed for dementia care. The facility census was 105. Findings include: Review of Resident #2's medical record revealed an admission date of 06/04/25 and diagnoses including but not limited to dementia, frontotemporal neurocognitive disorder, atrial fibrillation, hypertension, major depressive disorder, hyperlipidemia, and osteoarthritis. Review of Resident #2's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) due to being rarely or never understood, had behaviors of physical symptoms directed at others for four to six days during the assessment window, verbal symptoms directed toward others for one to three days during the assessment window, and rejection of care for four to six days during the assessment window. Further review of the MDS revealed Resident #2 required partial to moderate assistance with eating and mobility, and required substantial assistance for all other activities of daily living (ADLs), was always incontinent of bladder and bowel, and had one venous wound. Resident #2 received antipsychotic, antidepressant, hypnotic, anticoagulant, and anticonvulsant medications during the review period. Review of Resident #2's care plans revealed all care plan problems were dated as being initiated on or after 06/10/25. There was no evidence that a baseline plan of care had been initiated within 48 hours of admission. In an interview on 08/19/2025 at 2:55 P.M. Licensed Practical Nurse (LPN) Unit Manager #215 confirmed all of Resident #2's care plan problems were dated as being initiated on or after 06/10/25 more than 48 hours after the resident was admitted on [DATE].

Based on interview and record review, the facility failed to ensure the care plan included comprehensive psychosocial interventions to address identified behaviors. This affected one resident (#64) out of thirty residents reviewed for care planning. The facility census was 105.Findings include:Review of the medical record for Resident #64 revealed an admission date of 05/30/25 with diagnoses including depression, anxiety disorder, hypertension, and insomnia.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #64 was cognitively intact and has no mood or behavioral concerns.Review of the care plan dated 07/14/25 revealed the resident was known to make inappropriate and sexual comments to staff. Interventions included one-on-one supervision, every 15-minute and 30-minute checks as needed for safety of both this resident and others, referral to psych as needed, and staff monitoring for any inappropriate behaviors.Interview on 08/18/25 at 3:52 P.M. with Resident #64 revealed he wanted to grow a relationship with a cognitively impaired resident located within the facility. Resident #64 was unhappy the facility had forbidden him from seeing this resident in person and was forced to have supervised visits or visits behind glass walls.Interview on 08/19/25 at 8:19 A.M. with the Administrator confirmed Resident #64 voiced a desire to grow a relationship with a cognitively impaired resident, Resident #107. They informed Resident #107's Power of Attorney (POA) who requested the resident have no contact with Resident #64. The facility agreed, stating they wanted Resident #64 to cool off. The Administrator was unsure if Resident #64 was seeing psych services at this time but believed it could be beneficial. The Administrator reported that staff are well aware that Resident #64 was to stay away from Resident #107. The Administrator shared Resident #64 had become obsessed with Resident #107, and staff are diligent to ensure that during the entire friendship, interactions were only under supervised visits. The facility will continue to keep Resident #64 and Resident #107 separate until Resident #107's POA agreed otherwise, at which time the situation would be revisited. The Administrator confirmed these current concerns were not noted on the resident's care plan. This deficiency represents non-compliance investigated under Complaint number 2592657.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on closed medical record review, hospital record review, emergency call center documentation, facility investigation, interviews, review of the weather information at localconditions.com, and facility policy review the facility failed to ensure adequate supervision was provided to Resident #1, who was cognitively impaired and exhibited wandering behavior to prevent elopement. This resulted in Immediate Jeopardy on 03/08/23 at 5:24 P.M. when Resident #1 was found confused in front of hospital (by another patient's family member), face down on the ground, with abrasions and swelling to the right side of face, bilateral hands, and left forearm. The facility staff were unaware the resident had left the facility prior to this time. The likelihood of serious harm or injury occurred when after exiting the facility without staff knowledge, the resident crossed a two-lane street and fell at a drugstore on the corner of the two-lane street and a four-lane road. The resident then left that location and was subsequently located face down on hospital property located behind the drugstore. The resident was admitted to the hospital for evaluation and treatment. This affected one resident (#1) of three residents reviewed for elopement. On 03/16/23 at 4:05 P.M., the Director of Nursing (DON) was notified Immediate Jeopardy began on 03/08/23 when Resident #1, who was cognitively impaired, exited the facility without staff knowledge and was found with injuries in the parking lot of a local hospital near the facility. The Immediate Jeopardy was removed and corrected on 03/09/23 when the facility implemented the following corrective actions: On 03/08/23 at 7:15 P.M. the DON notified the nurse practitioner of resident leaving facility. The resident's family had already been notified of the incident by the hospital. On 03/08/23 at 9:47 P.M. Regional Director of Clinical #301 reviewed the last 72 hours of progress notes with no new wandering or exit seeking behaviors noted for residents. On 03/09/23 at 8:45 A.M. a sign letting visitors know not to allow residents to leave facility while the door was open was posted on front door by Admissions Director #215. On 03/09/23 at 9:00 A.M. Maintenance Director #213 ensured all doors in the facility were in good working condition with no negative outcomes noted. On 03/09/23 at 9:00 A.M. Unit Manager/Licensed Practical Nurse (LPN) #219 completed elopement/wandering assessments on all residents currently in the facility. The facility ensured any appropriate interventions were put in place if needed. On 03/09/23 at 10:00 A.M. education was completed with nursing staff (14 LPNs, five Registered Nurses RNs and 43 State tested Nursing Assistants (STNAs)) in person and via telephone by the DON on ensuring interventions were put in place when wandering/exit seeking behavior occurred and not allowing residents to leave facility without the nurse assessing the resident for appropriateness of being able to leave the facility. On 03/09/23 at 10:00 A.M. education was completed for all 13 dietary staff by Dietary Manager #221 via telephone and in person on not allowing residents to leave facility without the nurse assessing the resident for appropriateness of being able to leave the facility. On 03/09/23 at 10:00 A.M. education was completed for all 13 housekeeping and laundry staff by Housekeeping Supervisor #214 via telephone and in person on not allowing residents to leave facility without the nurse assessing the resident for appropriateness of being able to leave the facility. On 03/09/23 at 10:00 A.M. education was completed for all eight therapy staff by the DON via telephone and in person on not allowing residents to leave facility without the nurse assessing the resident for appropriateness of being able to leave the facility. On 03/09/23 at 10:00 A.M. education was completed for all four activities staff by DON via in person and via telephone on not allowing residents to leave facility without the nurse assessing the resident for appropriateness of being able to leave the facility. On 03/09/23 at 1:30 P.M. Admission Director #215 sent a Carefeed text message notification to families and staff members educating them to not allow residents to leave the facility without the nurse assessing the resident for appropriateness of being able to leave the facility. On 03/09/23 at 1:51 P.M. Maintenance Director #213 completed an elopement drill with no issues noted. On 03/09/23 at 8:00 P.M. RN #220 completed an elopement drill with no issues noted. On 03/09/23 at 6:15 P.M. a head count was completed by LPN #210 with no further concerns noted. On 03/09/23 at 11:00 A.M. Activities Director #217 ensured all residents in house had pictures in their electronic medical record. On 03/09/23 at 11:30 A.M. Activities Director #217 reviewed the facility elopement books and ensured all books were updated with identification of those residents at high risk for elopement. On 03/09/23 at 10:00 A.M. Minimum Data Set (MDS) Nurse #218 reviewed the behavior log for wandering/exit seeking behaviors for the past 72 hours with no issues noted. On 03/09/23 at 10:30 A.M. Maintenance Director #213 placed an order for wanderguard bracelets to ensure nurses had access if needed. Beginning on 03/09/23 a plan for all newly hired nursing staff to be educated by DON/designee on putting interventions in place when wandering/exit seeking behaviors were present and not allowing residents to leave facility without the nurse assessing the resident for appropriateness of being able to leave the facility was implemented. Beginning 03/09/23 a plan for the DON/designee to audit resident referrals prior to admission to ensure proper interventions were in place and a review of the 24-hour report for wandering/exit seeking behavior three times per week for two weeks and then as needed was implemented. Beginning 03/20/23 a plan for all audits to be brought to QAPI meetings and reviewed starting with the first QAPI meeting scheduled for 03/20/23. Findings include: Review of the closed medical record for Resident #1 revealed an admitted [DATE]. Resident #1 had diagnoses including pericardial effusion, atherosclerotic heart disease, major depressive disorder, anxiety disorder, weakness, difficulty in walking, lack of coordination, assistance with personal care, and presence of cardiac pacemaker. Review of the hospital history and physical, dated 03/06/23 revealed Resident #1 had some underlying dementia and was oriented to person and place at baseline. The patient was hard of hearing and had difficulty answering some questions, significant assistance was provided by family at bedside. An entry Minimum Data Set (MDS) 3.0 assessment was completed on 03/06/23. An electronic Medication Administration Record (eMAR) note, dated 03/06/23 at 11:21 P.M. revealed Resident #1 paced and wandered into several resident's rooms. Redirection was not always successful. The resident was non-combative, but very confused. The resident was alert only to self. A plan of care dated 03/07/23 revealed Resident #1 had impaired cognitive process for daily decision making. Resident #1 was also at risk for further decline in cognitive status. Interventions included to anticipate needs and keep resident clean, dry, and comfortable every shift and reorient and redirect as needed. Review of an elopement risk assessment dated [DATE] revealed Resident #1 was at low risk for elopement. The assessment was marked that Resident #1 was not cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disoriented), the resident did not have any sensory deficits (vision, hearing, communication), the resident did not wander aimlessly or non-goal directed (i.e. confused moves without purpose, may enter others room and examines others belongings), and the resident had not been recently admitted and not accepting to the situation. However, a plan of care dated 03/07/23 revealed Resident #1 was at high risk for elopement. Interventions included to develop an activity program to divert attention and meet individual needs, discuss with resident/family risks of elopement/wandering, if a resident was missing from facility, follow elopement protocol, notify the physician and family immediately and document, if resident was wandering in potentially unsafe area or situation, redirect to safer area, observe/record/report to physician risk factors for potential elopement, and take photograph of resident to maintain on file for identification purposes. A progress note by Certified Nurse Practitioner (CNP) #300 dated 03/07/23 (no time) revealed Resident #1 was standing/ambulating in her room. The resident appeared restless and alert but confused. Resident #1's daughter was present in the room and stated Resident #1's cognition was poor at baseline but had worsened since hospitalization . The daughter reported Resident #1 lived alone prior to hospitalization . A skilled nursing note dated 03/08/23 at 1:34 A.M. revealed Resident #1 was alert with impaired decision making and disorganized thinking. Resident #1 was able to transfer and walk without assistance. The resident tended to wander into other resident's rooms. The resident continued to have mild confusion. Review of the weather/temperature conditions on https://www.localconditions.com revealed on 03/08/23 at 5:00 P.M. it was 48 degrees Fahrenheit with a wind speed of ten miles per hour. Review of Call for (Emergency) Service Detail revealed a phone call was received from the manager at a drug store on 03/08/23 at 5:09 P.M. regarding a female (identified to be Resident #1) who had fallen in the drug store parking lot. The detail noted the female had serious bleeding from the wrist. The female was not responding normally (not completely alert). At 5:12 P.M. the female refused help and walked across the street toward apartments. The female was wearing blue scrub-like pants and a white sweater. Review of an emergency department (ED) triage note dated 03/08/23 at 5:24 P.M. revealed Resident #1 was found in front of hospital by another patient's family member. Resident #1 was face down on the ground and seemed confused. Resident #1 had abrasions and swelling to the right side of face, bilateral hands, and left forearm. The resident was not answering questions appropriately. Resident #1 stated she was not trying to come to the hospital. She stated was walking home and slipped on the grass and fell . A nursing progress note dated 03/08/23 at 6:00 P.M. revealed Resident #1 was not in her room. The building was search and the resident was in the emergency department of the hospital. The physician and family were aware. The facility investigation dated 03/08/23 at 6:08 P.M. revealed Resident #1 was not in her room at 5:15 P.M. The investigation noted resident was last seen at 5:00 P.M. on Unit 3 and Unit 4. The entire facility was searched indoors and then outdoors. Some of the staff were at the drug store looking for Resident #1 and they were told a female fitting her description had fallen and refused help from emergency personnel and walked toward the hospital. At 5:51 P.M. the hospital ED confirmed the resident was at the ED. No injuries were observed at the time of the incident. The resident was oriented to person and place. Predisposing factors included confusion and impaired memory. Review of written statements by staff revealed STNA #205 saw Resident #1 around 5:00 P.M. to 5:15 P.M. The resident was walking down the hallway towards Unit 1. The dinner trays were passed, and the staff noticed Resident #1 was not in her room. STNA #205 checked with Unit 3, and they stated they saw Resident #1 around 4:45 P.M. Some of the staff went down the street to