Every finding on record at Normandy Manor of Rocky River

Based on record review, staff interviews and review of the employee handbook, the facility failed to ensure staff did not neglect resident care due to staff sleeping while on duty. This had the potential to affect all twenty-two residents (#3, #12, #14, #15, #20, #34, #43, #46, #51, #53, #55, #57, #64, #70, #79, #116, #119, #123, #124, #128, #131, #134) residing on the 500-Hall and had the potential to affect all twenty-three residents (#8, #9, #16, #17, #26, #31, #39, #47, #58, #59, #68, #72, #80, #85, #86, #88, #97, #103, #106, #117, #125, #127, #133,) residing on the 800-Hall. The facility census was 136. Findings include: Review of the resident council meeting minutes dated 09/25/24 revealed an identified concern by Resident #17 regarding staff sleeping outside of his room with blankets. Resident #17 resided on the 800-Hall. Review of the facility Employee Handbook effective 05/01/16 revealed the facility had in place requirements of its staff to promote efficiency, productivity, and cooperation. Review of the handbook, page 28 and 29, revealed prohibited actions that would result in disciplinary actions up to and including termination of employment, including sleeping on duty. Review of email correspondence on 11/06/24 at 10:24 A.M. from the Administrator revealed a termination form dated 11/05/24 for Certified Nursing Assistant (CNA) #844 indicating she was terminated after receiving three previous disciplinary actions related to work performance. Review of the termination form revealed CNA #844 was noted to be sleeping on her hallway during the 11/04/24 shift and witnessed by the charge nurse. Interview on 11/04/24 at 8:34 A.M. with Resident #109 revealed staff slept during the night shift and even in their cars. Resident #109 revealed staff informed her that they went to their cars to sleep and would set their alarms to 6:00 A.M. to ensure they entered the building prior to shift change. Resident #109 revealed due to staff sleeping, she went without care for up to an hour at times. Interview on 11/05/24 at 6:04 A.M. with Licensed Practical Nurse (LPN) #806 revealed there were four CNA and one nurse for the 500-Hall and 800-Hall. LPN #806 revealed she caught CNA #722 asleep on the 800-Hall in a chair. LPN #806 verified the finding and appeared upset and stated, I don't work under these circumstance or conditions and all staff need to be prepared to handle their business. LPN #806 revealed she would alert the administration staff of her concerns. Observation and interview on 11/05/24 at 6:08 A.M. with CNA #722 revealed she was aware of the facility policy regarding sleeping on duty as it was listed in the employee handbook. When asked if she was caught sleeping by LPN #806, CNA #722 rolled her eyes in an upward direction indicating annoyance. CNA #722 stated she did not go to sleep on duty. Review of the facility document titled Abuse, Neglect and Exploitation reviewed 10/01/22, revealed the facility had a policy in place to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent neglect. Review of the policy revealed neglect included but not limited to failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the document revealed the facility did not implement policy. This deficiency represents non-compliance investigated under Complaint Number OH00158488.

Based on observations, resident record review, resident and family interviews, staff interviews, facility policy review, call light audit review, resident council meeting minutes review, and concern log review, the facility failed to ensure call lights were in reach for two residents (#31, #62) and also failed to ensure call lights were answered in a timely manner for eighteen residents (#6, #17, #20, #24, #27, #60, #61, #65, #68, #72, #89, #92, #94, #101, #110, #127, #133, #136). This had the potential to affect all residents residing in the facility. The facility census was 136. Findings include: 1. Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses including sepsis, hyperlipidemia, and atherosclerotic heart disease. Review of the physician orders revealed an order to encourage Resident #65 to reposition dated 10/04/24 and an order dated 10/08/24 for hoyer lift transfers at all times. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had a memory problem, was moderately impaired regarding task of daily life with inattention that was present but fluctuated and was dependent on staff for care. Review of the care plan dated 10/04/24 revealed Resident #65 was at risk for falls and had a self-care performance deficit related to limited mobility and pain. Interventions included ensure the call light was within reach, assist with transfers, require hands-on assistance including holding, lifting, and supporting trunk and limbs, and transfers of two staff with mechanical hoyer lift. Interview on 11/04/24 at 8:34 A.M. with Resident #109 revealed her call light response time were always too long. Resident #109 revealed staff would enter her room after she activated the call light, turn it off, and not return until later. Resident #109 revealed she always waited over 15 minutes. Resident #109 revealed there were never enough staff to cover staff breaks. Resident #109 revealed after activating her call light, staff didn't return until at least 45 minutes later. Observation and interview on 11/04/24 at 2:31 P.M. revealed Resident #65 was sitting in her tilt-in-space wheelchair, slouched down, leaning on her right side. Resident #65 revealed she was uncomfortable, sliding down in her wheelchair, and was feeling sick. Resident #65's daughter, who was in the room, pacing back and forth looking out the door for staff, revealed Resident #65's call light was activated 30 minutes ago. Resident #65's daughter revealed Certified Nursing Assistant (CNA) #889 came in the room, turned off the call light, and stated she would return to assist Resident #65 into bed. Resident #65's daughter revealed the resident was not feeling well, was uncomfortable in the wheelchair, and wanted to be placed in bed. Resident #65's daughter reactivated the call light. Observation on 11/04/24 at 2:40 P.M. revealed CNA #889 entered Resident #65's room and turned off the call light and left the room. Interview on 11/04/24 at 2:42 P.M. with CNA #889 revealed Resident #65's call light was turned on twice and she turned it off both times and would return when able to assist the resident. CNA #889 confirmed, verified, and acknowledged Resident #65 wanted to be placed in bed and was not feeling well. Observation on 11/04/24 at 2:45 P.M. revealed CNA #889 walked by Resident #65's room without providing assistance. Interview on 11/04/24 at 2:50 P.M. with Registered Nurse (RN) #648 revealed Resident #65's call light was activated approximately 40 minutes ago due to her not feeling well. RN #648 revealed she provided Resident #65 with Zofran at that time. RN #648 revealed Resident #65 was a two-person hoyer lift and utilized a tilt-in-space wheelchair. RN #648 revealed Resident #65 always slid down in her wheelchair and would lean towards one side. RN #648 revealed she would alert the CNA to put her in bed. RN #648 confirmed and verified Resident #65 wasn't feeling well, wanted to be placed in bed, and was positioned uncomfortably in her wheelchair. Observation on 11/04/24 at 2:58 P.M. revealed CNA #889 arrived to Resident #65's room with a hoyer lift and left it at the entrance to the door. CNA #889 was observed walking down the hall. Observation on 11/04/24 at 3:00 P.M. revealed CNA #889 and RN #648 returned to Resident #65's room and entered the room. RN #648 was observed exiting the room and continued to pass medications. Resident #65 was still observed to be sitting in her wheelchair with the transfer to bed incomplete. Observation on 11/04/24 at 3:02 P.M. revealed CNA #726 and #889 arrived at Resident #65 room to complete the hoyer transfer after approximately 1 hour of feeling sick and positioned uncomfortably in her wheelchair. CNA #726 and #889 confirmed and verified they arrived to complete the transfer at this time. Review of the call light audit report dated 11/01/24 through 11/03/24, provided by the Director of Nursing (DON) on 11/04/24 at 9:30 A.M. and confirmed and verified as accurate, revealed the following: The call light belonging to Resident #72 was activated on 11/01/24 at 8:31 P.M. and wasn't answered until 20 minutes later. The call light belonging to Resident #110 was activated on 11/01/24 at 9:48 P.M. and wasn't answered until 25 minutes later and activated again on 11/03/24 at 4:11 A.M. and wasn't answered until 26 minutes later. The call light belonging to Resident #24 was activated on 11/01/24 at 9:53 P.M. and wasn't answered until 20 minutes later and activated again on 11/02/24 at 3:04 A.M. and wasn't answered until 39 minutes later. The call light belonging to Resident #17 was activated on 11/01/24 at 10:10 P.M. and wasn't answered until 22 minutes later and activated again on 11/02/24 at 6:54 P.M. and wasn't answered until 27 minutes later. The call light belonging to Resident #60 was activated on 11/02/24 at 7:17 A.M. and wasn't answered until 29 minutes later and activated again on 11/02/24 at 10:15 A.M. and wasn't answered until 22 minutes later and activated again on 11/02/24 at 10:59 A.M. and wasn't answered until 28 minutes later and activated again on 11/02/24 at 8:39 P.M. and wasn't answered until 25 minutes later. The call light belonging to Resident #92 was activated on 11/02/24 at 8:29 A.M. and wasn't answered until 23 minutes later and activated again on 11/02/24 at 10:46 P.M. and wasn't answered until 34 minutes later. The call light belonging to Resident #133 was activated on 11/02/24 at 8:32 A.M. and wasn't answered until 22 minutes later. The call light belonging to Resident #27 was activated on 11/02/24 at 9:29 A.M. and wasn't answered until 26 minutes later. The call light belonging to Resident #6 was activated on 11/02/24 at 9:56 A.M. and wasn't answered until 24 minutes later. The call light belonging to Resident #89 was activated on 11/02/24 at 10:01 A.M. and wasn't answered until 22 minutes later. The call light belonging to Resident #61 was activated on 11/02/24 at 10:06 A.M. and wasn't answered until 35 minutes later. The call light belonging to Resident #136 was activated on 11/02/24 at 11:28 A.M. and wasn't answered until 23 minutes later and activated again on 11/02/24 at 1:42 P.M. and wasn't answered until 21 minutes later. The call light belonging to Resident #68 was activated on 11/02/24 at 2:44 P.M. and wasn't answered until 21 minutes later. The call light belonging to Resident #20 was activated on 11/02/24 at 6:52 P.M. and wasn't answered until 28 minutes later. The call light belonging to Resident #127 was activated on 11/02/24 at 9:34 P.M. and wasn't answered until 23 minutes later. The call light belonging to Resident #94 was activated on 11/02/24 at 11:29 P.M. and wasn't answered until 21 minutes later and activated again on 11/03/24 at 3:03 A.M. and wasn't answered until 33 minutes later and activated again on 11/03/24 at 3:39 A.M. and wasn't answered until 23 minutes later. The call light belonging to Resident #101 was activated on 11/02/24 at 11:29 P.M. and wasn't answered until 21 minutes later and activated again on 11/03/24 at 3:05 A.M. and wasn't answered until 28 minutes later. 2. Review of the medical record for Resident #62 revealed she was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, and anemia. Review of the physician orders revealed an order for tilt-in-space wheelchair dated 06/05/23 and two-person transfer at all times dated 06/17/24. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 9 that indicated she was alert and oriented with cognition impairment and dependent on care from staff. Review of the care plan dated 10/25/24 revealed Resident #62 had a self-care performance deficit related to limited mobility, limited balance, fatigue, and was at risk of falls. Interventions included tilt-in-space wheelchair, assist of two staff, and ensure the call light was within reach for prompt response. Observation and interview on 11/04/24 at 2:34 P.M. revealed Resident #62 call light was laying on the floor behind her wheelchair. Resident #62 revealed she needed the CNA assigned to her for help. Resident #62 revealed she could not reach her call light. Observation and interview on 11/04/24 at 2:35 P.M. with CNA #889 revealed Resident #62's call light was out of reach. CNA #889 was observed picking up the call light and stated to Resident #62 Your call light was out of reach; you wouldn't be able to reach it. CNA #889 confirmed and verified the findings. 3. Review of the medical record for Resident #31 revealed she was admitted to the facility on [DATE] with diagnoses including portal vein thrombosis, essential hypertension, and hyperlipidemia. Review of the physician orders revealed Resident #31 had an order dated 06/03/24 for transfer assist of two staff with hoyer. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had a memory problem, dependent on staff for care, and was severely impaired regarding task of daily life. Review of the care plan dated 09/26/24 for Resident #31 revealed an activities of daily living (ADL) self-care performance deficit related to limited mobility, deconditioning and was at risk for falls. Interventions included ensuring the call light was within reach, hands-on assistance and the use of a mechanical hoyer lift with two staff. Observation on 11/04/24 at 3:44 P.M. revealed Resident #31 was observed from the hall, laying in bed. The call light was wrapped around the bedrail and was hanging low to the floor and out of reach. Observation and interview on 11/04/24 at 3:44 P.M. with Licensed Practical Nurse (LPN) #710 revealed Resident #31 required assistance from staff for all care and call light was to remain in reach at all times. LPN #710 revealed Resident #31 was unable to engage in conversation and staff were to complete rounds to ensure safety. LPN #710 confirmed and verified Resident #31 call light was not within reach. Review of the resident council meeting minutes dated 08/21/24 revealed an identified concern by Resident #86 related to long call lights on the weekends. Review of the concern log dated 09/30/24 revealed an identified concern by Resident #17 related to call lights. Review of the facility document titled Call Lights: Accessibility and Timely Response reviewed 04/01/22, revealed the facility had a policy in place to ensure the facility was adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Review of the policy revealed call lights would be directly relayed to a staff member or centralized location to ensure an appropriate response and staff would ensure the call light was within reach of resident and secured, as needed. Further review of the policy revealed a procedure was in place that required staff to answer a call light, turn off the signal and respond accordingly, and if assistance was needed, keep the call light on until help arrived. This deficiency represents non-compliance investigated under Complaint Number OH00158808 and Complaint Number OH00158488.