the drugstore. It was reported that Resident #1 had been there but left. A staff member called the hospital and the hospital confirmed Resident #1 was there. The rest of the staff were notified around 6:00 P.M. that Resident #1 had been located at the hospital. A written statement by LPN #206 revealed the LPN had seen Resident #1 walking towards the dining room but did not know the resident was at risk for wandering. A statement by STNA #207 revealed the STNA saw Resident #1 around 5:00 P.M. The resident was on Unit 3 and stated she was looking for her son. The resident was redirected back to Unit 4 because supper trays were arriving. A written statement by LPN #210 revealed at approximately 5:35 P.M. STNAs notified the nurse they were unaware of Resident #1's location. The nursing staff looked inside the facility and then outside for Resident #1. At 5:55 P.M. the DON was notified Resident #1 could not be located. At 6:03 P.M. Resident #1's daughter called about orders being put in the resident's MyChart. LPN #210 stated they would gather information and call the family back. LPN #210 called Resident #1's family back at 6:15 P.M. with an update. A statement by STNA #212 revealed staff called the hospital on 03/08/23 at 5:51 P.M. and was told Resident #1 was there. The employees at the drugstore stated Resident #1 had been there 45-minutes prior to the STNAs looking for the resident. Interview on 03/16/23 at 8:27 A.M. with the DON revealed the exit doors required a code to leave the building and at the time of the incident, none of the doors alarmed, so it was assumed Resident #1 left the facility with a visitor. The staff noticed the resident was not in her room at supper time and had not eaten anything, so they started looking for the resident. After staff called the hospital, it was discovered Resident #1 was in the ED at the hospital across the street. Interview on 03/16/23 at 9:14 A.M. with family of Resident #1 revealed after being admitted to the hospital on 03/08/23 following the elopement, the resident was discharged from on the hospital on 03/15/23 to another rehabilitation nursing center. Resident #1 was not able to use her left arm at this time. The family stated they received a notification in MyChart Resident #1 was scheduled for some tests. The hospital then called the family and said the resident was at the hospital. An additional interview with family at 3:40 P.M. revealed Resident #1 had a lot of swelling to left arm (as a result of the falls on 03/08/23). The left arm was scanned twice due to concerns of possible fracture. The resident did have cellulitis and large hematoma to left arm. The resident could not use the left arm to help push up from a sitting to standing position. Resident #1 could no longer walk more than 80 feet, had lost a lot of use of her left arm, and has had a lot of pain since suffering the two falls while missing from the facility (on 03/08/23). Interview on 03/16/23 at 11:18 A.M. with the DON verified on 03/08/23 Resident #1 left the facility without staff being aware. The DON verified the facility did not have a picture of Resident #1 and verified Resident #1's elopement/wander assessment revealed the resident was not at risk for elopement/wandering but there was documentation in the medical record of Resident #1 being confused and wandering into other resident rooms. Interview on 03/16/23 at 12:56 P.M. with STNA #212 revealed 03/08/23 was the STNAs first day providing care for Resident #1. STNA #212 was told in report Resident #1 did everything for herself. Nothing was said about the resident wandering or being at risk for elopement. The STNA revealed Resident #1 appeared to be a little confused. When the resident was not in her room for supper, the staff began looking for the resident. STNA #212 stated no doors had alarmed so at first, they thought Resident #1 was still in the building. Interview on 03/16/23 at 1:14 P.M. with LPN #206 revealed on 03/08/23 she had seen Resident #1 walking in the hallway but was not aware the resident was at risk for wandering for elopement. LPN #206 stated she did not think the facility had any residents with wanderguard devices in place. LPN #210 revealed she was told Resident #1 was ambulatory and walking back and forth between Unit 3 and Unit 4. LPN #210 stated she was not told Resident #1 was wandering, exit seeking, or going into other resident rooms. On 03/16/23 at 2:13 P.M. interview with STNA #205 revealed the STNA was aware Resident #1 wandered. STNA #205 stated on 03/08/23, she called Unit 1 and told them Resident #1 was a risk for wandering and to redirect the resident back to Unit 4. Interview on 03/16/23 at 2:19 P.M. with the Certified Nurse Practitioner (CNP) revealed the CNP had seen Resident #1 in person following her admission and denied the resident had a diagnosis of dementia. The family stated the resident's obsessive-compulsive disorder (OCD) was out of control. The CNP stated Resident #1 did not have a diagnosis of OCD but did appear restless. The resident did not focus on the CNP during the visit. The family stated the resident lived alone but had increased confusion with the changes in environment and routine. Review of facility policy titled Missing Resident, revised 05/01/17 revealed upon identifying a missing resident the nurse would page Dr. [NAME] (and name of the unit). A representative from all departments would respond to the nursing unit that paged the Dr. Walker. The nurse would identify the missing resident and provide a picture to the staff. If the alert was during dark hours the nurse would dispense the disaster bag handing out flashlights, walkie-talkies, and any other equipment in the bag needed for the perimeter search. Review of the facility policy titled Elopement and Wandering Residents, revised on 10/01/22 revealed the facility residents would be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Adequate supervision would be provided to help prevent accidents or elopements. Charge nurses and unit managers would monitor the implementation of interventions, response to interventions, and document accordingly. The effectiveness of interventions would be evaluated, and changes would be made as needed. Any changes or new interventions would be communicated to relevant staff. If the resident was not located in the building or on the grounds, administrator or designee would notify the police department. The police would be given a description and information about the resident, including any photos. This deficiency represents noncompliance investigated under Complaint Number OH00141086.

Based on record review, hospital record review and interview the facility failed to ensure a urinary tract infection (UTI) was timely identified and treated for Resident #98. Actual Harm occurred on 12/19/22 when Resident #98, who was symptomatic of a UTI/sepsis (including lethargy, tachycardia, altered mental status) was transferred to the hospital and admitted with the diagnosis of a UTI and sepsis (blood infection) due to the UTI. Resident #98 was originally admitted to the facility on [DATE] with a pending urinalysis (U/A) result for a specimen that had been collected at the hospital. The U/A culture results were not obtained by the facility resulting in a repeat U/A being collected on 12/17/22 causing a delay in the resident receiving appropriate treatment for his UTI. This affected one (Resident #98) of three residents reviewed for UTI's Findings include: A review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including mild intellectual disability, adult onset diabetes mellitus, hypertension, bipolar disorder, and an acute kidney injury. A review of Resident #98's hospital records for his hospital stay prior to his admission to the nursing facility revealed he was in the hospital for weakness, adult failure to thrive, and repeated falls. During his hospital stay, he had one episode of hematuria (blood in his urine) and a U/A and cat (CT) scan of his abdomen and pelvis. The CT scan was non-acute and indicated cystitis (inflammation of the bladder) was suspected. A urology appointment was to be scheduled for outpatient follow up. The resident's discharge summary from the hospital, dated 12/16/22 revealed the resident had a U/A done and the urine culture test results were still pending at the time of his discharge. A review of Resident #98's Medicare (MCR) 5 day Minimum Data Set (MDS) 3.0 assessment, dated 12/19/22 revealed the resident had unclear speech. He was able to make himself understood and was usually able to understand others. He had short and long term memory impairment and his cognitive skills for daily decision making were moderately impaired. The resident was identified as having had hallucinations, but no other behaviors were noted. He was dependent on two for toilet use and always incontinent of his bladder and bowel. A review of Resident #98's electronic health record (EHR) revealed it was absent for the results of the U/A that had been obtained in the hospital prior to the resident's admission into the facility on [DATE]. A review of Resident #98's progress notes revealed he was admitted to the facility on [DATE] at 6:43 P.M. He was assessed to be alert with confusion noted. A nurse's progress note, dated 12/17/22 at 4:08 P.M. revealed Resident #98's case worker was in the facility to see the resident and and reported the resident was not at his baseline. The case worker felt the resident's confusion may be caused by a UTI. The on call physician was contacted and gave an order for laboratory tests to be performed including a U/A. There was no documentation regarding the prior U/A that had been obtained at the hospital prior to his admission. The U/A was indicated to have been collected on 12/17/22 at 7:11 P.M. A review of Resident #98's history and physical completed by the attending physician on 12/19/22 revealed the resident was evaluated while he was lying in bed and he appeared ill. He was lethargic and non-verbal. It was discussed with the Director of Nursing (DON), who stated it was reported over the weekend, the resident had been in that state. STAT laboratory tests had been previously ordered by the on call team and were ready for review. The U/A results were notable (positive) for a UTI. The resident's case worker presented shortly after and informed the physician the resident's baseline cognitive status was that he was normally alert and oriented to all spheres (x3-4). Given the rapid decline of mental status and increased lethargy, concern for sepsis were present although the resident's his vital signs were only notable for mild tachycardia (increased heart rate). The resident was sent to the emergency room for further evaluation. The note indicated a discussion regarding getting antibiotic treatment started in house but there were concerns with the resident not being able to take antibiotics by mouth as the resident was noted to have a poor oral (po) intake. A review of Resident #98's progress notes revealed the DON had made a note on 12/19/22 at 3:33 P.M. that indicated the resident was alert that morning but confusion was noted. He was indicated to have been able to take all medications by mouth and was able to drink water. He was only able to take a few bites of his breakfast and at that time was assessed to be non-responsive to verbal stimuli. He appeared to be sleeping and did not wake up. Vital signs were unremarkable and all within normal limits at that time. The physician was noted to have seen the resident that day and ordered the antibiotic, Macrobid (Nitrofurantoin) for the treatment of a UTI. The resident's case worker was also noted to be present and felt the resident should be sent to the hospital. The DON was in agreement since they could not get the ordered antibiotic in him. 911 was called and the resident was transported to the hospital. A copy of the initial U/A report (that had been collected when Resident #98 was in the hospital prior to his initial admission) was requested from the DON. She denied the facility had a copy on hand or that was part of the resident's medical record but they did have access to the hospital's laboratory reports. She provided a copy of that U/A and culture report for review. It showed the resident's urine was collected for that U/A on 12/15/22 at 2:40 P.M. It was received in the lab at 2:58 P.M. The results of that U/A were available as of 12/17/22 at 8:01 A.M. The final culture report showed the urine had greater than 100,000 colonies/ milliliter of urine of proteus vulgaris (a gram negative bacteria that inhabits the intestinal tracts of humans and animals). A susceptibility report revealed it was resistant to Macrobid, which was the antibiotic the resident was ordered to receive beginning on 12/19/22. A review of the U/A report the facility obtained as ordered on 12/17/22 revealed it had been collected on 12/18/22 at 12:00 A.M. It was indicated to have been received at 8:13 P.M. It was verified on 12/18/22 at 8:31 P.M. The initial report showed the urine had a high pH level of > 9.0 (4.5- 8.0 was normal). Protein, ketones, blood, nitrites, and leukocytes (type of a white blood cell that circulated in the blood and was involved in counteracting foreign substances and disease) were also indicated to be present. The final urine culture for the U/A done on 12/17/22 continued to show proteus vulgaris was the bacterium identified. The sensitivity report again indicated the organism was resistant to Macrobid. A review of Resident #98's hospital records for the hospitalization on [DATE] revealed the resident presented to the emergency room with complaints of suprapubic abdominal pain, dysuria, and hematuria. He was also found to be minimally responsive at the extended care facility. The resident was assessed to meet the criteria for sepsis in the emergency room as his blood pressure was borderline low (lowest 80/60) that improved with fluid bolus. The resident was assessed to have a UTI with positive urine for leukocytes and loaded WBC's. The resident was administered two different types of antibiotics which included intravenous administration. The resident was diagnosed and admitted to the hospital with a UTI and sepsis due to a UTI. On 02/08/23 at 1:16 P.M., an interview with the DON revealed Resident #98 had a repeat U/A done on 12/17/22 because they were unaware he had one done while he was in the hospital prior to his admission. She confirmed the hospital's discharge summary that was part of his admission paperwork did indicate a U/A had been done on 12/15/22 and the results were still pending at the time of his admission. The DON indicated the hospital should have known to send those results to the facility when they were available on 12/17/22. She acknowledged it was the facility staff's responsibility to review his admission paperwork and to follow up to obtain and laboratory test results that were still pending. She also acknowledged as a result, there was a delay in the resident receiving appropriate antibiotic therapy to treat his UTI. He was to be started on an antibiotic (Macrobid) that the organism he had that caused the UTI was resistant to. She confirmed the initial U/A results were available on 12/17/22, the same day the resident had another U/A ordered and obtained. The DON verified the resident could have been started on an appropriate antibiotic the known organism causing the UTI was sensitive to which could have prevented him from developing sepsis and having to return to the hospital. This deficiency represents non-compliance investigated under Master Complaint Number OH00139971, Complaint Number OH00139377, and Complaint Number OH00139069.