Based on record review and interview, the facility failed to timely notify Resident #146's physician or nurse practitioner (NP) regarding the resident's decreased oral intake. This affected one resident (#146) of three residents reviewed for notification of change. The facility census was 136. Findings include: Review of Resident #146's medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including cerebral infarction, unspecified dementia, hypothyroidism and major depressive disorder. Review of Resident #146's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment; the resident had not had a weight loss or weight gain. Review of Resident #146's weight tracking form revealed on 05/02/24 the resident weighed 147.8 pounds in a wheelchair and on 09/05/24 the resident weighed 148 pounds in a wheelchair. Review of Resident #146's physician orders revealed an order dated 04/24/24 (discontinued 05/20/24) for a no concentrated carbohydrates diet, mechanical soft texture with a thin liquid consistency. Review of Resident #146's Documentation Survey Report (nurse aide tracking form) from 09/01/24 to 09/20/24 revealed 45 entries were documented and the resident consumed 25% of eleven meals, 50% of ten meals, 75% of fifteen meals, 100% of no meals and refused nine meals. The documentation on the report form indicated on 09/16/24 the resident refused the breakfast, lunch and dinner meal and on 09/17/24 the resident refused the breakfast meal for a total of four meals at 25% or less consumed. The documentation from 09/16/24 for breakfast, lunch and dinner and 09/17/24 for breakfast revealed the resident refused fluids. Review of Resident #146's physician orders revealed an order dated 05/20/24 (discontinued 09/26/24) for a no concentrated carbohydrates diet, regular texture, thin liquids consistency. Review of Resident #146's Functional Abilities and Goals assessment dated [DATE] revealed the resident had no impairment on the upper extremity (shoulder, elbow, wrist, hand) and required setup or clean-up assistance to use suitable utensils to bring food and/or liquids to the mouth and swallow food and/or liquid once the meal was placed in front of the resident. Review of Resident #146's Nutrition Assessment form dated 08/17/24 revealed the resident was on a no concentrated sweets regular thin liquids diet and the snacking preference was cookies. The resident was independent with eating. Review of Resident #146's physician orders revealed an order dated 09/16/24 (discontinued 09/20/24) for a no concentrated carbohydrates diet, mechanical soft texture with a thin liquid consistency. Review of Resident #146's progress note dated 09/16/24 at 9:39 A.M. revealed the resident consumed soft foods effectively and the resident's diet was downgraded to mechanical soft and ground meats. Review of Resident #146's progress note dated 09/16/24 at 2:04 P.M. revealed the resident consumed 25% of breakfast and lunch and consumed a total of 480 ml (milliliters) of fluids with breakfast and lunch. Review of Resident #146's progress note dated 09/16/24 at 2:06 P.M. revealed to continue to encourage the resident's fluid intake. Review of Resident #146's progress note dated 09/16/24 at 6:21 P.M. revealed the resident consumed two bowls of fruit and 360 ml of water. Resident #146's medical record and progress notes did not have documentation for the breakfast meal on 09/17/24 except the resident refused the meal and fluids. Review of Resident #146's progress notes did not reveal evidence the physician/NP were notified of Resident #146's decreased oral intake which included 25% for the breakfast, lunch and dinner meals on 09/16/24 with a total of 840 ml of fluids (for all three meals) and no fluids or food consumed for the breakfast meal on 09/17/24 as evidenced by the documentation in the medical record. Review of Resident #146's Multidisciplinary Care Conference form dated 09/17/24 at 3:30 P.M. (with the resident's nephew by phone) revealed the facility was working on the resident's hands to get them less tight using a splint for the lower tightness and the resident was now a feed for all meals. A conversation was held discussing hospice services. Review of Resident #146's medical record and progress note dated 09/19/24 at 6:27 P.M. revealed the resident did not eat her dinner and refused to open her mouth. Staff would continue to monitor. Review of Resident #146's speech therapy (ST) Discharge Summary form dated 09/19/24 revealed the resident was discharged from ST due to hospitalization . The form indicated instruction was provided to the resident and primary caregivers in cognitive-communicative strategies and functional memory techniques in order to facilitate improved functional abilities, increase safety and decrease need for assistance and prevent decline from current level of skill performance with carryover demonstrated. Review of Resident #146's physician orders revealed an order dated 09/20/24 for a pureed food diet with regular thin liquids. Interview on 1/05/24 at 9:26 A.M. with NP #897 revealed she was notified of Resident #146's change in condition on 09/19/24. She confirmed she was in the building on 09/17/24 and staff did not notify her of concerns in Resident #146's care. Interview on 11/06/24 at 11:43 A.M. with the Administrator confirmed the documentation revealed Resident #146 refused the breakfast meal on 09/17/24. The Administrator indicated she had only refused one meal in sequence but consumed 25% of the breakfast, lunch and dinner on 09/16/24 for a total of four meals at 25% or less consumed. Interview on 11/06/24 at 11:56 P.M. with the Administrator and Director of Nursing (DON) confirmed Resident #146's son was aware of the resident's poor appetite. The Administrator and DON indicated the resident had consumed 840 ml fluids between 09/16/24 for breakfast, lunch and dinner and 09/17/24 for the breakfast meal and stated the NP was made aware of the resident's poor appetite on 09/19/24. Interview on 11/06/24 at 12:22 P.M. with the Administrator indicated on 9/17/24 occupational therapy (OT) worked with the resident. Interviews on 11/06/24 at 12:29 P.M. with OT #899 and Physical Therapy Assist (PTA)/Rehab Director #900 confirmed OT #899 assisted Resident #146 with the lunch meal on 09/17/24 and she had consumed approximately 25% to 50% of her meal. She stated the resident was a maximum assist with meals and she did have increased pocketing and needed more cues for swallowing. Review of the Notification of Changes policy revised 09/30/22 revealed the purpose of the police was to ensure the facility promptly informed the resident, consults the resident's physician; and notifies the resident's representative of a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00158595.

Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) were consistently implemented for Resident #67. This affected one (#67) of one resident reviewed for EPB. The facility identified 27 additional residents (#2, #9, #12, #14, #16, #27, #32, #33, #36, #44, #50, #54, #59, #60, #63, #76, #79, #80, #82, #101, #105, #107, #108, #118, #123, #126, and #127) on EBP. Additionally, the facility failed to ensure hand hygiene was performed following resident care. This affected two (#73 and #85) of two residents reviewed for personal care. The facility census was 127. Findings include: Record review for Resident #67 revealed an admitted [DATE]. Diagnoses included gastrostomy status. Review of the Admission Minimum Data Set (MDS) assessment, dated 06/07/24, revealed Resident #67 was cognitively intact. Resident #67 was dependent for toileting, bathing, personal hygiene and was always incontinent of bowel and bladder. Resident #67 had medically complex conditions and had a feeding tube. Review of a physician order, dated 06/01/24, revealed EBP - gloves and gown to be worn when providing: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and/or wound care (any skin opening requiring a dressing). Review of a physician order dated 07/23/24 revealed an order to cleanse gastrostomy (g)-tube site with normal saline (NS), pat dry and cover with dry split gauze daily and as needed. Review of the care plan, 06/03/24, revealed Resident #67 was on EBP related to a feeding tube and included gloves and gown to be worn when providing the following: dressing, bathing/showering, transferring, hygiene assistance, changing linens, incontinence care, toileting and device care or use. Observation on 08/22/24 at 9:00 A.M. of g-tube site care and treatment with Licensed Practical Nurse (LPN) #272 revealed Resident #67 had a sign near the entrance door to the room revealing the resident was on EBP. There was an isolation cart with personal protective equipment (PPE) near the entrance of the door. Continued observation revealed LPN #272 gathered the supplies to complete the dressing change to Resident #67's g-tube site. LPN #272 entered Resident #67's room without donning an isolation gown. LPN #272 proceeded to remove the old dressing, cleanse the g-tube site, applied new dressing and washed her hands. Concurrent interview with LPN #272 verified Resident #67 was on EBP and confirmed she did not wear an isolation gown while providing care, including the dressing change to Resident #67 g-tube site. LPN #272 stated, Well that's just a state thing. Interview on 08/22/24 at 10:37 A.M. with Resident #67 revealed staff do not wear a gown when they assist him with personal care. 2. Record review for Resident #85 revealed an admitted [DATE]. Diagnoses included pleural effusion and muscle weakness. Review of the Medicare five-day MDS assessment, dated 07/17/24, revealed Resident #85 was cognitively intact. Resident #85 was dependent for toileting, hygiene and was frequently incontinent of bowel. Observation on 08/22/24 at 9:36 A.M. of toileting assistance for Resident #85 provided by State tested Nursing Assistant (STNA) #277 revealed Resident #85 was sitting on the toilet when STNA #277 entered the resident's room. STNA #277 donned a pair of disposable gloves, assisted Resident #85 with standing and proceeded to provide perineal (peri) care for Resident #85, following a bowel movement. STNA #277 pulled Resident #85's brief and pants up and assisted the resident to a chair near her bed. STNA #277 then removed her gloves, gathered dishes from Resident #85's bedside table and took the dishes to the kitchenette area. Concurrent interview with STNA #277 verified she did not perform hand hygiene, either by washing her hands or using hand sanitizer, after providing peri care to Resident #85 or prior to leaving the resident's room. Interview on 08/22/24 at 9:48 A.M. with the Director of Nursing (DON) revealed after doing peri care, staff should wash their hands or use hand sanitizer before leaving the room. 3. Record review for Resident #73 revealed an admitted [DATE]. Diagnoses included epilepsy and need for assistance with personal care. Review of the quarterly MDS assessment, dated 07/10/24, revealed Resident #73 was cognitively intact. Resident #73 was dependent for toileting and required substantial/maximum assist for personal hygiene. Resident #73 was always incontinent of bowel and bladder. Observation on 08/22/24 at 10:11 A.M. of incontinence care provided by STNA #341 for Resident # 73 revealed STNA #341 provided care, removed her gloves, then exited Resident #73's room, without performing hand hygiene. Continued observation revealed STNA #341 walked up the hall and entered another resident's room. Upon exit from the the other resident's room, interview with STNA #341 revealed she did not provide care for the resident. STNA #341 verified she did not wash her hands or use hand sanitizer after providing incontinence care for Resident #73 or prior to exiting Resident #73's room. Review of the facility policy titled, Enhanced Barrier Precautions, revised 07/13/22, revealed it was the policy of the facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multi drug-resistant organisms. Implementation of enhanced barrier precautions included making gowns and gloves available outside the resident's room and was used for high-contact resident care activities to include dressing, bathing, transferring, hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. Review of the facility policy titled, Perineal Care, revised 11/10/22, revealed prior to providing care, perform hand hygiene and put on gloves. After completion of peri care, remove gloves and discard. Perform hand hygiene. Ensure call light is within reach and replace all equipment used.

Based on observation, staff interview, and review of the facility policy, the facility failed to maintain a clean and sanitary dumpster area. This had the potential to affect all of the residents residing in the facility. The facility census was 126 residents. Findings include: Observation on 07/08/24 at 9:02 A.M. with Dietary Director (DD) #470 of facility dumpster area behind the kitchen revealed there were two dumpsters. The sliding doors on the sides of both dumpsters were open with a significant amount of garbage and debris on the ground outside the dumpsters and in the surrounding brush. There was an unpleasant odor emanating from the dumpster. Interview on 07/08/24 at 9:03 A.M. with DD#470 confirmed maintaining the dumpster area was a shared responsibility with grounds and kitchen staff. DD#470 confirmed the dumpster area was not maintained in a clean and sanitary manner. Review of facility policy titled Garbage Removal and Dumpster undated revealed the dumpster would have a tight fitting lid and slide doors and would be kept covered at all times. This deficiency represents noncompliance investigated under Complaint Number OH00155054.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure physician's orders were followed regarding dressing changes for an enteral tube feeding site. This affected one (Resident #67) of one reviewed for enteral nutrition. The facility identified two Residents (#67 and #378) as receiving enteral nutrition feedings. The facility census was 126 residents. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including left non-dominant sided hemiplegia and hemiparesis, cerebral infarction, difficulty walking, dysphagia, gastrostomy status, aphasia, and enterocolitis due to clostridium difficile. Review of the physician's orders for Resident #67 revealed an order dated 06/01/24 revealed the resident to receive nothing by mouth (NPO) and was to receive continuous enteral feeding to meet nutrition and hydration needs. Review of the physician's order dated 06/13/24 revealed Resident #67's percutaneous endoscopic gastrostomy (PEG) tube site should be cleaned and covered with a dry dressing daily and as needed. Observation on 07/09/24 at 8:04 A.M. revealed Resident #67 had two Styrofoam cups of water on his bedside tray table. Resident #67 had a dressing to his PEG tube site which was dated 07/07/24. Interview on 07/09/24 with Resident #67 confirmed staff regularly leave water on his tray table and reported he was not supposed to have it. Resident #67 also confirmed nursing staff did not change his PEG tube dressing daily as ordered by the physician. Interview on 07/09/24 at 8:18 A.M. with Licensed Practical Nurse (LPN) #473 confirmed Resident #67 had an NPO diet order and had cups of water at his bedside. LPN #473 further confirmed the cups of water should be removed, and she requested State tested Nursing Assistant (STNA) #496 remove the water from the resident's bedside table. LPN #473 confirmed Resident #67's PEG tube dressing was dated 07/07/24, and the dressing should be changed daily. Review of facility policy titled Care and Treatment of Feeding Tubes dated 11/14/22 revealed feeding tubes will be utilized according to physician's orders.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure baseline care plans were developed and failed to ensure summaries of the baseline care plan were provided to the residents and/or their representatives. This affected two (Residents #120 and #67) out two residents who were reviewed for baseline care plans. The facility census was 126 residents. Findings include: 1. Review of the medical record for Resident #120 revealed admitted [DATE] and diagnoses including sepsis due to streptococcus pneumoniae, aphasia, and dysarthria. Review of the admission Minimum Data Set (MDS) assessment for Resident #120 dated 06/01/24 revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADLs.) Review of the medical record for Resident #120 revealed it did not include a baseline care plan. Interview on 07/11/24 at 1:04 P.M. with MDS Nurse #508 confirmed the facility had not completed a baseline care plan for Resident #120. 2. Review of the medical record for Resident #67 revealed admitted [DATE] and diagnoses including left non-dominant sided hemiplegia and hemiparesis, cerebral infarction, difficulty walking, gastrostomy status, aphasia, and enterocolitis due to clostridium difficile. Review of the admission MDS assessment dated [DATE] revealed Resident #67 had intact cognition and was dependent on staff for ADLs. Review of the medical record for Resident #67 revealed it did not include a baseline care plan. Interview on 07/11/24 at 1:08 P.M. with MDS Nurse #508 confirmed the facility had not completed a baseline care plan for Resident #67. Review of the facility policy titled Baseline Care Plan revealed a baseline care plan would be developed within 48 hours of a resident's admission which would include minimum care planning information. A written summary of the baseline care plan would be provided to the resident and representative in a language that the resident/representative would understand.

Based on medical record reviews, observations, family interview, staff interviews, and policy review the facility failed to ensure adequate fall interventions were in place to promote resident safety and prevent falls. Actual harm occurred on 12/05/23 when Resident #120, who was severely cognitively impaired and assessed at risk for falls, sustained an unwitnessed fall from a bed that was not in low position resulting in increased pain and hospitalization for traumatic sacral fractures with presacral edema and lumbar one and four compression fractures. The resident was not a candidate for invasive procedures and returned to the facility with hospice consultation orders. This affected three residents (#2, #88 and #120) of three residents reviewed for falls. The facility census was 117. Findings include: 1. Review of Resident #120's medical record revealed an admitted [DATE], a re-admitted [DATE] and a discharge date of [DATE]. Diagnosis included unspecified dementia, chronic atrial fibrillation, difficulty in walking, muscle weakness, need for assistants with personal care, and cognitive communication deficit. Review of the Morse Fall Scale completed on 12/19/22 revealed Resident #120 was at high risk for falls. Review of the care plan dated initiated 12/20/22 revealed Resident #120 was at risk for falls related to confusion, reconditioning, gait/balance problems, unaware of safety needs, history of falls and cognitive impairment. Interventions included reminder sign, Dycem in front of recliner, anticipate and meet the resident needs, assist with ambulation, transfer, and toileting, call light in reach and non-skid socks as ordered. Review of the care plan revealed there was no intervention in place for Resident #120 to have the bed in lowest position while in bed. Review of an incident note dated 01/02/23 at 5:54 P.M., completed by Registered Nurse (RN) #273 revealed this nurse was alerted by the aide that the resident was on the floor. The resident was observed sitting on her buttocks with back up against the recliner. Following the incident, a Dycem was applied to the recliner as a fall/safety intervention. Review of a progress note for Resident #120 dated 01/13/23 at 6:42 A.M., completed by Licensed Practical Nurse (LPN) #257 revealed this nurse was alerted by resident calling out that she needed help and that she was on the floor. Upon entry into the room, the resident observed sitting straight up on the side of the bed, back towards nightstand, knees bent, when asked what happened, she stated she was trying to go to the bathroom and forgot to utilize call button. Following the incident, the interdisciplinary team (IDT) met and identified the resident stated she was trying to go to the bathroom and forgot to use the call light. A reminder sign was placed for the resident to ensure use of call system for help. Review of the Morse Fall Scale completed on 01/13/23, 04/18/23, and 07/19/23 revealed Resident #120 was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was severely cognitively impaired. Review of the All Staff Inservice dated 11/17/23 included staff were educated to be sure Resident #120's bed was in the lowest position after you are done providing care. The All Staff Inservice was signed by four LPN's and ten State tested Nursing Assistants (STNA). Record review revealed no evidence the resident's plan of care was updated following this inservice to reflect the bed position as an intervention for falls/safety for the resident. Review of a progress note dated 12/05/23 at 2:48 P.M., for Resident #120 completed by Registered Nurse (RN) #258 revealed Resident #120 was found lying on her back on the floor between her bed and her nightstand. Housekeeper #346 informed RN #258, Housekeeper #346 stated she had heard a Slap sound and then heard someone calling out. Resident #120 was crying at the moment and expressing she was in pain. An x-ray was ordered. On 12/05/23 at 3:49 P.M., Resident #120 had a change in mental status with more confusion post fall. The Certified Nurse Practitioner (CNP) was notified, and Resident #120 was sent to the emergency room (ER). Review of the hospital record for Resident #120 dated 12/06/23 at 10:06 A.M. revealed the status post fall, traumatic sacral fractures with presacral edema, lumbar one and four compression fractures, and a suspected type two myocardial infarction. Resident #120 was not a candidate for any invasive procedure and was referred to Hospice. Review of the progress note dated 12/08/23 at 12:00 P.M., completed by LPN #354 revealed Resident #120 returned to the facility. Hospice was in to evaluate patient. Review of the physician orders for Resident #120 dated 12/08/23 revealed Morphine Sulfate 0.25 milligrams (mg) to five mg every two hours as needed for pain. On 12/09/23, Resident #120 received additional orders for Tramadol 50 mg every six hours as needed for pain. Review of the Medication Administration Record for December 2023 revealed prior to Resident #120's fall on 12/05/23, Resident #120's only pain medication order was for Tylenol 325 mg as needed for pain which was not used prior to the fall on 12/05/23. After returning from the hospital on 12/08/23 Resident #120 required 20 doses of narcotic pain medication rating her pain a two to a nine level (on a scale of one to 10 with 10 being the most severe pain) prior to passing away on 12/15/23. Review of the progress note dated 12/15/23 at 2:00 P.M., revealed the son came and got nurse and stated that his mom had passed. Two nurses verified resident absence of vital signs. Interview on 02/06/24 at 3:34 P.M., with Resident #120's son revealed he visited his mother, daily over the past year while she resided at the facility. Resident #120's son revealed Resident #120 was confused and had already had two falls at the facility when he met with the Administrator, DON, and the Unit Manager to request her bed be placed in the lowest position while she was in bed. He feared if she fell out of bed at a routine bed height, she could be seriously injured. Resident #120's son revealed the Administrator, DON, and the Unit Manager assured him the bed would be placed in the lowest position while she was in bed. On multiple visits he stated he would find Resident #120's bed was not in the lowest position while she was in bed. Resident #120's son revealed he continued to meet with the Administrator, DON, and the Unit Manager on multiple occasions who consistently assured him the bed would be placed in the lowest position while she was in bed. Resident #120's son revealed facility staff who found Resident #120 on the floor on 12/05/23 confirmed her bed was not lowered when she was left unattended and fell out of bed resulting in multiple fractures. Interview on 02/07/24 between 2:45 P.M. and 4:40 P.M., with the DON, Administrator, and Unit Manager confirmed Resident #120's son had spoken with each of them on a few different occasions regarding his concerns of her bed being placed too high with concerns of her falling out of bed. The DON confirmed the facility used electric beds, the beds were able to raise and lower by using a remote control. During care, staff would raise the bed but were to lower it when care was complete. The DON revealed Resident #120's bed was to be in a low position while she was in bed unattended. The DON revealed staff were in-service to keep Resident #120's bed in a low position. The DON confirmed the low bed intervention was not placed in Resident #120's care plan and revealed he had met with the Interdisciplinary Team on several occasions, discussed the concern of staff not keeping her bed in the low position in morning meetings several different times and the MDS nurse who was present during those meetings was supposed to put the intervention in the care plan but never did. The DON stated if the resident was at risk for falls then the beds should always be in the lowest position when unattended by staff. The DON confirmed the MDS nurse at that time was no longer employed at the facility. The DON confirmed he was also able to add interventions to the care plans. Interview on 02/07/24 at 3:54 P.M., with Housekeeper #346 revealed she was the first one in the room after Resident #120 fell out of bed on 12/05/23. Housekeeper #346 revealed she heard Resident #120 screaming as she was talking to Housekeeping Supervisor #243 in the hall. They both started walking and went into Resident #120's room. Resident #120 was on the floor between the bed and nightstand. Housekeeper #346 revealed Resident #120's bed was not in any low position when she found her on the floor. Interview on 02/07/24 at 3:57 P.M., with Housekeeping Supervisor # 243 revealed she was with Housekeeper #346 when they heard someone screaming. They went into Resident #120's room and could see she had fallen; she was lying on the floor between the bed and nightstand, no one else was there. Housekeeping Supervisor #243 revealed Resident #120's bed was at regular height, not in the low position. Interview on 02/08/24 at 10:14 P.M., with RN #258 confirmed she was the charge nurse on 12/05/23 when Resident #120 fell out of bed. Housekeeping notified her of the fall. RN #258 revealed she remembered seeing Resident #120 lying on her back next to her bed. Resident #120 said she was in a lot of pain. RN #258 revealed Resident #120's bed was not in the low position; it was standard position a resident would use if they transferred themselves in an out of bed. RN #258 revealed she was not aware Resident #120's bed was supposed to be in a low position and revealed, It was not in her care plan. Interview on 02/08/24 at 10:55 A.M., with LPN Unit Manager (UM) #361 confirmed Resident #120's son spoke with her a couple times about Resident #120's bed needing to be in low position. LPN UM #361 revealed she in serviced staff several times about it. LPN UM #361 confirmed the All Staff Inservice in November 2023 was not signed by RN #258. LPN UM #361 confirmed not all the staff were in serviced and the intervention was not placed on the resident's care plan. 2. Review of Resident #88's medical record revealed an admitted [DATE]. Diagnosis included Alzheimer's disease with early onset, abnormal posture, and transient cerebral ischemic attack. Review of the quarterly MDS dated [DATE] revealed Resident #88 was severely cognitively impaired. Resident #88 required substantial to maximum assistants with care. Resident #88 had a history of falls. Review of the care plan for Resident #88 revealed Resident #88 was at risk for falls related to diabetes mellitus, hypertension, psychoactive drug use, and needs staff assist for transfers. Interventions included bolstering to exit side of bed. Review of the care plan revealed no interventions were in place to have the bed in low position while in bed. Record review of the physician orders for Resident #88 revealed an order dated 04/16/21 for bolster to exit side of bed. Observation on 02/06/24 at 2:55 P.M., revealed Resident #88 was lying in bed. Observation revealed Resident #88's bed was not in a low position. Resident #88 did not have a bolster in place to the exit side of the bed. LPN #354 verified Resident #88's bed was not in a low position and revealed Resident #88 was at risk for falls and the bed should be in the lowest position while she was in bed. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #88 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON stated Resident #88 did not have the intervention for a low bed in her care plan. Observation on 02/08/24 at 2:37 P.M., revealed Resident #88 was lying in bed. Observation revealed the bed was not in low position and there was no bolster on the bed Resident #88 was lying in. Interview and observation on 02/08/24 between 2:38 P.M. and 2:40 P.M., with RN #379 and LPN #277 confirmed Resident #88's bed was not in low position but should be because she was at risk for falls and confirmed Resident #88 did not have a bolster to the exit side of the bed and should have had one at all times while in bed to assist in preventing falls. 3. Review for Resident #2's medical record revealed an admitted [DATE]. Diagnosis included anxiety disorder, difficulty in walking, muscle weakness, lack of coordination, repeated falls, unspecified fall subsequent encounter subluxation of cervical four and five vertebrae, sequela. Record review of the Quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired. Resident #2 required substantial maximum assist for sitting to stand, transfers, and ambulation. Review of the care plan on 02/07/24 for Resident #2 dated 08/30/23 revealed Resident was at risk for falls related to confusion, deconditioning, gait balance problems and a history of falls. Interventions included assessing the resident for fall risk upon admission, quarterly and as needed. Assist with ambulation, transfer, toileting as needed, and to be sure the residents call light was within reach and encourage the resident to use it for assistants as needed. Review of the care plan on 02/07/24 revealed there was no intervention in the care plan to have the bed in the low position well in bed. Review of the care plan revealed interventions were added to included bed in lowest position while occupied added 02/09/23. Review of the progress note for Resident #2 dated 12/24/23 at 3:36 A.M., completed by LPN #403 revealed a State tested Nurse Aides (STNA) informed this nurse (Resident #2) was found lying the left side of her bed on the floor, this nurse entered resident, noted floor clear from clutter, bed placed in lowest position, approached the resident, this nurse noted resident positioned on her right side on the side of her bed, this nurse asked Resident #2 what happened, resident stated she rolled out of bed. Intervention for resident rolling out of bed would be placing a floor mat on each side of the bed. Review of the progress note for Resident #2 dated 01/07/24 at 1:17 P.M., completed by Registered Nurse (RN) #336 revealed a fall occurred in the resident's room. The reason for the fall was not evident. The resident was up in wheelchair for breakfast, she did not want to stay up in wheelchair and attempted to transfer to bed unassisted. Review of the progress note for Resident #2 dated 01/12/24 at 1:36 P.M., completed by Unit Manager #361 revealed the IDT team reviewed the resident's fall. Resident #2 has had an increase of restlessness in the past couple weeks. Resident was found on floor in room, wheelchair located behind resident. Immediate intervention was resident was assessed for injury, pain and neuro checks initiated. When asked by the staff what she was doing resident stated that she was trying to get back into bed. At the time of fall, the resident is currently being seen by therapy for Part B services. With resident's gradual decline there is an order for a hospice consult. Due to resident's decline, there will be a move room closer to nursing station. Staff educated on ensuring that resident's wheelchair brakes are locked before leaving room. Review of the progress note for Resident #2 dated 01/16/24 at 1:43 P.M., completed by Unit Manager #361 revealed the IDT team reviewed resident's fall. The resident was found on the floor in a room. The resident was unable to clearly state what she was doing. She stated that they moved my room, and they did not come back to make my bed. Immediate intervention for fall was assessed for injury, pain, neuro checks initiated. No apparent injury noted at time of fall no complaints of pain noted. Immediate intervention was provided new intervention for this fall is bolster overlay mattress. Observation on 02/06/23 at 1:57 P.M., revealed Resident #2 was in bed eating her lunch. The bed was not in a low position and a bed bolster was observed. Unit Manager #361 verified the bed was not in a low position and stated it should have been. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #2 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON confirmed Resident #2 did not have the intervention for a low bed in her care plan. Observation on 02/12/24 at 3:00 P.M. revealed Resident #2 was lying in bed. Resident #2's bed was not in the lowest position, but the bed bolster mattress was in place. Observation and interview on 02/12/24 at 3:01 P.M., with RN #258 confirmed Resident #2's bed was not in the lowest position and confirmed bed should be in the lowest position if resident at risk for fall. Review of the policy titled, Fall Prevention and Management Policy, dated 04/01/22, revealed each resident will be assessed for fall risk on admission, quarterly, after any fall and as needed. If risks are identified, preventive measures will be put in place and added to the resident's care plan. All falls will be reviewed and investigated. This deficiency represents non-compliance investigated under Complaint Number OH00150460 and OH00149914.