Based on observation, interview, medical record review, and hospital record review, the facility failed to ensure Resident #22 was treated timely for a urinary tract infection ([CONDITION(S)]) after being discharged from the hospital. Actual harm occurred on 05/19/22 when Resident #22 returned to the facility from the hospital with a [CONDITION(S)] and the facility failed to continue the resident's antibiotic treatment resulting in a prolonged [CONDITION(S)] with delusions, paranoia, tearfulness, and urinary incontinence. This affected one resident (Resident #22) out of three residents reviewed for medication administration. The facility censes was 92. Findings include: Review of Resident #22's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's quarterly Minimum Data Set (MDS) 3.0 dated 04/13/22 revealed she was cognitively intact and needed supervision with physical assistance of one person for toilet use. Review of Resident #22's Hospital Discharge Summary from 05/15/22 through 05/19/22 revealed the resident was admitted to the hospital on 05/15/22 and was diagnosed with a [CONDITION(S)]. At the time of her admission to the hospital she had a change in her behavior, and she was noted to be confused in the emergency department. She was diagnosed with a [CONDITION(S)] and had a positive urine culture for extended spectrum beta-lactamase (ESBL). While in the hospital she received two doses of intravenous [MEDICATION(S)] (antibiotic) and was discharged with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon discharge, Resident #22 was alert and oriented to person, place, time, and event per her baseline. Review of Resident #22's May 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's 05/15/22 nurses note at 7:03 P.M. revealed Resident #22 began crying inconsolably around the time her pain pill was due. The nurse went into the resident's room to give her morning medication and to address why resident was crying. Upon entry, the resident's crying became amplified and the resident refused to answer questions. Later that day the nurse went into the resident's room in afternoon, the resident was making animal/gurgling noises with exaggerated tongue movements and tongue protrusion. Resident #22 continued refusing to answer any questions. When the state tested nursing assistant (STNA) went into the room to pick up her tray, the resident stated she is putting a hex on the STNA. The resident continued to state various mixed verbalizations, hallucinations, and delusions of various manifestations and placed the call light around her neck. The physician was notified, and orders were received to send the resident out to the hospital for evaluation. Review of the 05/19/22 nurses not at 8:41 P.M. revealed Resident #22 returned from the hospital at this time and was pleasant with no needs at that time. The note did not address the residents [CONDITION(S)] or antibiotic that was ordered to treat the [CONDITION(S)]. Review of Certified Nurse Practitioner (CNP) #100 progress note dated 05/23/22 revealed that the resident was being seen that day for a follow up related to her [CONDITION(S)]. The note continued with the resident was in the hospital from 05/15/22 through 05/19/22 for change in behavior with confusion. She was found to have [CONDITION(S)]. The hospital course of treatment included initiation of [MEDICATION(S)], transitioned to [MEDICATION(S)], and then [MEDICATION(S)]. The note did not indicate that the [MEDICATION(S)] was not continued when she was admitted back to the facility on [DATE]. Review of the 05/26/22 physician's progress note revealed that the physician believed she had completed her course of [MEDICATION(S)]. Review of the 06/01/22 CNP progress note revealed Resident #22 reported having urinary incontinence that had been worse for the last few days, and staff reported the resident had been confused, agitated, very anxious, and tearful. The CNP ordered a urinalysis with a culture and sensitivity. Review of the 06/01/22 urine culture revealed the resident was positive for a [CONDITION(S)] with ESBL noted in the resident's urine. Review of the 06/02/22 nursing note revealed at 12:41 A.M. Resident #22 was in bed awake and had been confused that day. Review of the nurses note dated 06/03/22 at 6:18 P.M. revealed Resident #22 was experiencing increased delusions and paranoia. It continued with the facility was awaiting a culture and sensitivity from the resident's urine analysis (UA). Review of the nurses note dated 06/04/22 at 10:32 A.M. revealed Resident #22 UA lab results came back with a positive culture, indicated the resident had at [CONDITION(S)]. The physician was notified and new orders for [MEDICATION(S)] 500 mg twice daily for five days was ordered to treat the [CONDITION(S)]. Observation on 06/26/22 at 1:00 P.M. revealed Resident #22 lying in her bed with an incontinence brief on. Lying beside her bed was a used incontinence brief. Interview on 06/26/22 at 1:00 P.M. with Resident #22 revealed she was admitted to the hospital in May 2022 with a [CONDITION(S)], and upon her discharge she was prescribed an antibiotic that she never received. She also stated the facility did not provide her timely incontinence care so she requested a bag of incontinence briefs so she can change herself. Interview on 06/27/22 at 2:28 P.M. with Corporate Registered Nurse #101 confirmed the facility missed the order for the resident to continue [MEDICATION(S)] 500 mg twice daily for five days upon her return from the hospital on 05/19/22. She revealed not treating Resident #22's [CONDITION(S)] could have contributed to her increased delusions, paranoia, tearfulness, and urinary incontinence. Interview on 06/27/22 at 3:05 P.M. with CNP #100 revealed he was under the impression Resident #22 received the [MEDICATION(S)] 500 mg as it was ordered from the hospital upon her return to the facility on [DATE]. He continued that until now he was not made aware that the resident did not the antibiotic that the hospital ordered. He continued that since the resident was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 630.

Based on observation, interview, record review, and policy review the facility failed to ensure Resident #22 received her as order pain medication timely. This affected one out of three residents reviewed for pain. Actual harm occurred on 06/27/22 at 6:31 A.M. when the facility did not administered Resident #22 ordered narcotic pain medication after receiving approval to do so. This affected one out of three residents reviewed for pain (Resdient #95, Resdient #50 and Resdient #22). The facility census was 92. Findings include: 1. Review of Resident #22 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22 quarterly MDS dated [DATE] revealed she was cognitively intact. Review of Resident #22 care plan dated, dated 06/09/22, revealed Resident #22 will express pain level within satisfactory limits. Interventions included for medications as ordered by physician. Review of Resident #22's June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 6:00 A.M., 12:00 P.M., and 6:00 P.M.) , Tylenol 650 mg by mouth every four hours as needed for pain management, and [MEDICATION(S)] HCl Solution 2 % one teaspoon by mouth every four hours as needed for pain. Review of Resident #22 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Her pain was rated a 9 out of 10 at this time. Continued review revealed the resident did not receive any of her as needed pain medication including (Tylenol or [MEDICATION(S)]) even with a pain level of 9 out of 10. Observation on 06/28/22 at 10:42 A.M. revealed Resident #22 lying in bed with tears coming out of her eyes. Continued observation at this time revealed Resident #22 tell Licensed Practical Nurse (LPN) #102 that she did not receive her 6:00 A.M. pain medication and that she is in pain and labeled it an 8 out of 10. Resident #22 asked LPN #102 for her pain medication at this time and LPN #102 tells her that she will have to wait until her next scheduled dose which can be given at 11:00 A.M. Interview on 06/27/22 at 11:10 A.M. with LPN #102 revealed that Resident #22 ran out of her prescribed [MEDICATION(S)] Tablet 5-325 milligram (mg) (narcotic pain medication) after her 12:00 A.M. dose this morning. She continue that Registered Nurse (RN) #103 requested it to refilled and sent over a request to pull the medication out of the contgency box that the facility has on site. She stated that RN #103 gave her the approval from the pharmacy at around 8:00 A.M. but she has not had time to pull it yet. She confirmed that Resident #22 did not receive her 6:00 A.M. dose of [MEDICATION(S)] 5/325 mg, the doctor had not been notified of the missed dose, and she had not received any other as needed pain medication (Tylenol or [MEDICATION(S)]) that morning. She also stated that she did not call the doctor at 8:00 A.M. to see if it would be ok to give the medication late since at that time she had the approval to pull the medication. Interview on 06/27/22 at 11:16 A.M. Resident #22 stated that she has been on a lot of mouth pain this morning due to not receiving her ordered pain medication. She continued that she had been asking for her medication all morning and was only able to eat her scrambled eggs for breakfast due to the pain. She continued that she also has a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated her pain is a 8 out of 10. Review of the Request for Removal of Controlled Drug Substances Medication From the Emergency Box/Starter box form dated 06/27/22 revealed the pharmacist approval the removal of Resident #22 [MEDICATION(S)] 5/325 mg. The fax receipt shows that the facility received the fax back with the approval on 06/27/22 at 6:31 A.M. This was within the one hour before and one hour after window for Resident #22 scheduled 6:00 A.M. medication. Interview on 06/27/22 at 2:28 P.M. with Corporate Registered Nurse # 101 stated her expectation would have been for Resident #22 [MEDICATION(S)] 5/325 mg pain medication to be given at the time that the approval form the pharmacy was recieved at 6:31 A.M. She stated that if the medication as missed she would expect the nurse to notify the physician of the residents pain and missed dose for further direction. She confirmed that this was not done. Review of the undated facility policy Pain Management, reveled the facility manage or prevent pain consistent with the comprehensive assessment and plan of care, current professional standards of practice and resident goals and preferences. 2. Review of Resident #22 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22 quarterly MDS, dated [DATE], revealed she was cognitively intact. Review of Resident #22 care plan dated, 06/09/22 revealed Resident #22 will express pain level within satisfactory limits. Interventions included for medications as ordered by physician. Review of Resident #22's June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. 6:00 A.M., 12:00 P.M., and 6:00 P.M.), Tylenol 650 mg by mouth every four hours as needed for pain management, and [MEDICATION(S)] HCl Solution 2 % one teaspoon by mouth every four hours as needed for pain. Review of Resident #22 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. scheduled dose of [MEDICATION(S)] 5-325 mg on 06/28/22 until 2:35 P.M. Her pain was rated a 9 out of 10 at 12:00 P.M. Continued review revealed the resident did not receive any of her as needed pain medication including (Tylenol or [MEDICATION(S)]) even with a pain level of 9 out of 10. Review of the 06/28/2022 Nursing note at 12:13 P.M. revealed the Pharmacist called into facility and stated that they did not have any refills on Resident 22's medication. Interview on 07/05/22 at 10:00 A.M. with the Director of Nursing stated it is the facility nurses responsibility to monitor when when residents need refill request on medications and to obtain these request timely before the resident runs out of the medications. She confirmed this was not done prior to Resident #22's running out of her scheduled [MEDICATION(S)] 5-325 mg used to treat her pain. Review of the undated facility policy Pain Management, reveled the facility manage or prevent pain consistent with the comprehensive assessment and plan of care, current professional standards of practice and resident goals and preferences. This deficiency substantiates Complaint Number OH 630 and Complaint Number OH 289.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's policies and procedure, review of the facility's Coronavirus (COVID-19) outbreak timeline, review of daily resident census reports, record review, staff and family interview, the facility failed to perform adequate contact tracing to properly identify, quarantine, and appropriately test all residents with known exposure to a staff member who had tested positive for COVID-19. This resulted in Immediate Jeopardy on [DATE] when Licensed Practical Nurse (LPN) #3 notified the facility on [DATE] that she tested positive for COVID-19. LPN #3 last worked in the facility on their quarantine unit (Units 6 and 7) on [DATE]. Residents #10, #202, #206 and #207 all resided on the quarantine unit on [DATE] but had been moved to other units in the facility between [DATE] and [DATE]. They had been placed in semi-private rooms with four other residents (Resident #29, #49, #70, and #208) resulting in spread of COVID-19 and death of residents. This resulted in the likelihood to cause serious harm injury or death and affected eight residents (Residents #10, #29, #49, #70, #202, #206, #207, and #208) with the potential to affect all the residents in the facility. On [DATE] at 9:15 A.M., the Administrator was notified Immediate Jeopardy began on [DATE] when the facility had been made aware LPN #3 tested positive for COVID-19 after she last worked the facility's quarantine unit on [DATE]. The facility failed to perform adequate contact tracing to identify all residents who had been exposed to LPN #3 when she worked on [DATE]. This resulted in four residents (Resident #10, #202, #206, and #207), who had been moved off the quarantine unit since their exposure, not being immediately quarantined or tested . All four residents were allowed to remain in a semi-private room with another resident after their known exposure had occurred. Resident #206 moved again and was placed in a new room with another roommate on [DATE] (two days after the facility had been made aware of her exposure) when the facility was clearing out a unit to be used as their new quarantine unit. Resident #206 was never tested for COVID-19 after she had been exposed and was discharged home on [DATE] not knowing if she had COVID-19 or not. Residents #10, #202, and #207 were not immediately tested for COVID-19 when the other residents who resided on the quarantine unit got tested for COVID-19 on [DATE]. Their testing was not completed until [DATE] when the facility started testing the residents on the remaining units in the building. The facility's failure to immediately quarantine and test those residents likely contributed to the COVID-19 outbreak that spread throughout the facility infecting 71 residents with COVID-19 resulting in 20 deaths. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following correction actions: · On [DATE], the facility developed QIO Action Plan focused on testing of residents in a more timely and efficient manner to include test frequency, rapid testing, online requisition processing for faster turnaround times. It will provide updates to Ohio QIO coordinator. · As of [DATE], Units 5, 6, and 7 remain the COVID-19 unit. It currently has 22 residents who remain in transmission-based precautions. The quarantine unit currently has nine (9) residents. · As of [DATE], the facility has 75 COVID-19 tests available in house with an additional 200 tests on order, which will be used for symptomatic residents and to test residents if new cases develop in the future. · On [DATE], the Director of Nursing (DON), who is also the facility infection preventionist, audited all resident rooms to validate isolation procedures were correctly implemented, including location of residents and implementation of isolation precautions. The audit revealed all isolation precautions were correctly implemented. · On [DATE] the facility implemented a new COVID 19 Testing and Contract Tracing policy. The policy identified the facility will determine which residents received direct care from and which staff had unprotected exposure to staff member who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset, or any staff or residents who had exposure to a resident with symptoms of COVID-19. Residents who had exposure to symptomatic resident or were cared for by symptomatic staff will be restricted to their room and be cared for using all recommended COVID-19 PPE until results of health care provider (HCP) COVID-19 testing are known. If the HCP or resident is diagnosed with [REDACTED]. Exposed staff will be assessed and evaluated for work exclusion. · On [DATE], the DON began mandatory staff in-service education on COVID-19 procedures with emphasis on contact tracing, quarantine and testing requirements and frequency. All education will be completed by [DATE] for licensed nurses, nurse aides, dietary and housekeeping, therapists and additional staff. Staff not educated by [DATE] will not be permitted to work until the in-servicing is completed. As of [DATE], 120 staff had received in-service training. Twenty (20) staff had not received in-service training. The DON or assistant director of nursing (ADON) will call the 20 staff by the end of the day [DATE] and provide verbal in-service training. These 20 staff will also receive in person training when they return to work. · On [DATE] the DON and Administrator were in-serviced by the Chief Clinical Officer on contact tracing guidance and testing of all residents when an outbreak occurs. · On [DATE] the DON will begin to monitor all newly diagnosed residents and newly admitted residents or readmitted residents to ensure they are placed in appropriate transmission-based precautions according to their [DIAGNOSES REDACTED]. Audits will be completed weekly x 4 weeks or until otherwise directed by the QAPI committee. · On [DATE] an ad hoc QAPI committee meeting was held with the medical director to review the preliminary survey findings and internal action plan. · On [DATE] the DON or designee will conduct interview audits of a minimum of ,[DATE] staff members weekly x 4 weeks to evaluate retention of Inservice content. · On [DATE] between 10:55 A.M. and 12:10 P.M. twelve (12) staff were interviewed and verified they had received in-service training in the areas of contact tracing, quarantine and testing requirements and frequency. All staff interviewed were knowledgeable on the in-service training. · On [DATE] the facility had 208 COVID-19 test kits onsite at the facility for needed testing. · Onsite observations on [DATE] revealed all staff were wearing appropriate PPE including N95 face masks and face shields. Although the Immediate Jeopardy was removed on [DATE], 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 was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed CMS is committed to taking critical steps to ensure America ' s healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). 1. Review of the facility's timeline of their COVID-19 outbreak confirmed they were first notified by LPN #3 on [DATE] that she had been tested for COVID-19 the day before and her test results came back positive. LPN #3 was indicated to have been a nurse who worked Units 6 and 7 (quarantine unit) on an as needed basis (prn). The facility started their timeline on [DATE], as that was the date LPN #3 last worked. The facility started COVID-19 testing for the residents who currently resided on Units 6 and 7 on [DATE]. On [DATE], six of those residents had tested positive for COVID-19 after their exposure to LPN #3 occurred. The timeline indicated on [DATE] room changes were made on Unit 5. Unit 5 was cleared out to allow the facility to utilize it as their new COVID-19 unit. Those residents who resided on the quarantine unit that were tested on [DATE] and found to be negative for COVID-19 were moved to Unit 5. The facility designated Units 6 and 7 as their COVID-19 units when the first six residents tested positive for COVID-19. Those on Units 6 and 7 that tested negative for COVID-19 and still had quarantine days remaining were moved to Unit 5 when it was made the new quarantine unit. The timeline also reflected those residents, who had resided on Units 6 and 7 on [DATE] but had been moved to other units within the facility between [DATE] and [DATE]. There was a total of four residents (Residents #10, #202, #206 and #207) who were identified as having been moved off Units 6 and 7 between that time. A focused review of those four residents (Residents #10, #202, #206, and #207) was completed as there was no indication on the facility's timeline of those residents being placed back onto the quarantine unit after their known exposure had occurred. The facility also was not able to provide any COVID-19 test results to show those residents were included within the initial testing that had been done on those residents that resided on Unit 6 and 7. 1(a). A review of Resident #206's electronic health record (EHR) revealed she was originally admitted to the facility on [DATE]. Her most recent admitted was [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #206's census report revealed she resided on Unit ,[DATE] on [DATE] when LPN #3 last worked and potentially exposed all the residents on that unit to COVID-19. She remained on that unit until [DATE] when she was moved to Unit 5 (a rehabilitation/ long term care unit at that time). There was no evidence of any room changes occurring on [DATE] when it had been known by the facility the resident had been possibly exposed to COVID-19 through LPN #3. She was moved again on [DATE] from Unit 5 when the facility was clearing that unit off to make room for their new quarantine unit. Review of the resident's record revealed Resident #206 was not retained on Unit 5 despite her having had a potential exposure from a staff member that tested positive for COVID-19 that should have required her to have a quarantine period of 14 days after the last date of her exposure. Resident #206's medical record provided no evidence of her being tested for COVID-19 after her known exposure on [DATE]. She did not get tested when the other residents who resided on Unit 6 and 7 with her were tested after their known exposure. A review of Resident #206's progress notes provided no documentation about her being tested for COVID-19 or an explanation as to why testing had not been completed. She was discharged home from the facility on [DATE] never being tested to know whether she contracted COVID-19 from her exposure. On [DATE] at 8:49 A.M., the surveyor received an email response from the Administrator with a follow up phone call confirming they did not have any evidence of a COVID-19 test being completed on Resident #206. He acknowledged she was one of the 23 residents that resided on Units 6 and 7 on [DATE] when LPN #3 worked shortly before she tested positive for COVID-19, potentially exposing all the residents on that unit. The Administrator stated the resident was abruptly discharged to home on [DATE] before they could test her. He was not able to explain why she could not have been tested on [DATE] when the other residents who resided on Units 6 and 7 were tested . On [DATE] at 12:46 P.M., a phone interview with LPN #12 revealed the facility tested the residents that still resided on Units 6 and 7 first, before testing other residents on other units. She denied Resident #206 was included in the testing of those residents on [DATE] despite her being one of the residents who resided on Units 6 and 7 on [DATE] when LPN #3 last worked and possibly exposed them to COVID-19. She stated if the residents had been moved off those units between [DATE] and [DATE], they would have been tested when their respective units were tested . When asked why those residents were not put back into quarantine after their known exposure, she replied they were following protocol and CDC guidelines. She indicated those residents that were taken off Units 6 and 7 between [DATE] and [DATE] completed their initial 14-day quarantine period and were not having symptoms at the time they were moved. She did not feel their exposure to LPN #3 on [DATE] and risk they may contract COVID-19 warranted the need for them to be placed back into quarantine for another 14 days. When asked why Resident #206 would have been taken off Unit 5 on [DATE] when the facility was making that their new quarantine unit and her having her recent exposure to a positive staff member with COVID-19 she again stated they were following CDC guidelines on what they recommend them to do. She was not able to give any specific information on what CDC guidelines they were following. On [DATE] at 10:30 A.M. a call was placed to Resident #206's son. He reported Resident #206 came home after being discharged from the facility on [DATE] and passed out a day or two after her discharge. He stated they sent her to the local hospital, and she tested positive for COVID-19. He confirmed she had passed away on [DATE] as a result of her COVID-19 infection. On [DATE] at 10:32 A.M., a return call was received by Resident #206's daughter. She stated she was not informed the facility had a COVID-19 outbreak nor was she aware the resident had been exposed to a staff member who had tested positive for COVID-19. She did not know whether the resident had been tested while in the facility. She assumed she had been as she had not been told otherwise. She confirmed the resident was discharged from the facility on [DATE] but denied it was at the request of the family. She stated her brother called her on that date and told her they were discharging the resident. Her brother was working and was not able to go pick her up. They arranged for a granddaughter to go get her and bring her home. She stated the resident was so weak she had a fall earlier that morning while still in the nursing home and fell again when she got home. The family sent her to the hospital on [DATE] because she was so weak, she could not stand. The hospital immediately tested her for COVID-19, and she tested positive. She stated she felt they had poor communication at the facility, and she did not feel they kept them aware of the resident's change in condition. She reported the resident was placed on [MEDICAL CONDITION] at the hospital and was admitted to the critical care unit (CCU), but she never recovered. She confirmed her mother passed away on [DATE]. 1(b). A review of Resident #49's medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #49's census report revealed she resided on Unit 4 in room [ROOM NUMBER]-A from [DATE] through [DATE]. She shared a room with Resident #206 between [DATE] and [DATE]. Resident #206 was brought to her room after the resident had been exposed to LPN #3 on [DATE]. LPN #3 later tested positive for COVID-19 when she was tested at a hospital on [DATE]. A review of Resident #49's Coronavirus report for [DATE] revealed the facility was monitoring her temperature and oxygen saturation (level of oxygen in the blood measured by a pulse oximeter placed on the finger) four times a day. She was noted to start having a fever beginning [DATE]. Her temperature was recorded as having been between 99.2 degrees F. and 100.4 degrees F. She had one episode of her oxygen saturation level being low (less than 90%) on [DATE] when her reading was 89%. A review of Resident #49's COVID-19 Person Under Investigation (PUI) Case Report dated [DATE] revealed her symptoms of COVID-19 included a fever with a date of onset being [DATE]. Her exposure history was marked as having been unknown. The course of treatment at that time was to move her to a private room. An updated COVID-19 PUI Case Report dated [DATE] revealed the resident was moved to the COVID-19 unit. Full barrier precautions were in place. The resident was indicated to previously have been on droplet precautions. The physician declined any further interventions at that time. A review of Resident #49's COVID-19 test done on [DATE] revealed the results came back on [DATE] showing she tested positive for COVID-19 (11 days after Resident #206 had been moved into her room). A review of Resident #49's nurses' progress notes revealed a note dated [DATE] that indicated the resident was in the active dying phase. She expired in the facility with her family at her bedside on [DATE]. 2 (a). A review of Resident #202's medical record revealed she was originally admitted to the facility on [DATE]. Her most recent admission was on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #202's census report revealed she resided on the facility's quarantine unit on [DATE] when LPN #3 (who was the first person in the facility known to test positive for COVID-19 on [DATE]) last worked on [DATE]. The census report showed she was moved from the quarantine unit to Unit 2 in room [ROOM NUMBER]- A on [DATE]. She was placed in the same room as Resident #208, who resided in room [ROOM NUMBER]- B. She remained in that room even after [DATE] when the facility had known on that date that she was potentially exposed to COVID-19 by LPN #3 on [DATE]. Resident #202 was tested for COVID-19 on [DATE] when the residents on Unit 2 were being tested . She was tested as part of the facility's facility wide testing after LPN #3 was known to have tested positive for COVID-19. Her specimen was collected on [DATE]. The lab received the specimen on [DATE] and the results were reported back to the facility as being positive on [DATE]. While her COVID-19 test was still pending, Resident #202 was moved onto the COVID-19 unit on [DATE] before it was known whether she was positive for COVID-19 and asymptomatic at that time. She was then moved the very next day on [DATE] off the COVID-19 unit onto the quarantine unit in room [ROOM NUMBER]- A. On [DATE], they moved her again and back on the COVID-19 unit when her COVID-19 test results were received, and she was positive for COVID-19. Review of a COVID-19 PUI Case Report dated [DATE] revealed Resident #202 was asymptomatic, but the date of symptom onset was listed as [DATE]. The course of treatment indicated the resident had a positive COVID-19 test come back and was moving to the COVID-19 positive unit. She was placed in full barrier precautions. Resident #202's Coronavirus report for [DATE] revealed she started to have temperatures recorded that were above 99 degrees F. on [DATE]. On [DATE], her SPO2 began to drop below 90 as well. Her highest temperature between [DATE] and [DATE] was 99.8 degrees F. On [DATE], her SPO2 was recorded as being 79%. Review of her progress notes revealed she had a [MEDICAL CONDITION] the morning of [DATE] with no prior history. The physician was notified, and new orders were received for [MEDICATION NAME] [MEDICATION]) and stat labs. Her condition continued to decline and on [DATE] she had crackles and wheezes in her lungs and low oxygen saturation despite being on oxygen at 5 LPM. The physician was updated, and new orders were received for her to receive [MEDICATION NAME] prn. The family was updated on her condition. She continued to decline and started refusing everything orally. She expired in the facility on [DATE]. On [DATE] at 12:46 P.M., an interview with LPN #12, who was standing in for the DON during her absence, was conducted. She was asked why Resident #202 was not placed back into quarantine when she had a known exposure to LPN #3 on [DATE], who tested positive for COVID-19 on [DATE]. She confirmed the facility was aware of LPN #3 ' s positive COVID-19 status on [DATE]. She stated they were following CDC guidelines and protocols. She did not feel leaving Resident #202 in Resident #208's room after [DATE] (when Resident #202 was exposed to LPN #3) put Resident #208 at risk of getting COVID-19 herself. She was then asked why Resident #202 was not tested for COVID-19 on [DATE] when the other residents on Units 6 and 7 that were also exposed to LPN #3 were tested . She stated the resident graduated from quarantine and they did not consider her exposure on [DATE] to require a new quarantine period. She was not able to explain why the census in the resident's EHR showed she had been moved to the COVID-19 unit without her being symptomatic at that time and before her test results came back. She was then asked why Resident #202 was moved to the quarantine unit on [DATE] the day after. She thought maybe the resident had an appointment outside the building that would require her to be quarantined but the nurses' progress notes did not support that she had been out of the facility. 2 (b). A review of Resident #208's medical record revealed her most recent admission to the facility was on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #208's census report confirmed she shared a room with Resident #202 between [DATE] and [DATE], after Resident #202 had been exposed to LPN #3 on [DATE]. She remained in room [ROOM NUMBER]- B even after [DATE] when the facility had known of Resident #202's potential exposure to COVID-19. Resident #202 subsequently tested positive for COVID-19 on [DATE] when she was tested as part of the facility's facility wide testing. Review of Resident #208's COVID-19 report for [DATE] revealed the facility was checking her temperature and SPO2 four times a day. She was noted to start having an elevated temperature above 99.4 degrees F. when her temperature was 101.5 degrees F. on [DATE] (six days after Resident #202 had moved into her room). On [DATE] her temperature was elevated three different times that day when checked. The temperatures recorded for that day was 101.7 degrees F., 102.9 degrees F., and 103.2 degrees F. On [DATE], her temperature was 99.5 degrees F. There were no abnormal SPO2 readings recorded. Review of Resident #208's COVID-19 test completed on [DATE] revealed she was positive for COVID-19 and her results were reported to the facility on [DATE]. Review of Resident #208's COVID-19 PUI Case Report dated [DATE] revealed the resident had a cough and fever with date of onset of [DATE]. Her exposure to COVID-19 was indicated to be unknown. The course of treatment indicated was an x-ray along with stat labs. She was indicated to be in isolation at that time, but her census report showed she shared a room with Resident #202 through [DATE]. The COVID-19 PUI Case Report for [DATE] again documented her symptoms as an elevated temperature above 99.4 and a cough. The course of treatment was to send her to the local hospital. Review of Resident #208's progress notes confirmed she became symptomatic of COVID-19 on [DATE]. The physician was notified, and the note indicated in addition to an x-ray and stat labs she was placed in isolation. Her chest x-ray came back negative. The resident's family was updated on her condition and the plan of action. She continued to have a fever through [DATE] being medicated with [MEDICATION NAME]. She was increasingly weak, was having more confusion and her SPO2 was noted to be 78%. The physician was notified, and she was transferred to the hospital on [DATE]. She was admitted to the hospital with [REDACTED]. The resident expired on [DATE] as noted by a Google search for her obituary. She was also included on the list the facility provided of those residents who had COVID-19 and died . On [DATE] at 12:46 P.M., an interview with LPN #12, who was standing in for the DON in her absence, was conducted. LPN #12 was asked why they continued to allow Resident #208 share a room with Resident #202, after it had been known on [DATE], that Resident #202 had been exposed to a staff member that tested positive for COVID-19. She stated they were following guidelines and protocols provided by CDC. She was asked to clarify why Resident #208's COVID-19 PUI Case Report dated [DATE] indicated she was placed on isolation when there was no evidence in her census report showing a room change had taken place. She was supposed to check into that but did not provide any additional information to support she had a room change on [DATE] and it was known Resident #208 still resided in room [ROOM NUMBER] until [DATE]. 3 (a). A review of Resident #207's medical record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #207's census report revealed he resided on the facility's quarantine unit on [DATE] when he was exposed to a staff member that later tested positive for COVID-19. He was moved to Unit 1 and placed in room [ROOM NUMBER]- A on [DATE]. He shared a room with Resident #70 who was in room [ROOM NUMBER]- B. There was no evidence of Resident #207 being placed on the facility's quarantine unit after the facility had been made aware of Resident #207's exposure to a staff member who tested positive for COVID-19. The daily census report for Unit 1 on [DATE] confirmed they remained in the same room with one another after [DATE] until Resident #207 was placed on the facility's quarantine unit. Review of Resident #207's COVID-19 tests revealed he was not tested for COVID-19 until [DATE] when the residents on Unit 1 were tested as part of the facility's facility wide testing of residents. The specimen was collected on [DATE] but the lab did not receive the specimen to process it until [DATE] (4 days after it had been obtained). The results were reported back to the facility on [DATE] as being negative. He was tested and positive results were reported to the facility on [DATE]. Resident #207 was placed on droplet precautions on [DATE] as a result of his positive COVID-19 test. Review of Resident #207's COVID-19 PUI Case Report dated [DATE] revealed he was noted to have a fever greater than 99.4 degrees F. The date of onset for his symptoms was [DATE]. His exposure was marked as having been unknown. His course of treatment indicated he was to be put on droplet isolation precautions and in a private room. His COVID-19 report for [DATE] that documented his temperature and SPO2 levels revealed they were being checked four times a day. He started having a temperature above 99 degrees F. on [DATE] when it was noted to be 99.3. It was elevated again on [DATE] three different times when it was recorded as being 99 degrees F., 99.3 degrees F., and 99.4 degrees F. His temperature was elevated again on [DATE] with temperature of 99.1 degrees F. and 99.3 degrees F. His SPO2 was low on [DATE] when it was recorded as being 88% when checked at 5:00 P.M. with his oxygen at 5 liters per minute (LPM). No additional checks were done. A review of Resident #207's progress notes revealed he was transferred to the hospital on [DATE] and admitted . He did not return to the facility and the facility had him on their list of residents that died as a result of COVID-19. On [DATE] at 12:46 P.M., an interview with LPN #12, who was standing in for the DON during her absence, was conducted. She was asked why Resident #207 was not placed in quarantine when it had been known by the facility that he had potentially been exposed to COVID-19 through LPN #3. She stated they were following the guidelines and protocols of the CDC. She stated he graduated from quarantine after he completed his initial 14-day quarantine period. She did not see the reason for him to be put back into quarantine for 14 more days after his known exposure to LPN #3. She was asked why he was not tested when all the other exposed residents that resided on the quarantine unit were tested on [DATE]. She stated they tested those residents who were exposed and still on the quarantine unit first as they felt they were a priority. She did not see the importance in testing him at the same time as the other residents despite him being exposed at the same time. She stated they tested all residents on the other units throughout the facility when they got to them. She was then asked why it took four days after the specimen had been collected for the lab to receive it. She stated it was a holiday weekend and was collected on Thursday but not picked up until the following Monday. She was not sure if the delay in delivery had any impact in his results as those came back negative and the COVID-19 test done the following day was positive for COVID-19. She stated the specimen was just sent in a Fed-Ex bag that was provided by the lab. She denied they had any instructions to store or deliver the specimen packaged in ice. She did not know it was recommended to deliver it in dry ice or other means to keep it in a temperature of minus 94 degrees F. or below if the delivery was going to be delayed for more than 72 hours. She was not concerned the resident was exposed on [DATE] and his first COVID-19 test results were not received until [DATE]. She did not feel leaving Resident #207 in Resident #70's room, after he had been known to be exposed to a staff member that tested positive for COVID-19, (TRUNCATED)

Based on medical record review and staff interview the facility failed to ensure a resident was free from significant medication errors when staff administered insulin to Resident #131 causing a significant medication error. This affected two (Residents #67 and #131) of three residents reviewed for medication errors. Harm occurred to Resident #131 when he was administered 50 units of Xultophy insulin incorrectly resulting in Resident #131 becoming hypoglycemic and being subjected to extensive blood glucose monitoring. Findings include: Review of the medical record for the Resident #131 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 11/21/18, revealed Resident #131 had intact cognition and did not receive insulin. Review of physician orders [REDACTED].#131 did not receive insulin. An order dated 01/06/19 revealed Resident #131 was to have his blood sugars checked every four hours. Review of the January, 2019 Medication Administration Records revealed Resident #131's blood glucose levels were: on 01/06/19 at 4:00 P.M. was 70 milligrams per deciliter (mg/dL), at 9:00 P.M. was 62, on 01/07/19 at 12:00 A.M. was 63, at 4:00 A.M. was 73, at 8:00 A.M. was 146, at 4:00 P.M. was 77, at 9:00 P.M. was 82, and on 01/08/19 at 12:00 A.M. was 86, at 4:00 A.M. was 86, at 8:00 A.M. was 92 and at 12:00 P.M. was 89. Normal blood glucose levels are between 70 mg/dL and 100 mg/dL. Review of the nursing progress notes from 01/05/19 to 01/07/19 revealed no documentation of the incident of Resident #131 receiving his roommate's insulin. Review of an incident report with a revision dated of 01/10/19 and an original date of 01/06/19 revealed Agency LPN #10 observed patient lying in bed. She addressed the resident as Resident #67 and the resident responded so she proceeded to administer 50 units of Xultophy insulin in his right arm. Interview on 01/16/19 at 1:05 P.M. Licensed Practical Nurse (LPN) #4 indicated Agency LPN #10 had drawn up insulin for Resident #131's roommate (Resident #67) down the hallway at the medication cart and went into the room and asked for Resident #67. Resident #131 had answered her so she administered 50 units of Xultophy insulin to Resident #131 and not to Resident #67. LPN #4 indicated it was strange because Resident #131 was alert and oriented so he had to still be asleep. LPN #4 indicated Agency LPN #10 had worked in the facility previously and had been spoken to her about not taking her medication cart with her so she would have all the resident identifiers with her. She stated the nurse was no longer allowed to come back to the facility. Interview on 01/16/19 at 2:51 P.M. with Resident #131 stated he was sleeping, and the agency nurse came in and stated she needed to check his blood sugar. He indicated he did not think anything of it plus he was still half asleep. He stated after she checked his blood sugar she immediately gave him a shot in his right arm then she tried to give him his roommate's medication. He indicated by this time he was fully awake and told her those were not his medications and he was not ordered to receive insulin. He stated he felt horrible all day, but they were checking his blood sugar every four hours. He said the nurse was sent home. An interview on 01/16/19 at 3:55 P.M. with the Director of Nursing verified Resident #131 was given Resident #67's insulin incorrectly and sustained a significant medication error. This deficiency substantiates Complaint Number OH 039.

Based on observation, medical record review, staff and physician interview and review of facility policy, the facility failed to ensure pressure ulcer treatment was administered as ordered for one resident (Resident #339). Actual Harm occurred when facility staff failed to provide physician ordered treatment to a pressure ulcer for five of seven days resulting in Resident #339's Stage 2 pressure ulcer declining to an unstageable pressure ulcer. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #339 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0, dated 08/28/18 revealed a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment). The resident required extensive assistance from staff for all activities of daily living. Review of the nursing progress note dated 10/11/18 revealed the weekly pressure ulcer report. The notes revealed Resident #339 had a coccyx pressure ulcer, measuring 8.9 centimeters (cm) by 11 cm by zero cm. The pressure ulcer was classified as a Stage 2 pressure ulcer (defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister). This was the initial observation. Review of the physician's orders [REDACTED]. The treatment consisted of cleansing the area with normal saline, pat dry, then apply an adhesive foam dressing to the area every dayshift and as needed. Review of the dietary progress notes dated 10/15/18 revealed a care conference with the family. The notes revealed Resident #339 had skin alterations, and the treatment nurse was following the resident with treatments in place. Review of Resident #339's plan of care (P[NAME]) revealed the resident had a potential for skin/tissue integrity of moderate risk, related to a [DIAGNOSES REDACTED]. The P[NAME] dated 08/14/18 indicated the resident had activities of daily living and self-care performance deficit also related to a [DIAGNOSES REDACTED].#339 required staff participation to reposition and turn in bed. Review of Resident #339's treatment administration record (TAR) revealed a treatment to cleanse the coccyx area with normal saline, then pat dry and apply an adhesive foam dressing to the area every dayshift. The treatment was dated 10/12/18. Further review of the TAR revealed on 10/12/18, 10/13/18, 10/14/18 and 10/15/18 no treatment was initialed as being administered. Observations made on 10/16/18 at 1:00 P.M., 3:30 P.M. and 4:20 P.M. revealed Resident #339 was in bed positioned on her back. Interview on 10/16/18 at 3:38 P.M. with State tested Nurse Aide (STNA) #29 confirmed she had not repositioned Resident #339 since she had put her to bed after lunch. Interview on 10/16/18 at 4:00 P.M. with Registered Nurse (RN) #96 confirmed she knew the resident had a pressure ulcer, but RN #96 stated she did not know what was ordered. RN #96, with surveyor, reviewed the physician's orders [REDACTED].#339's coccyx each day on dayshift. RN #96 confirmed the order was written on 10/12/18. Observation on 10/16/18 at 4:27 P.M. of the pressure ulcer treatment administered by RN #96 revealed Resident #339 had a large bright red area on her coccyx with a moderately large opened area, covered with a yellowish substance. Treatment was performed according to physician's orders [REDACTED].#339 was positioned on her back following treatment. On 10/17/18 at 2:49 P.M. an interview with Unit Supervisor RN #104 reviewed the TAR for Resident #339 and confirmed no treatment had been administered to Resident #339's coccyx per physician's orders [REDACTED]. She verified the dayshift nurse for 10/17/18 had already gone home and no treatment had been administered. On 10/18/18 at 9:07 A.M. Resident #339's coccyx was observed with Wound Physician #115. Physician #115 examined the resident's coccyx pressure ulcer. The pressure ulcer measured 3.1 cm by 5.2 cm by unknown depth, with 60 to 70 percent slough. Physician #115 stated the wound was unstageable (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed). Review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 03/2014 revealed the facility did not following its policy regarding pressure ulcers.