Based on observation, record review, resident interview, Ombudsman interview, and staff interviews, the facility failed to deliver all of residents mail to them and or their authorized representative. The facility also failed to provide residents mail to them unopened. This affected five (#10, #36, #97, #122, and #123) of five reviewed for mail and had the potential to affect all residents. The facility census was 117. Findings include: 1. Review for Resident #97's medical record revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #97 revealed Resident #97 was cognitively intact. Interview on 02/06/24 at 3:04 P.M., with Resident #97 revealed she received her mail the previous day delivered by an Activities Assistant #262. Resident #97 revealed she received four envelopes of mail and one of the envelopes was opened prior to her receiving it. Resident #97 grabbed the four envelopes. One of the four envelopes were opened. The envelope opened had Resident #97's full name on the top line of the envelope. Under her name was the facility name then the facility address. The sender was a bank. Resident #97 removed the paper inside the envelope which was a non-negotiable check with Resident #97's name on it. Resident #97 revealed this was very upsetting, the facility should not be opening her mail. Interview on 02/06/24 at 3:38 P.M., with Activities Director #262 revealed the receptionist separates the mail. The resident's business mail goes to the business office and the resident's personal letters goes to the activities department to be delivered. Activities Director #262 revealed she had seen resident's mail opened prior to giving it to the residents. Interview on 02/06/24 at 3:47 P.M., with Business Office Manger (BOM) #275 revealed she received all resident's business mail. If the mail had anything from the payment distribution center, she opened it because a lot of families members would pay the resident's bill with a check. If anything was from Medicaid she opened it to verify the check list verification mailed to the resident. If it was from a bank and looked like a check she opened it to see what was inside or if it just looked like a bank statement, she usually would just filed it in the file cabinet. BOM #275 revealed she use to give residents the bank statements in the past but usually they just said file them, so now she just filed them all without asking the resident. BOM #275 revealed she did open Resident #97's mail because it was from a bank and had a payment distribution on it. BOM #275 stated if any mail to any resident had the facility name on the envelope anywhere, even under the resident name, that was considered distribution, so she had the right to open it. BOM #275 revealed that was what she was told by the Regional BOM, she said if it looks like a check, open it. BOM #275 revealed she had been in the position of BOM for over a month and had been opening resident's mail the whole time. Interview on 02/06/24 at 3:57 P.M., with Director of Social Services #304 revealed the resident has the right to receive mail unopened. Director of Social Services #304 revealed she had not received concerns from residents receiving unopened mail until this day. Interview on 02/06/24 at 4:10 P.M., with Administrator revealed the resident has the right to receive all of their mail and mail unopened. Administrator verified all residents received mail at the facility. Phone interview on 02/07/24 at 8:30 A.M., with Ombudsman #401 revealed she had concerns which included the Business Office Manager (BOM) not giving resident's their bank statements or billing statements. Ombudsman #401 revealed she spoke with three residents who verified this but only one, Resident #97 gave permission to release their name. Ombudsman #401 revealed she had many concerns with the BOM at the facility. Interview and record review on 02/07/24 at 10:38 A.M., with BOM #275 revealed a large filing cabinet in the office. BOM #275 opened the top drawer and revealed this was where she placed all resident's mail opened or unopened that was not going to be delivered. Observation revealed multiple files with resident's names in alphabetic order. BOM #275 removed four random files, Resident #10 had an unopened letter from an unknown source with his name on the top line of the letter, Former Resident #122 had multiple envelopes with some from Care Source/Centers for Medicaid and Medicare unopened. Resident #36 had a statement from Care Source unopened. Former Resident #123 had an unopened envelope from personal insurance company. BOM #275 revealed all residents residing in the memory care unit has all their mail automatically filed, none was to be delivered. BOM #275 revealed Activities will make one attempt to deliver mail to all other residents, if the resident is not there, the mail is returned to her and she filed it. There was no second attempt or notification made to the resident regarding their mail. Interview on 02/07/24 at 10:45 A.M., with Resident #10 revealed he wanted all his mail, he was never told he was not receiving any mail, the post office delivered mail no matter what, so he was not worried. Interview on 02/07/24 at 2:13 P.M., with Regional Business Office Manager (BOM) #402 revealed if the facility's name is on any letter, anywhere on the envelope, that gives the facility permission to open the mail. Regional BOM revealed it was not a policy, it is just something she was told. Review of the policy titled, Resident Rights dated 04/04/22, revealed the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than postal service, including the right to privacy of such communications consistent with this section. This deficiency represents an incidental finding investigated under Master Complaint Number OH00150460, and Complaint Numbers OH00150319, OH00150244, and OH00149914.

Based on record review, resident interview, Ombudsman interview and staff interview, the facility failed to provide timely monthly billing statements to a resident for care and services. This affected one (#97) of three residents reviewed for monthly billing statements. The facility census was 117. Findings include: Review of Resident #97's medical record revealed an admitted [DATE]. Record review of diagnoses included congestive heart failure and collapsed vertebrae. Record review of the census form revealed from 06/09/23 through 09/20/23 Resident #97 was private pay. Resident #97 had a hospital stay from 09/20/23 and returned to the facility on [DATE] under Managed Care. On 12/04/23, Resident #97 was again private pay. Review of the quarterly Minimum Data Set (MDS) for Resident #97 revealed Resident #97 was cognitively intact. Resident #97 had no impairment of upper or lower extremities. Resident used a wheelchair for mobility. Review of the form titled, Rescinded 30-day discharge for (Resident #97) dated 01/26/24, completed by Business Office Manager (BOM) #275 revealed this was a formal notice that the 30-day discharge notice had been rescinded. The decision had been based on the check received the morning of 01/26/24. Payments moving forward are made by the fifth of every month. Interview on 02/06/24 at 3:04 P.M., with Resident #97 revealed she got a letter from BOM #275 the previous week after she paid $6,700.00 dollars which rescinded the 30-day notice. Resident #97 was holding the Rescinded 30-day discharge notice in her hand and revealed she nor her brother received a bill from the facility for the previous six months so she thought the insurance company must have been paying the bill until the previous Administrator and BOM #275 went in her room demanding payment. Resident #97 revealed the previous Administrator confirmed her bill was not sent out for six months because one of the girls from the business office was let go. So now, Resident #97 owed $29,000.00 that must be paid within 30 days or she will put you out in the streets. Resident #97 revealed BOM #275 stated I hate to do it, but we will have to unless the bill is paid. Resident #97 revealed they were going to charge a $500.00 a month late fee but they decided to remove it. Interview on 02/06/24 at 3:47 P.M., with BOM #275 revealed the previous BOM did not bill Resident #97 for an undetermined amount of time, for several months the bills were processed but was not given to Resident #97 or her brother. BOM #275 revealed she did have words with Resident #97 regarding a 30-day notice, but she never actually gave her a written 30-day notice. BOM #275 revealed late fees for $500.00 per month were removed for the months Resident #97 did not receive a bill. BOM #275 revealed Resident #97 told the Ombudsman the facility gave her a 30-day notice, so the Ombudsman suggested they gave Resident #97 a letter rescinding the notice. BOM #275 confirmed Resident #97 did not receive a bill from the facility during the six-month period until discussing her bill and 30-day notice with her. Review with BOM #275 of requested billing statements for Resident #97's previous six months billing revealed a billing statement dated 10/01/23 which had a due date of 10/05/23 and a billing statement of 01/01/24 with a due date of 01/05/24. BOM #275 revealed those were the only two statements available. BOM #275 confirmed Resident #97 did not receive any bill from the facility for the previous six months including the billing statement dated 10/05/23 because it had been misplaced. Phone interview on 02/07/24 at 8:30 A.M., with Ombudsman #401 revealed she had concerns which included the Business Office Manager (BOM) not giving residents their bank statements or billing statements. Ombudsman #401 revealed she spoke with three residents who verified this but only one (#97) gave permission to release their name. Ombudsman #97 revealed she did not tell anyone at the facility to give a retraction of a 30-day notice to any resident and revealed she had many concerns with the BOM at the facility. Interview on 02/07/24 at 10:11 A.M., with Administrator revealed she had been on leave, recently returning and an Interim Administrator assisted while she was gone. Administrator revealed there was confusion in the business office and some residents were not getting billed for several months. This deficiency represents non-compliance investigated under Complaint Number OH00150244.