Based on record review and interview the facility failed to ensure one resident's, (Resident #153), Type I Diabetes was adequately monitored and insulin administered as ordered. This resulted in actual harm when Resident #153 did not receive insulin medication resulting in a critical blood glucose level of 600 requiring hospitalization . This affected one resident (Resident #153) of three sampled residents. Findings include: Review of the medical record revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed no Minimum Data Set 3.0 assessment was completed as the resident was discharged to the hospital on [DATE]. Review of Resident #153's hospital discharge ordered medications, dated 05/28/18, revealed the resident was to receive the following anti- diabetic medications: [REDACTED] Insulin [MEDICATION NAME] ([MEDICATION NAME] -[MEDICATION NAME]) 300 unit/3 ml 5 units three times daily with meals. Insulin Detemir ([MEDICATION NAME] -Flextouch 300 units/3 ml 15 units every morning. Insulin Determir ([MEDICATION NAME] Flextone) 300 units/3 ml 12 units subcutaneous at bedtime. Resident #153 also had an order for [REDACTED].>Although Resident #153's Medication Administration Record [REDACTED].M., the physician was not notified of the elevated blood sugars. There was no documentation in the record Resident #153 was administered Insulin [MEDICATION NAME] ([MEDICATION NAME] -[MEDICATION NAME]) 300 unit/3 ml 5 units three times daily with meals. Review of Resident #153's nursing progress note, dated 05/29/18 (no time), revealed no notation of Resident #153's condition when the resident was discharged from the facility to the emergency room with a critical blood glucose level of 600 mg/dl. Review of a hand- written paragraph by Unit 300 Manager, Registered Nurse (RN) #191 on 06/02/18 (with no time), as a late entry four days following the resident being sent to the hospital, indicated on 05/29/18 they were called to the resident's room by an upset family member. The family stated they were concerned about their father. From what the resident had told the family, he had not had his insulin that morning. The family asked another nurse to check the resident's blood sugar before they arrived and his sugar was 426. According to the MAR, Resident #153 had received his evening dose of [MEDICATION NAME] and his 15 units of [MEDICATION NAME] at 6:00 A.M. At 6:00 A.M. Resident #153's blood sugar was 268. The daughter-in -law requested the blood sugar be checked again. The blood sugar was 600. The family immediately gathered the resident with his walker and left the facility stating they were taking him to the emergency room . The nurse documented they were waiting on the physician to come to the facility that day to clarify Resident #153's insulin orders because they were confusing. The hand written paragraph was not documented in the resident's medical chart, nurse's notes, or any portion of the electronic record or on the facility SBAR that was used to indicate a change in medical condition. Resident #153's physician was not notified of the elevated blood sugar of 426 on 05/28/18 or 268 on 05/29/18. Resident #153's insulin order was not transcribed onto the MAR. When Resident#153 left the facility with his family on 05/29/18 with a critical blood sugar of 600 to go to the emergency room there was no documentation of the resident's condition on departure. An interview with Registered Nurse (RN) #189 on 06/02/18 at 7:50 A.M. revealed she was the admitting nurse for Resident #153 on 05/28/18. RN #189 stated she admitted the resident and then reconciled the resident's orders from his hospital discharge list. RN #189 stated the only order she questioned was the resident's sliding scale insulin order and called the physician's office for a clarification. RN #189 stated she completely missed the order for the resident to receive Insulin Aspect ([MEDICATION NAME]) 300 units/3 ml five units three times a day with meals, and did not notify the physician of the elevated blood sugar of 429 or the blood sugar of 268. RN #189 stated she left the faciity on an appointment and when she came back the resident had left the facility with his family to go to the emergency room . RN #189 stated this was when she found out she had missed the third insulin order. An interview with the Regional Director of Clinical Operations on 06/02/18 at 11:30 AM verified there was no documented evidence the facility notified the physician of the blood sugar of 429 and no documentation of the elevated blood sugar of 600 or the resident's condition An interview with Unit 300 Manager, Licensed Practical Nurse (LPN) #191 on 06/05/18 at 8:30 A.M., verified RN #189 did not reconcile and transcribe Resident #153's physician's orders [REDACTED]. Unit 300's Manager, LPN #191 verified the missed order and verified the elevated blood sugars were not reported to the physician until after Resident #153 had left with his family to go to the hospital emergency room for evaluation. This deficiency substantiates Complaint Number OH 302 and Complaint Number OH 247. This deficiency is also an example of continued non-compliance from the survey dated 05/01/18 and 02/06/18.

Based on observation, medical record review, policy review and interview, the facility failed to assess, treat, and implement interventions to prevent the development and decline of avoidable pressure ulcers. This affected three (Resident #40, #88, and #104) of four residents reviewed for pressure ulcers. The facility inaccurately identified three residents with pressure ulcers excluding Stage I and two of the three pressure ulcers were present upon admission. The facility census was 143. Actual harm resulted to Resident #40 when the facility failed to implement pressure relieving interventions when the resident was wearing a foot splint resulting in three suspected deep tissue injuries (SDTI) (non-blanchable deep red, maroon or purple discoloration that results from intense and/or prolonged pressure and shear forces at the bone-muscle). Actual harm resulted to Resident #88 when Registered Nurse (RN) #10 failed to assess the resident after a state tested nurse aide (STNA) informed her the resident had a newly developed buttock pressure ulcer. There was no treatment or assessment of the area for two days at which time it had declined to an unstageable pressure ulcer. Actual harm resulted to Resident #104 when the resident was admitted to the facility with no pressure ulcer, was at risk for pressure ulcer development due to debility, interventions were not implemented and the resident developed four facility acquired pressure ulcers within 30 days including pressure ulcers on both ears. Findings include: 1. Medical record review revealed Resident #104 was admitted on [DATE]. [DIAGNOSES REDACTED]. At the time of admission, Resident #104 had no skin breakdown but was assessed to be at high risk for the development of pressure ulcers. Review of the admission Physician order [REDACTED]. Review of the physician progress notes [REDACTED]. There was no evidence Ensure Plus was given with meals between 01/10/18 and 02/06/18. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was severely impaired for daily decision-making, was dependent on staff for transfers, incontinent of bowel and bladder and had no pressure ulcers. Review of the Progress Notes revealed on 01/16/18, a scabbed area was noted to the resident's right ear, as well as, redness to her buttocks. The areas were documented as non-pressure skin alterations and there was no evidence of a comprehensive assessment of the scabbed area. On 01/16/18 and 01/17/18, the physician ordered to apply triple antibiotic ointment (TAO) to the resident's right ear, apply [MEDICATION NAME] (ointment to prevent and treat a variety of minor skin irritations) to buttocks and use a neck pillow when she was in bed. Prior to 01/16/18, there was no evidence of a barrier cream or ointment being applied to the resident's buttocks. Review of the physician progress notes [REDACTED]. The physician documented the resident's medical prognosis was good. Review of the Weekly Pressure Ulcer report dated 01/19/18 revealed a facility acquired, right ear pressure ulcer measuring 1.0 centimeter (cm) in length (l) by 1.0 cm in width (w) by <0.1 cm in depth (d). New interventions included to elevate her head in bed and use a neck collar. Review of the Progress Notes dated 01/22/18, 01/26/18, 01/31/18, 02/01/18 and 02/02/18 revealed Resident #104 was up in the wheelchair most of the day. A late entry documented on 02/06/18 revealed the resident had moisture associated skin damage (MASD) to the buttocks measuring 2.0 cm by 2.0 cm. Review of the Health Status Note dated 02/05/18 revealed the resident developed a scabbed area to the left ear and MASD to the buttock. Review of the record revealed no comprehensive assessment of the left ear, coccyx or buttock. On 02/06/18 Weekly Skin Alteration Reports were completed and revealed a scabbed area to the left ear measuring 3.0 cm in (l) by 2.0 cm in (w). The coccyx was described as a red open area measuring 1.5 cm in (l) by 1.5 cm in (w) with partial thickness skin loss. The right buttock was described as a red open area measuring 1.1 cm in (l) by 0.6 cm in (w) with partial thickness skin loss. None of the above areas were assessed to be pressure ulcers. Review of the care plan: Actual Impairment to Skin Integrity due to fragile skin initiated 01/05/18 and revised 02/06/18 revealed interventions included to apply a protective barrier to the buttock after incontinence, avoid friction and shearing, use a turn sheet for repositioning, a pressure reducing mattress, a chair cushion, turn the resident every two hours, the resident was to be up for meals only and laid down after eating. On 02/06/18 at 11:45 A.M., observation revealed Resident #104 was in a reclined geri-chair (specialized wheelchair) in the dining room with a gray neck pillow around her neck. The resident's head was turned to the left and the left ear could not be fully observed due to it was pressed against the pillow. Observation of the right ear revealed a dark purple hue to the middle aspect of the auricle (outer edge of the ear) above a Stage 2 pressure ulcer measuring 0.3 cm in diameter and 0.1 cm in depth (d). Registered Nurse (RN) #3 verified the above at the time of the observation. On 02/06/18 at 11:54 A.M. to 11:58 A.M., interview with Licensed Practical Nurse (LPN) #20 stated it was not time for lunch for another 30 minutes and the resident had been up in the chair for about two hours and staff were getting ready to take her to her room to complete incontinence care. LPN #20 stated she routinely cares for Resident #104 and currently knew of one pressure ulcer on her left ear. LPN #20 stated currently the resident did not have any special pressure relieving interventions in place except for a standard pressure relief mattress, a neck pillow and was not to wear an incontinence product while in bed. On 02/06/18 between 12:05 P.M. and 12:27 P.M., observation of incontinence care revealed LPN #18 and State tested Nurse Aide (STNA) #19 transferred Resident #104 to the edge of the bed, and STNA #19 put her hands under the resident's legs, lifted and pivoted the resident with her buttock pressed against the mattress to the center of the bed. During the observation, STNA #19 was observed pulling a cloth incontinence pad out from underneath the resident causing her hips and buttocks to slide across the bed towards the STNA. The STNA then positioned the resident on her side revealing two unstageable pressure ulcers. There was no dressing on the ulcers and stool was observed to be wiped across the unstageable pressure ulcers four times as the STNA stated wipe, wipe, wipe, wipe with each new corner of the wash cloth. STNA #19 then rinsed the resident and dried her with a towel. She started to roll a clean incontinent brief under the resident's left side, when she stopped, removed her gloves and went to the bathroom to wash her hands. STNA #19 donned gloves, applied ointment to the resident's buttock including both pressure ulcers and placed an incontinence product with tabs on the resident. STNA #19 stated she put the tabs on loosely so she can have air flow to her skin. LPN #18 verified there was a coccyx and right buttock pressure ulcer and stated the coccyx wound was approximate 3.0 cm in (l) by 2.0 cm in (w) that was covered with yellow slough, and a right buttock pressure ulcer measuring approximately 1.5 cm in (w) by 1.0 cm in (l) that was covered with yellow slough. LPN #18 verified they were currently applying an ointment to the coccyx and buttock with no dressing. After incontinence care was complete, STNA #19 pulled the resident up in bed by putting her hands on the resident's upper torso causing a shearing motion. A draw sheet was not used to reposition the resident. On 02/06/18 at 12:27 P.M., interview with LPN #18 revealed Resident #104 had four facility acquired pressure ulcers. A 3.0 cm in (l) by 2.0 cm in (w) pressure ulcer to the coccyx covered with yellow slough, a right buttock pressure ulcer measuring 1.5 cm by 1.0 cm in (l) covered with yellow slough, an unstageable left ear pressure ulcer measuring 3.0 cm in (l) by 0.5 cm in (w) with brown eschar covering the center portion of the auricle (projecting outer portion of the ear) and a right auricle suspected deep tissue injury adjacent to a healing right ear Stage 2 pressure ulcer measuring 0.3 cm in diameter. On 02/06/18 at 2:32 P.M., interview with RN #16 stated the resident had developed MASD on 01/16/18 and was put on a turn schedule and up for meals only. RN #16 stated at some point it healed and was developed again on 02/05/18. RN #16 stated she did not consider the left ear area a pressure ulcer and verified there was no evidence pressure relieving interventions were implemented. On 02/06/18 at 4:00 P.M., interview with the Director of Nursing (DON) verified there was no evidence of pressure relief interventions being followed after review of the medical record and the resident's right and left ear, coccyx and buttock should have been assessed to be pressure ulcers. 