Based on record review, family interview, staff interview, and policy review, the failed to update to care plans to included fall interventions. This affected three (#2, #88, and #120) of three resident reviewed for care plans. The facility census was 117. Findings included: 1. Review of Resident #120's medical record revealed an admitted [DATE], a re-admitted [DATE] and a discharge date of [DATE]. Diagnosis included unspecified dementia, chronic atrial fibrillation, difficulty in walking, muscle weakness, need for assistants with personal care, and cognitive communication deficit. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 was severely cognitively impaired. Review of the Morse Fall Scale completed on 12/19/22, 01/02/23, 01/13/23, 04/18/23, and 07/19/23 revealed Resident #120 was at high risk for falls. Review of the Morse Fall Scale completed on 10/21/23 revealed Resident #120 was a moderate risk for falls and review of the Morse Fall Scale completed on 12/05/23 and 12/08/23 revealed Resident #120 was at high risk for falls. Review of the care plan dated 12/20/22 and revised 12/18/23 for Resident #120 revealed Resident #120 was at risk for falls related to confusion, reconditioning, gait/balance problems, unaware of safety needs, history of falls and cognitive impairment. Interventions included reminder sign, dycem in front of recliner, anticipate and meet the resident needs, assist with ambulation, transfer, and toileting, call light in reach and non-skid socks as ordered. Review of the care plan revealed there was no intervention in place for Resident #120 to have the bed in lowest position while in bed. Review of the All Staff Inservice dated 11/17/23 included to be sure Resident #120's bed was in the lowest position after you are done providing care. The All Staff Inservice was signed by four LPN's and ten State tested Nursing Assistants (STNA). Interview on 02/06/24 at 3:34 P.M., with Resident #120's son revealed he visited his mother, daily over the past year while she resided at the facility. Resident #120's son revealed Resident #120 was confused and had already had two falls at the facility when he met with the Administrator, DON, and the Unit Manager to request her bed be placed in the lowest position while she was in bed. He feared if she fell out of bed at a routine bed height, she could be seriously injured. Resident #120's son revealed Administrator, DON, and the Unit Manager assured him the bed would be placed in the lowest position while she was in bed. On multiple visits he would find Resident #120's bed was not in the lowest position while she was in bed. Resident #102's son revealed he continued to meet with the Administrator, DON, and the Unit Manager on multiple occasions who consistently assured him the bed would be placed in the lowest position while she was in bed. Resident #120's son revealed facility staff who found Resident #120 on the floor on 12/05/23 confirmed her bed was not lowered when she was left unattended and fell out of bed resulting in multiple fractures. Interview on 02/07/24 between 2:45 P.M. and 4:40 P.M., with DON, Administrator, and Unit Manager confirmed Resident #120's son had spoken with each of them on a few different occasions regarding his concerns of her bed being placed too high with concerns of her falling out of bed. DON confirmed the facility used electric beds, the beds were able to raise and lower by using a remote control. During care, staff would raise the bed but were to lower it when care was complete. DON revealed Resident #120's bed was to be in a low position while she was in bed unattended. DON revealed staff were in-service to keep Resident #120's bed in a low position. DON confirmed the low bed intervention was not placed in Resident #120's care plan and revealed he had met with the Interdisciplinary Team on several occasions, discussed the concern of staff not keeping her bed in the low position in morning meetings several different times and the MDS nurse who was present during those meetings was supposed to put the intervention in the care plan but never did. DON stated if the resident was at risk for falls then the beds should always be in the lowest position when unattended by staff. DON confirmed the MDS nurse at that time was no longer employed at the facility. DON confirmed he was also able to add interventions to the care plans. Interview on 02/08/24 at 10:14 P.M., with RN #258 confirmed she was the charge nurse on 12/05/23 when Resident #120 fell out of bed. Housekeeping notified her of the fall. RN #258 revealed she remembered seeing Resident #120 lying on her back next to her bed. Resident #120 said she was in a lot of pain. RN #258 revealed Resident #120's bed was not in the low position; it was standard position a resident would use if they transferred themselves in an out of bed. RN #258 revealed she was not aware Resident #120's bed was supposed to be in a low position and revealed, It was not in her care plan. Interview on 02/08/24 at 10:55 A.M., with LPN Unit Manager (UM) #361 confirmed Resident #120's son spoke with her a couple times about Resident #120's bed needing to be in low position. LPN UM #361 revealed she in serviced staff several times about it. LPN UM #361 confirmed the All Staff Inservice was not signed by RN #258. LPN UM #361 confirmed not all the staff were in service and the intervention was not placed in the care plan. 2. Review of Resident #88's medical record revealed an admitted [DATE]. Diagnosis included Alzheimer's disease with early onset, abnormal posture, and transient cerebral ischemic attack. Review of the quarterly MDS dated [DATE] revealed Resident #88 was severely cognitively impaired. Resident #88 required substantial to maximum assistants with care. Resident #88 had a history of falls. Review of the care plan for Resident #88 revealed Resident #88 was at risk for falls related to diabetes mellitus, hypertension, psychoactive drug use, and needs staff assist for transfers. Interventions included bolstering to exit side of bed. Review of the care plan revealed no interventions were in place to have the bed in low position while in bed. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #88 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON stated Resident #88 did not have the intervention for a low bed in her care plan. 3. Review for Resident #2's medical record revealed an admitted [DATE]. Diagnosis included anxiety disorder, difficulty in walking, muscle weakness, lack of coordination, repeated falls, unspecified fall subsequent encounter subluxation of cervical four and five vertebrae, sequela. Record review of the Quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired. Resident #2 required substantial maximum assist for sitting to stand, transfers, and ambulation. Review of the care plan on 02/07/24 for Resident #2 dated 08/30/23 revealed Resident was at risk for falls related to confusion, deconditioning, gait balance problems and a history of falls. Interventions included assessing the resident for fall risk upon admission, quarterly and as needed. Assist with ambulation, transfer, toileting as needed, and to be sure the residents call light was within reach and encourage the resident to use it for assistants as needed. Review of the care plan on 02/07/24 revealed there was no intervention in the care plan to have the bed in the low position well in bed. Review of the care plan revealed interventions were added to included bed in lowest position while occupied added 02/09/23. Interview on 02/07/24 at 5:07 P.M., with DON stated Resident #2 should have had the intervention in her care plan to have the bed in low position while in bed because she was at risk for falls. DON confirmed Resident #2 did not have the intervention for a low bed in her care plan. Review of the policy titled, Fall Prevention and Management Policy, dated 04/01/22, revealed each resident will be assessed for fall risk on admission, quarterly, after any fall and as needed. If risks are identified, preventive measures will be put in place and added to the resident's care plan. All falls will be reviewed and investigated. This deficiency represents non-compliance investigated under Complaint Number OH00150460 and OH00149914.

Based on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 118 residents receiving food from the facility's kitchen as Resident #13 was ordered nothing-by-mouth (NPO). The facility census was 119 residents. Findings include: Observation of the unit refrigerators on [DATE] starting at 10:23 A.M. with Dietary Manager (DM) #263 revealed the following areas of concern: In the east dining room refrigerator, a bag with Resident #17's name on it had a sell by date of [DATE] and contained bread and soup. There was a container with Resident #23's name on it that had no date and contained salad and pita bread. There was a pizza box labeled with Resident #4's name and the date [DATE]. There was a pie with no name or date and another pizza with no name or date. On the door of the refrigerator, a sign in bright pink stated, RESIDENT FOOD ITEMS ONLY. All items must be dated. Discard all items after 72 hours once opened. An additional sign in bright orange dated [DATE] read, ATTENTION ALL STAFF AND FAMILY MEMBERS: All food and beverages must be labeled with [the] resident's name and dated. Food and beverages will be thrown away three days from the date that is marked on the item. In the west nutrition room, a putrid odor was present immediately upon opening the door. No thermometer was present in the refrigerator. Two undated and unlabeled takeout bags were noted that had a strong odor. There was a container with Resident #105's name and no date. A bottle of expired French dressing dated [DATE] was in the door of the refrigerator. In the memory care refrigerator, the bottom shelf was stained and there was not a thermometer. There was a container of expired milk dated [DATE] and an opened milk that expired [DATE]. There was a can of whipped cream with the date [DATE] in the door of the refrigerator and an undated bag of shredded lettuce. Interviews with DM #263 on [DATE] starting at 10:23 A.M. verified the observations at the time of discovery. DM #263 stated the State tested Nursing Assistants (STNAs) would yell at dietary staff when they tried to throw away resident food so going through the refrigerators had been difficult. Interview on [DATE] at 10:58 A.M. with the Director of Nursing (DON) and the Interim Administrator revealed families were responsible for labeling and dating resident food before putting it in the designated refrigerators but staff would remind them to do this. Dietary staff were ultimately responsible for going through these refrigerators to dispose of expired food. Review of a list of resident diets provided by the facility revealed Resident #13 received nothing by mouth. Review of the undated policy regarding food brought into the facility revealed no staff food may be stored in unit refrigerators. Food brought in by the resident, family or visitors for resident use will be labeled with the resident's name and the date the item was stored. Food would be kept five days from label date then discarded except condiments which would be kept for two months (60 days) and non-perishable drinks and frozen foods would be kept one month (30 days). Any food or beverage that is not labeled with the residents' name and date will be discarded immediately. This deficiency is an example of noncompliance investigated under Master Complaint Number OH00148665.

Based on observation, interview, and policy review, the facility failed to properly store medications. This had the potential to affect all 133 residents in the facility. Findings include: On 07/24/23 at 8:42 A.M. during preparation of medication administration observation, Registered Nurse (RN) #108 had unlocked the medication cart, exposing one five-ounce drinking cup approximately half full of white tablets. The cup was uncovered and written on the outside of the cup, with marker, was sodium bicarb 325 mg. Interview with the RN revealed she was unsure how many tablets were in the cup and she verified there was no expiration date listed for the medications. RN #108 revealed she was unsure how many days the cup with the white tablets had been stored in the cart. Further interview revealed sodium bicarb was an over the counter medication and there was only one cart that had a bottle of sodium bicarb 325 mg available for resident administration, so the medication was shared by pouring some of the tablets into a medication cup to store them in the medication cart for resident administration. Interview on 07/25/23 at 2:00 P.M. with the Director of Nursing (DON) verified medications were to be stored in the original packaging with the appropriate label and expiration date and never be stored outside of the original package with clear labeling. Review of the facility undated policy titled, Medication Storage revealed it was the facility policy to ensure all medications housed on the premises would be stored in the pharmacy and or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. This deficiency represents non-compliance investigated under Complaint Number OH00144205.

Based on interview, record review, and review of the facility policy, the facility failed to report an allegation of misappropriation to the state agency as required. This affected one resident (Resident #84) of three residents reviewed for missing items. The facility census was 133. Findings include: Record review for Resident #84 revealed an admitted [DATE]. Diagnoses included Parkinson's Disease, chronic obstructive pulmonary disease, spinal stenosis, muscle weakness, abnormal posture, and need for assistance with personal care. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #84 had a Brief Interview of Mental Status score of 12 (moderately impaired). Resident #84 required extensive assistants of two for bed mobility, total dependence for transfers, and toilet use, and extensive assistants of one for personal hygiene. Resident #84 was always incontinent of bowel and bladder. Record review of Resident #84's medical record revealed no documentation of a missing item. Record review of a Complaint/Concern form dated 10/20/22 completed by Administrator revealed Resident #84 described a large black ring with a diamond that looked like a man's ring, had gone missing. Resident #84 revealed she was wearing the ring on her middle finger at night, and it was gone in the morning. Resident #84 revealed the ring was loose on her finger and this happened a couple of days ago. The family was notified and the family does not have the ring. The concern was referred to nursing, laundry, Social Services and the Administrator. Resident #84's room and the laundry room was searched. The form included the Administrators signature and date of 10/20/22 next to the signature. The second page of the report had a typed notation reading, This writer completed a room search on 10/20/22 to look for resident's ring that she reported missing. This writer did not find the ring. Resident reported she did not think it was stolen but that it might have fallen off in her bed. This writer informed the resident that we would continue looking for the ring. The form was signed by the Administrator and dated 10/20/22. Interview on 07/25/23 at 8:22 A.M. with Resident #84 revealed she was missing a ring. The resident stated the ring was her father's ring that came up missing at the facility. Resident #84 revealed she reported the missing ring to the Director of Nursing (DON) a few months ago and nothing happened. Resident #84 shared she always wore the ring on her left middle finger, but it was loose on her finger. She went to sleep one night and when she woke up in the morning, it was gone. That's when she reported it to the DON. Resident #84 shared nobody came back to tell her they didn't find it and they never asked if she wanted it replaced. Resident #84 shared nobody could replace her father's ring, it was a real diamond and the band was gold with black [NAME]. Resident #84 revealed the ring might have fallen off her finger then someone stole it. Resident #84 stated she told them she thought that someone may have stolen the ring. Interview on 07/25/23 at 8:50 A.M. with the DON revealed he did not know about Resident #84's missing ring. Interview on 07/25/23 at 9:10 A.M. with Licensed Social Worker (LSW) #106 revealed shortly after Resident #84 was admitted to the facility, she was missing her black ring. The ring had gold on the band with a stone. LSW #106 revealed there were inventory sheets that were to be filled out on admission by the staff and family, but they (the inventory sheets) don't always get done. LSW #106 revealed she did see a picture from the resident's admission with the ring on her finger, that's how she remembered what the ring looked like. LSW #106 was unsure what happened to the photo of the resident wearing the ring. Interview on 07/25/23 at 9:24 A.M. with LSW #101 revealed she reviewed the concern log for Resident #84's missing ring. LSW #101 revealed the inventory list was always an issue to remind staff and family to fill out. Resident #84's inventory list was not in her chart. LSW #101 revealed if a resident had a missing item, the facility would offer to replace it but the facility did not offer to replace Resident #84's ring. Interview on 07/25/23 at 9:29 A.M. with the Administrator confirmed the facility did not complete a self-reported incident (SRI) for Resident #84's missing ring. The Administrator revealed unless the resident reported an item stolen, an SRI would not be completed. The Administrator revealed Resident #84 did not use the word stolen, she reported it lost and that was different. The Administrator revealed she received the concern on 10/20/22 and personally looked in Resident #84's room and the laundry room for Resident #84's ring but it wasn't found. The Administrator revealed she was not sure what happened to the missing picture of Resident #84 wearing the ring, a former medical records person took the picture, and she was unsure what the former medical records person did with the picture, but it was unable to be found. The Administrator revealed Resident #84 never asked for the ring to be replaced so she never offered. Review of the facility undated policy titled, Missing Items revealed should items become missing, the facility would take reasonable efforts to attempt to locate the missing items. The procedure included the resident or responsible party should notify a staff member of the missing item and the staff member would notify their supervisor, the Administrator, DON, social work designee and complete the missing items report. This person would then coordinate all efforts to locate the missing items. In the event that misappropriation of a resident's property was suspected or known, the facility would follow the investigation and follow up sections of its policy on abuse, neglect, and misappropriation of residents funds or property. Review of the Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy revised 10/2020 revealed the facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The Administrator or his/her designee will notify the state agency of all alleged violations involving Abuse, Neglect, exploitation, mistreatment of a resident, or misappropriation of resident property as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00144205.

Based on interview, record review, and review of the facility policy, the facility failed to ensure a thorough investigation was completed regarding an allegation of misappropriation. This affected one resident (Resident #84) of three residents reviewed for missing items. The facility census was 133. Findings include: Record review for Resident #84 revealed an admitted [DATE]. Diagnoses included Parkinson's Disease, chronic obstructive pulmonary disease, spinal stenosis, muscle weakness, abnormal posture, and need for assistance with personal care. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #84 had a Brief Interview of Mental Status score of 12 (moderately impaired). Resident #84 required extensive assistants of two for bed mobility, total dependence for transfers, and toilet use, and extensive assistants of one for personal hygiene. Resident #84 was always incontinent of bowel and bladder. Record review of Resident #84's medical record revealed no documentation of a missing item. Record review of a Complaint/Concern form dated 10/20/22 completed by Administrator revealed Resident #84 described a large black ring with a diamond that looked like a man's ring, had gone missing. Resident #84 revealed she was wearing the ring on her middle finger at night, and it was gone in the morning. Resident #84 revealed the ring was loose on her finger and this happened a couple of days ago. The family was notified and the family does not have the ring. The concern was referred to nursing, laundry, Social Services and the Administrator. Resident #84's room and the laundry room was searched. The form included the Administrators signature and date of 10/20/22 next to the signature. The second page of the report had a typed notation reading, This writer completed a room search on 10/20/22 to look for resident's ring that she reported missing. This writer did not find the ring. Resident reported she did not think it was stolen but that it might have fallen off in her bed. This writer informed the resident that we would continue looking for the ring. The form was signed by the Administrator and dated 10/20/22. Interview on 07/25/23 at 8:22 A.M. with Resident #84 revealed she was missing a ring. The resident stated the ring was her father's ring that came up missing at the facility. Resident #84 revealed she reported the missing ring to the Director of Nursing (DON) a few months ago and nothing happened. Resident #84 shared she always wore the ring on her left middle finger, but it was loose on her finger. She went to sleep one night and when she woke up in the morning, it was gone. That's when she reported it to the DON. Resident #84 shared nobody came back to tell her they didn't find it and they never asked if she wanted it replaced. Resident #84 shared nobody could replace her father's ring, it was a real diamond and the band was gold with black [NAME]. Resident #84 revealed the ring might have fallen off her finger then someone stole it. Resident #84 stated she told them she thought that someone may have stolen the ring. Interview on 07/25/23 at 8:50 A.M. with the DON revealed he did not know about Resident #84's missing ring. Interview on 07/25/23 at 9:10 A.M. with Licensed Social Worker (LSW) #106 revealed shortly after Resident #84 was admitted to the facility, she was missing her black ring. The ring had gold on the band with a stone. LSW #106 revealed there were inventory sheets that were to be filled out on admission by the staff and family, but they (the inventory sheets) don't always get done. LSW #106 revealed she did see a picture from the resident's admission with the ring on her finger, that's how she remembered what the ring looked like. LSW #106 was unsure what happened to the photo of the resident wearing the ring. Interview on 07/25/23 at 9:24 A.M. with LSW #101 revealed she reviewed the concern log for Resident #84's missing ring. LSW #101 revealed the inventory list was always an issue to remind staff and family to fill out. Resident #84's inventory list was not in her chart. LSW #101 revealed if a resident had a missing item, the facility would offer to replace it but the facility did not offer to replace Resident #84's ring. Interview on 07/25/23 at 9:29 A.M. with the Administrator confirmed the facility did not complete a self-reported incident (SRI) for Resident #84's missing ring. The Administrator revealed unless the resident reported an item stolen, an SRI would not be completed. The Administrator revealed Resident #84 did not use the word stolen, she reported it lost and that was different. The Administrator revealed she received the concern on 10/20/22 and personally looked in Resident #84's room and the laundry room for Resident #84's ring but it wasn't found. The Administrator also verified she did not interview the staff regarding the missing ring. Review of the facility undated policy titled, Missing Items revealed should items become missing, the facility would take reasonable efforts to attempt to locate the missing items. The procedure included the resident or responsible party should notify a staff member of the missing item and the staff member would notify their supervisor, the Administrator, DON, social work designee and complete the missing items report. This person would then coordinate all efforts to locate the missing items. In the event that misappropriation of a resident's property was suspected or known, the facility would follow the investigation and follow up sections of its policy on abuse, neglect, and misappropriation of residents funds or property. Review of the Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy revised 10/2020 revealed the facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of a resident,, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The person investigating the incident should take the following actions: Interview the resident, the accused and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members): and employees who worked closely with the accused employee (s) and/or alleged victim the day of the incident. Obtain a statement from the resident, if possible, the accused, and each witness. Evidence of the investigation should be documented. After a completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated. This deficiency represents non-compliance investigated under Complaint Number OH00144205.