2. Closed medical record review revealed Resident #88 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact for daily decision-making, required extensive assist with toileting, transfers and mobility, was frequently incontinent of urine and bowel, and had no pressure ulcers. Review of the care plan: Potential/Actual Impairment to Skin Integrity and At Risk for Pressure Ulcers due to incontinence and assistance with bed mobility revised 12/07/17 revealed interventions included to avoid friction and shearing, use of a turn sheet for repositioning, protective barrier cream to buttocks after incontinence, avoid scratching, daily skin inspection, keep skin clean and dry, and pressure reducing mattress while in bed. Review of the facility investigation and Registered Nurse (RN) #10's Performance Improvement Review dated 12/28/17 revealed on 12/18/17 a state tested nurse aide had reported to RN #10 that Resident #88 had a pressure area to her buttock with no dressing. RN #10 did not assess the wound, initiate a treatment or notify the physician of the pressure ulcer. RN #10 signed the performance improvement form. Review of the written statement regarding a phone interview with STNA #14 revealed she reported Resident #88's skin alteration to RN #10 (on 12/18/17) and the wound was about 0.5 cm in (l) by 0.3 cm in (w) and was kind of yellow and moist with no drainage or odor. Review of the weekly Pressure Ulcer Weekly Log revealed Resident #88's developed two facility acquired pressure ulcers on 12/20/17. The resident had an unstageable pressure ulcer to the coccyx measuring 1.5 centimeters (cm) in length (l) by 0.9 cm in width (w) with slough/necrotic tissue and a Stage 2 pressure ulcer to the left buttock measuring 1.4 cm in (l) by 1.0 cm in (w) by 0.2 cm in depth. On 02/01/18 at 12:27 P.M., interview with RN #5 verified Resident #88 was at risk for skin breakdown, was continent of urine on admission and then started having episodes of incontinence that was discussed at the care conference on 12/05/17; however, no interventions were implemented. The resident continued to be frequently incontinent of urine and on 12/20/17 was informed the resident had two unstageable pressure ulcers to the coccyx and buttock. RN #5 verified it was the facility practice to implement a standard pressure relief mattress upon admission and other standard interventions including to avoid friction and shearing, use of a turn sheet for repositioning, protective barrier cream to buttocks after incontinence, avoid scratching, daily skin inspection, keep skin clean and dry, and pressure reducing mattress while in bed would be written to be implemented until skin breakdown had occurred. RN #5 stated these were not always necessarily documented as being done. On 02/01/18 at 12:41 P.M., RN #5 verified Resident #88's skin impairments were due to the lack of pressure relieving interventions and toileting interventions, and verified the pressure ulcers were avoidable. On 02/01/18 between 12:50 P.M. and 1:00 P.M., interview with the DON stated staff informed her that Resident #88 had developed a pressure ulcer on 12/18/17 and RN #10 was notified. When the resident's unstageable pressure ulcers were identified on 12/20/17, it was brought to her attention that RN #10 had been informed of the developing pressure ulcer two days earlier. The facility began an investigation and determined the nurse failed to complete her work and had poor work quality. On 02/01/18 at 2:40 P.M., interview with Physician Assistant (PA) #11 stated Resident #88 was admitted with many health concerns and was at risk for skin breakdown. PA #11 stated he was unaware pressure relieving interventions were not being implemented upon admission and that would have contributed to the resident's skin breakdown. 3. Medical record review revealed Resident #40 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 09/23/17 revealed Surgeon #800 advised not to change the dressing and the wound would be evaluated on an outpatient basis. Review of the Surgeon #800 Order dated 09/26/17 revealed splint to right foot to remain in place until follow-up with surgeon on 09/27/17. Review of the record revealed no documented evidence of surgeon consult notes between 09/27/17 and 10/24/17. Surgeon #800 would not release the consult reports. Review of the admission MDS assessment dated [DATE] revealed Resident #40 was cognitively intact for daily decision-making, required extensive assist with bed mobility, had no unhealed pressure ulcers but was at risk for the development of pressure ulcers. Review of the Treatment Administration Record dated October, 2017 revealed no interventions had been implemented to prevent pressure from Resident #40's right foot splint. Review of the record revealed no evidence the facility implemented pressure relieving interventions related to the resident's foot splint. Review of the Wound Clinic history and physical examination [REDACTED]. Review of the Skin/Wound Note dated 10/25/17 by RN #5 revealed the resident returned from a follow-up appointment with the surgeon related to the right foot. After removal of the splint the resident was noted to have two Suspected Deep Tissue Injury (SDTI) to the right lateral and one to the right medial aspect of the foot. Review of the Weekly Pressure Ulcer assessment dated [DATE] by RN #5 revealed a SDTI to the right lateral foot measuring 3.0 cm in (l) by 1.0 cm in (w), a right lateral top of foot SDTI measuring 1.7 cm in (l) by 1.5 cm in (w) and a right lateral (documented as lateral however RN #5 stated it was an error and should have been documented as right medial) foot SDTI measuring 1.0 cm in (l) by 1.0 cm in (w). The three SDTI's were discovered when the resident's splint was removed. Review of the Weekly Pressure Ulcer assessment 01/25/18 revealed the right medial pressure ulcer measured 1.3 cm by 1.3 cm, no depth documented, unstagable with eschar. The right lateral pressure ulcer measured 1.9cm by 1.4 cm unstagable with eschar, the lateral pressure ulcer toward the heel was 2.8 cm by 3.1 cm, unstagable with eschar. On 02/01/18 at 3:05 P.M. and 3:30 P.M., interview with RN #5 verified there was no documented evidence the facility implemented off-loading or pressure relieving interventions in regard to the foot splint. On 02/02/18 at 10:37 A.M., interview with the DON stated Resident #40 refused to allow the surveyor to observe his pressure ulcer. The DON verified no preventative interventions upon admission, no evidence of pressure relieving interventions to prevent pressure under the splint. Review of the policy: Prevention of Pressure Ulcers revised September 2013 revealed pressure ulcers were usually formed when a resident remains in the same position. Common sites of a pressure ulcer development were where the bone was near the surface of the body including ears, hips, and backbone. Pressure could also come from splints or casts. If pressure ulcers were not treated when discovered, they quickly get larger, become very painful and often become infected. They are also often made worse by continual pressure, moisture, perspiration, feces, urine, decline in nutrition, acute illness or condition. The facility should have a system/procedure to assure assessments were timely and appropriate and changes in condition were recognized, evaluated, reported to the family, practitioner, physician and addressed. Interventions and general preventative measures included if the resident was in bed, their position should be changed at least every two hours or more frequently if needed, also determine if a special mattress would be needed, and raise the head of the bed as little and for the shortest time possible and only as necessary for meals, treatments and medical necessity. When repositioning, reduce friction and shear by lifting rather than dragging. Routinely assess and document the condition of the resident's skin and report any signs of a developing ulcer to the physician. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. This deficiency substantiates Complaint Number OH 896.

Based on medical record review, dietary card review, policy review and interview, the facility failed to pursue a resident's request for enteral feedings and failed to implement new nutritional interventions resulting in a severe weight loss. This affected two (Resident #90 and #104) of three residents reviewed for weight loss. The facility census was 143. Actual harm resulted when Resident #104 was ordered to receive ensure plus (high protein, calorie nutritional supplement) with meals due to provide 58% of daily nutritional needs and there was no evidence this was completed resulting in the resident sustaining a significant weight loss within 30 days of admission. Actual harm resulted when Resident #90, who had a history of [REDACTED]. The resident's request was not implemented and he experienced a severe weight loss. Findings include: 1. Medical record review revealed Resident #104 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident weighed 104 pounds at the time of admission. Review of the Nutrition Services Visit Note dated [DATE] revealed the resident preferred beverages and had some favorite foods. Review of the physician progress notes [REDACTED]. The resident's skin was intact at the time of the assessment. Review of the admission Medical Nutrition Therapy assessment dated [DATE] revealed Resident #104 was dependent on staff for eating, was 63 inches tall and weighed 104 pounds. The resident's meal intake had been 37%. Ensure plus (high protein, calorie nutritional supplement) was ordered to be given at meals and this supplement would provide 58% of the resident's nutritional needs. Review of the Weight Summary dated [DATE] revealed the resident weighed 98.6 pounds. There was no evidence the physician or Registered Dietitian (RD) #13 were notified of the weight loss. Review of the Weight Change Note dated [DATE] revealed a 5.2% weight loss over 30 days. The resident was eating 25% of meals and was drinking better than she was eating. RD #13 documented the resident was receiving Boost Plus (high protein, calorie nutritional supplement) 240 ml at meals; however, review of the record revealed no evidence the nutritional supplement was being offered or accepted. There was no evidence Registered Dietitian (RD) #13 reviewed the record for acceptance of the ordered nutritional supplement at meals between [DATE] and [DATE]. New recommendations included to add fortified foods and add another Boost plus 240 ml at 2:00 P.M. daily. Review of Resident #104's Medication Administration Record [REDACTED]. The resident was started on Boost plus daily on [DATE]; however, the order did not include the amount ordered and there was no intake percentage documented. Review of the Dietary Slip dated [DATE] revealed no evidence the resident received Ensure plus at meals. Review of the medical record revealed the resident had developed facility acquired pressure ulcers on [DATE] and [DATE]. On [DATE] at 11:54 A.M., interview with Licensed Practical Nurse (LPN) #20 stated Resident #104 had poor nutrition and weight loss since admission but stated the resident would drink whatever was given to her especially boost. LPN #20 stated the resident receives Boost plus at 2:00 P.M. since weight loss was noted last week and when the resident developed a left ear pressure ulcer around [DATE]. LPN #20 stated the resident was not receiving any other nutritional supplements and the percentage of supplement accepted was documented by the nurses. On [DATE] at 4:17 P.M., interview with the Director of Nursing (DON) stated nutritional supplements at meals were sent out on the meal trays and the nurses were responsible to document the percentage accepted. The DON verified there was no evidence the resident was receiving ensure plus or boost nutritional supplement at meals which would have provided over 50% of her daily nutritional needs and the resident had experienced a significant weight loss in 30 days. 2. Medical record review revealed Resident #90 was admitted on [DATE] with history of gastric bypass with protein calorie malnutrition, gastrostomy, anxiety and diabetes. Review of the Weight Change Note dated [DATE] revealed the resident stated he had no appetite and wanted back on tube feeding. RD #13 encouraged the resident to get out of bed for meals and resident again stated he wanted tube feeding. RD #13 documented called and discussed with daughter and was going to have the physician review his medications. Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired for daily decision-making, was 70 inches tall, weighed 142 pounds and had a 5% or more weight gain in last month or 10% in the last months and was on a physician prescribed weight gain program. The resident had a BIMS of 10 (moderately impaired). Review of the Medication Administration Record [REDACTED]. Review of the Weight Change Note dated [DATE] revealed a weight of 120 pounds on [DATE] indicating a significant weight loss of 12.3% noted from [DATE]. The resident's cognition had changed and his meal intake was zero to 25% over last few days. Physician, nurse and family notified of weight loss and change in cognition. There was no evidence of new nutritional interventions implemented. Review of the care plan: Nutrition Risk revised [DATE] revealed the resident had a history of [REDACTED]. The resident had frequent meal refusal, preferred to eat little to no breakfast, frozen meals, and ate candy and snack cakes versus meals. Interventions included to monitor and evaluate the resident for weight changes. The resident was ordered Ensure plus daily, Ensure clear twice a day, a frozen fortified treat daily, protein powder twice a day and [MEDICATION NAME]. Review of the care plan: Refusing to Eat/Resists Feeding revised [DATE] revealed a history of gastrostomy tube feedings and the resident stated he wanted his tube feeding back. There were no interventions regarding initiation of a tube feeding again for the resident. Review of the record revealed no evidence the facility addressed the resident's desire to have his nutrition by enteral feeding between [DATE] and [DATE]. On [DATE] at 1:07 P.M., interview with RD #13 and the DON revealed Resident #90 was readmitted on [DATE] with a weight of 147 pounds with previous nutritional interventions implemented. Review of the record revealed on [DATE] the resident weighed 128 pounds and RD #13 stated she was not informed of this 14% severe weight loss until [DATE]. RD #13 stated once she was notified of the weight loss, she went to see the resident and that was when she noticed a change in his cognition. At first, thought the weight loss would have been related to diuretic use; however, the DON verified this was not related to the use of a diuretic. RD #13 verified once the severe weight loss of 14% in 12 days was identified, she did not start any new interventions. RD #13 stated she was at the facility daily but did not see the resident again prior to his death on [DATE]. On [DATE] at 2:55 P.M., interview with RD #13 verified Resident #90's active care plans included a request to restart his tube feeding. RD #13 stated this had not been discussed or addressed with the resident since July, 2017 and no follow-up was documented. RD #13 stated the resident wanted enteral nutrition because he did not want to eat. Review of the policy: Weight Assessment and Intervention revised [DATE] revealed nursing staff was to weight residents upon admission and weekly for four weeks thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. IF the weight is verified, nursing was to immediately notify the dietitian in writing. The dietitian was to respond within 24 hours of receipt of written notification. Interventions for undesirable weight loss shall be based on careful consideration including resident choice and preferences, the use of supplementation and/or feeding tubes, nutrition and hydration needs of the resident, and the need for diet modifications. This deficiency substantiates Complaint number OH 896.

Based on observation, medical record review, policy review and interview, the facility failed to implement interventions to maintain and restore bladder function and failed to provide proper incontinence care. This affected three (Resident #88, #90 and #104) of four residents reviewed for incontinence. Harm resulted when Resident #88 was assessed upon admission to be continent of urine and declined to frequently incontinent of urine resulting in moisture associated skin damage with no interventions to restore bladder function. Harm resulted when Resident #90's bladder retraining program was not implemented, the resident was incontinent and developed moisture associated skin damage (MASD) to the right trochanter. Findings include: 1. Closed medical record review revealed Resident #88 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Physician order [REDACTED].#88 received [MEDICATION NAME] 20 milligrams (mg) daily and [MEDICATION NAME] ([MEDICATION NAME]) 2 mg daily. Review of the Bladder Evaluation assessment dated [DATE] revealed the resident was continent of urine with prompting. Review of the record revealed no evidence of a 3-day bowel and bladder assessment was completed. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact for daily decision-making, required extensive assist with toileting and was frequently incontinent of urine with no toileting program. Review of the record revealed staff documented Resident #88's urinary continence once a shift between 11/26/17 and 12/31/17. There was no evidence the facility was monitoring the resident's incontinence to establish a pattern. Review of the Urinary Continence Response History dated 01/02/18 to 01/04/18 revealed the resident was continent of urine on one of six occasions. Review of the Weekly Skin Check dated 12/04/17 revealed redness to the resident's groin and back of thighs due to incontinence (moisture associated skin damage). There was no evidence of new interventions implemented to restore the resident's bladder function. Review of the Care Plan Participation Record (care conference) dated 12/05/17 revealed areas discussed included concerns regarding starting to have some incontinence and she needed assistance with toileting. There was no evidence the resident's concerns regarding incontinence were addressed after the care conference. Review of the record revealed no evidence of an incontinence plan of care. On 02/01/18 at 12:27 P.M., interview with Registered Nurse (RN) #5 verified Resident #88 was continent upon admission and had no skin issue. On 12/04/17, the resident developed redness to her groin and back of thighs due to incontinence without evidence of interventions to restore bladder function. On 02/01/18 at 12:41 P.M., interview with RN #5 verified the facility did not implement interventions to restore the resident's continence which was a contributing factor to the development of the resident's MASD. 2. Closed medical record review revealed Resident #90 was admitted on [DATE] with internal right knee prosthesis infection, dementia, right knee contracture and diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #90 was moderately impaired for daily decision-making, was occasionally incontinent of urine with no toileting program and skin impairment included MASD. Review of the care plan: Functional Bladder Incontinence revised 01/14/17 revealed interventions including urinal at bedside within reach and check the resident every two to three hours for incontinence. The care plan: ADL Self-Deficit revised 04/21/17 revealed the resident was non-weight bearing with the right leg, used a urinal and was to be toileted with morning and evening care, before meals and PRN (as needed). Review of the Weekly Skin Check dated 11/21/17 revealed MASD to the resident's right trochanter measuring 6.0 centimeters (cm) in length by 3.5 cm in width by <0.1 cm in depth. Review of the medical record revealed no evidence the resident was checked for incontinence or toileted per plan of care to restore or maintain continence. On 02/01/18 at 12:41 P.M., interview with RN #5 stated Resident #90 acquired MASD to his right hip in November, 2017 after he was found in bed with his water spilled and incontinent of urine. RN #5 stated it was very upsetting and she would frequently have to address skin and incontinence concerns with the nurse and aides. On 02/06/18 at 10:53 A.M. interview with the Director of Nursing (DON) verified there was no evidence Resident #88 was toileted more than once a shift, no evidence Resident #90 was toileted per toileting schedule and both residents developed MASD. The DON stated it was her expectation for staff to toilet residents at least every two hours and if they had a toileting program it was to be followed. The DON verified Resident #88 was continent upon admission, had a decline in continence without intervention and Resident #90 had a toileting program that was not implemented, and the resident developed MASD to the right trochanter due to his incontinence. 3. Medical record review revealed Resident #104 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/06/18 between 12:05 P.M. and 12:27 P.M., observation of incontinence care revealed Licensed Practical Nurse (LPN) #18 and State tested Nurse Aide (STNA) #19 transferred Resident #104 to bed and washed their hands at the sink with soap and water. STNA #19 donned gloves and removed the resident's incontinence brief which was observed to be soaked with dark, yellow urine and a small bowel movement. STNA #19 handed the soiled, incontinence brief to LPN #18 and proceeded to provide incontinence care without changing her gloves or washing her hands. STNA #19 used a clean towel with her soiled gloves to dry the resident. Without changing her gloves, STNA #19 repositioned the resident's bed sheet and clothing, placed her soiled gloved hands on the resident's leg/back and rolled her onto her right side. An unstageable coccyx and right buttock pressure ulcers were observed. There was no dressing on the ulcers and stool was observed to be wiped across the unstageable pressure ulcers four times as the STNA stated wipe, wipe, wipe, wipe with each new corner of the wash cloth. STNA #19 then rinsed the resident and dried her with a towel. She started to roll a clean incontinent brief under the resident's left side, when she stopped, removed her gloves and went to the bathroom to wash her hands. STNA #19 donned gloves, applied ointment to the resident's buttock including both pressure ulcers and placed an incontinence product with tabs on the resident. STNA #19 stated she put the tabs on loosely so she can have air flow to her skin. On 02/06/18 at 12:26 P.M., interview with STNA #19 verified the above observation. Review of the policy: Types of Urinary Incontinence revised 06/27/05 revealed interventions for urge incontinence included if the resident was cognizant, pelvic muscle exercises and bladder retraining may be attempted. Review of the policy: Bladder Status Evaluation revised 04/28/11 revealed to obtain a baseline voiding record to determine if urine output is excessive or inadequate for three days. Initiate or update the care plan with individualized interventions for incontinence, communicate bladder and/or bowel interventions to staff and implement treatment/retraining interventions. This deficiency substantiated Complaint number OH 896.

Based on record review and interview the facility failed to adequately assess and provide care to ensure adequate and individualized pain management for Resident #116's to manage the resident's pain. Actual harm occurred when Resident #116's pain was not adequately controlled resulting in the resident voicing horrible, horrible pain and suffering which impacted her ability to eat. This affected one resident (Resident #116) of three residents reviewed for pain. Findings include: Review of the medical record for Resident #116 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pain management assessment completed on admission (08/16/17) at 9:00 P.M. revealed the resident had no pain at the time of the evaluation. The assessment asked: Does the resident receive an as needed (PRN) pain medication, yes. If yes, PRN medication in use, [MEDICATION NAME]. Is PRN medication effective, yes. Pain is relieved by: medication. Is pain management intervention necessary, no. Is change of intervention necessary, no. Pain assessment summary and rational for care plan decision, pain to remain under control. What is the resident's acceptable pain level? Document severity rating of acceptable pain and any other resident specific information related to pain tolerance, (section not completed). physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) revealed on 08/16/17 at 10:02 P.M. the resident was medicated with pain medication and indicated a pain level of 9 out of 10 (continuous severe pain at rest, severe excruciating pain with movement, worst pain that can be imagined) The nurse documented the medication was effective. At 2:52 A.M. (approximately 5 hours after last medication) the resident again rated her pain at 9 out of 10. At 7:56 A.M. (approximately 5 hours after last medication) the resident rated her pain at 8 (7-8 frequent significant pain at rest and severe pain with movement). At 2:25 P.M. (6.5 hours after last dose of pain medication) the resident again rated her pain at 9 and was given pain medication at that time. At 8:06 P.M. (5.5 hours after last dose) the resident rated her pain level at a 9 and was medicated with pain medication. Record review revealed the resident's pain level was being monitored every shift by the nurses and documented on the MAR. However, the MAR did not indicate at what time during the shift the pain was monitored. On nights: 08/16/17 score was 9, 08/17/17 score of 9, 08/18/17 score was 6, 08/19/17 score was 5, 08/20/17 score was 8, and 08/21/17 score was 3. On days: 08/17/17 score of 6, 08/18/17 score was 0, 08/19/17 score was 6, 08/20/17 score was 3, and 08/21/17 score was 3 and 08/22/17 score was 5. Record review revealed on 08/18/17 at 2:30 A.M. the as needed pain medication order was changed for the medication to be administered on a scheduled basis instead of on an as needed basis. On 08/18/17 the resident received three doses of the pain medication, at 4:00 A.M., 8:00 A.M. and 12:00 P.M. The medication was then again changed back to PRN on 08/18/17 at 12:21 P.M. There was no reason given or found in the record for the change in orders. The resident continued to require pain medication on 08/19/17 at 7:40 A.M. pain level of 7 and 12:19 P.M. pain level of 6 (5-6 moderate intermittent pain at rest moderate significant pain with movement). The nurse documented the pain medication was ineffective but there was no evidence the nurse contacted the physician or implemented any other pain relieving interventions at that time. At 5:11 P.M. the resident continued to voice her pain level was rated a 6 out of 10 and was medicated which was documented to be effective at that time. On 08/20/17 at 7:55 A.M. the resident scored her pain at 7 and the nurse documented pain medication was ineffective. However, no further intervention to control the pain was implemented at that time. On 08/22/17 at 1:12 A.M. the resident scored her pain level at 5 and again the nurse documented the medication was ineffective without further intervention to control pain. Review of the care plan developed for the resident revealed the resident had acute and chronic pain related [MEDICAL CONDITION] with a goal to not have interruption in normal activities due to pain, discomfort related to side effects of [MEDICATION NAME], verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included to administer medications as ordered and monitor for effectiveness. Encouraged to report early signs of pain. Evaluate pain level every shift using 1-10 scale. Record results and interventions taken. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Interview on 08/22/17 at 11:00 A.M. with Resident #116 revealed the resident stated she was told she should get her pain medication every three hours, then the facility changed it to every four hours. She stated she had to ask for it, they didn't just bring it. She stated she had been in horrible, horrible pain. She stated she had been suffering in pain and it shouldn't be that way. The resident stated she didn't know why it took so long for staff to bring pain medication. She stated the pain medication does help when she gets it but needs it more often than she is getting it. She stated, I can't eat when I am in pain and I need to eat. I do get nutrition through my tube so that helps. Interview on 08/22/17 at 4:05 P.M. with the Director of Nursing confirmed the pain assessment completed on admission was incomplete and did not assess the resident's acceptable pain level. She agreed the resident's pain medication was ordered that it could be given every four hours to manage the resident's pain and the medication was not given every four hours despite the resident's pain level continuing at a severe level on several occasions. She agreed the resident's pain should be addressed before it became severe and agreed there was no evidence the nurses did this as evidenced by continued severe pain score ratings as noted above. She also confirmed the medication was documented as ineffective on several occasions as noted above with no further interventions by the nurse to effectively manage the resident's pain. The DON verified there was no evidence in the record as to why the pain medication was changed to be given every four hours on a scheduled basis and then changed back to an as needed basis. She confirmed the nurses documented the resident's pain was effective or ineffective but did not state whether the pain was completely gone, somewhat better or acceptable by the resident since there was no score recorded and the resident did not have an acceptable pain level identified on the pain assessment. Review of the Pain Management Policy, dated 10/31/06 and revised on 08/31/13 revealed under the procedure: 4. Patient's receive education on the pain scale in use and the pain management plan to include interventions, pain treatment options and pain relief goals. 5. Pain is assessed at least every shift, when a patient complains of pain and after an [MEDICATION NAME] is given determine effectiveness of the [MEDICATION NAME], 9. The licensed nurse communicates the adequacy of pain management and/or changes in pain significance to the physician during the patient's length of stay. 11. Pain control measures are implemented before pain becomes severe. 16. Documentation of the effectiveness of the pain medication and documentation of the modifications performed if medication is not effective. This deficiency substantiates Complaint Number OH 067.