Based on observation, interview, and record review the facility failed to ensure the high temperature dish machine reached the minimum rinse temperature required to ensure appropriate sanitation of dishes and utensils. This had the potential to affect 87 residents receiving meals from the kitchen (Resident #345 was ordered nothing-by-mouth). The facility census was 88. Findings include: Observation on 04/11/22 at 8:57 A.M. of the facility's dish machine with Dietary Manager (DM) #546 revealed the machine was in use. There were two indicator gauges for the wash and rinse cycle water temperatures, and both read 90 degrees Fahrenheit (F). Dish machine temperature logs were posted to the left of the dish machine. Review of the April 2022 dish machine temperature logs revealed temperatures were taken at breakfast, lunch, and dinner meals. Data through 04/11/22 at the breakfast meal revealed final rinse temperatures were as follows: · 04/01/22 150 degrees Fahrenheit (F), breakfast; 149 degrees F, lunch; 150 degrees F, dinner · 04/02/22 155 degrees F, breakfast; 155 degrees F, lunch; 150 degrees F, dinner · 04/03/22 150 degrees F, breakfast; 154 degrees F, lunch; 147 degrees F, dinner · 04/04/22 155 degrees F, breakfast; 155 degrees F, lunch; 147 degrees F, dinner · 04/05/22 145 degrees F, breakfast; 150 degrees F, lunch; 150 degrees F, dinner · 04/06/22 140 degrees F, breakfast; 180 degrees F, lunch; 150 degrees F, dinner · 04/07/22 147 degrees F, breakfast; 150 degrees F, lunch; 150 degrees F, dinner · 04/08/22 160 degrees F, breakfast; 155 degrees F, lunch; 152 degrees F, dinner · 04/09/22 160 degrees F, breakfast; 155 degrees F, lunch; 154 degrees F, dinner · 04/10/22 155 degrees F, breakfast; 160 degrees F, lunch; 157 degrees F, dinner Interview with DM #546 on 04/11/22 at 8:47 A.M. revealed the dish machine was a high temperature dish machine. DM #546 was made aware during the interview that 90 degrees F was not a sufficient temperature to ensure adequate sanitizing of dishes and utensils and that the minimum temperature for heat sanitization through the rinse cycle on a high temperature dish machine was 180 degrees F. Interview on 04/11/22 at 3:35 P.M. with Assistant Administrator (AA) #547, DM #546 and Maintenance Director #521 revealed the two front temperature gauges of the dish machine were incorrect. DM #546 stated a temperature strip had been run through the dish machine around lunch and rinse temperatures had been in the 150 degrees F range. DM #546 confirmed this did not meet the minimum rinse temperature of 180 degrees F. Review of dish machine operating instructions dated 08/22/19 revealed the high temperature dish machine would have a final rinse temperature of 180 degrees F to 195 degrees F.

Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This had the potential to affect all residents residing in the facility. In addition, the facility failed to properly clean a shared glucometer between residents. This affected two (Resident's #79 and #64) of two residents reviewed for blood glucose monitoring. The facility census was 88. Findings include: 1. Review of Resident #248's medical records revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #248's immunizations revealed no evidence of a Covid-19 vaccination. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed an incomplete assessment. Review of the care plan dated 04/11/22 revealed Resident #248 was at risk for contracting the Covid-19 virus related to unvaccinated status. Observation on 04/13/22 at 7:53 A.M. revealed Resident #248 was on isolation precautions, and signage was posted outside of the resident's room that indicated a gown, gloves, N95 and face shield were to be worn prior to entering the room. Further observation revealed Clinical Manager (CM) #585 entered the resident's room to deliver her breakfast tray and assist with setting the residents tray up. Further observation revealed CM #585 did not wear a N95 or a face shield prior to entering the resident's room. Interview at 7:58 A.M. with CM #585 confirmed Resident #248 was on isolation precautions; however, CM #585 stated she was not aware she was required to wear a face shield or N95 into the resident's room. CM #585 confirmed the posted signage indicated a face shield and N95 were required prior to entering the resident's room. Interview on 04/13/22 at 8:03 A.M. with the Director of Nursing (DON) confirmed staff was required to wear a gown, gloves, face shield, and N95 prior to entering Resident #248's room. The DON further confirmed she had placed the required Personal Protective Equipment (PPE) requirements outside of the resident's room. Review of the CDC guidance updated 09/10/21 titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes revealed older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. In general, healthcare facilities should continue to follow the IPC recommendations for unvaccinated individuals (e.g., use of Transmission-Based Precautions for those that have had close contact to someone with [CONDITION(S)]-CoV-2 infection) when caring for fully vaccinated individuals with moderate to severe immunocompromise due to a medical condition or receipt of immunosuppressive medications or treatments. Manage residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. 2. Review of the medical record for Resident #79 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/12/22 at 7:30 A.M. of blood glucose testing by Accucheck glucometer used for multiple residents, by Registered Nurse (RN) #563 for Resident #79 revealed after the blood glucose was checked, RN #563 placed the glucometer in her pocket and did not sanitize it. Observation on 04/12/22 at 7:57 A.M. of RN #563 revealed she removed the glucometer from her pocket and placed it on top of the medication cart. There was no observation of RN #563 disinfecting he glucometer before placing it on the mediation cart. Interview on 04/12/22 at 7:57 A.M. with RN #563 verified she did not disinfect the glucometer and she was going home. 3. Review of the medical record for Resident #64 revealed an admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and at bedtime (8:00 P.M.) and notify physician if blood glucose is less than 80 or greater than 350. Observation on 04/12/22 at 12:18 P.M. of blood glucose testing by Accucheck glucometer for Resident #12 by Licensed Practical Nurse (LPN) #539 revealed she proceeded to use the glucometer for glucose testing on Resident #64 without disinfecting or sanitizing the glucometer between residents. Interview on 04/12/22 at 12:19 P.M. verified she did not disinfect the glucometer between residents. Review of the undated facility policy titled Glucometer Cleaning revealed all glucometers would be cleaned and disinfected using Clorox Germicidal wipes, or equivalent. All glucometers that would be shared by multiple patients would be thoroughly wiped with disinfectant and allowed to air dry after every use and between every patient.

Based on observation, interview, and review of the facility's menu spreadsheet the facility failed to serve portions as specified on the menu spreadsheet. This affected 27 residents including 19 residents on a mechanical soft diet (Residents #9, #13, #15, #18, #22, #33, #49, #55, #59, #65, #68, #73, #77, #78, #85, #88, #91, #246 and #445) and eight residents on a pureed diet (Residents #27, #34, #37, #44, #47, #56, #72 and #74). The facility census was 88 residents. Findings include: Review of the menu spreadsheet for 04/12/22 for the lunch meal revealed a meal consisting of chicken, potatoes au gratin, California blend vegetables, and mint chocolate chip ice cream with alternates listed as pork roast, gravy, sweet potatoes, and Prince [NAME] vegetable mix. Portions for the chicken included three ounces for regular consistency diets, a #10-scoop for mechanical soft chicken, and a #10-scoop for pureed chicken. Observation of tray line on 04/12/22 starting at 11:27 A.M. revealed a lunch meal consisting of chicken, potatoes au gratin, mixed vegetables, mechanically altered chicken, pureed chicken, pureed vegetables, gravy, mashed potatoes, and soup as well as pork and alternate vegetable items. The pureed chicken was served with a green #12-scoop, and the mechanically altered chicken was served with a green #12-scoop. Tray-service began at 11:39 A.M. and both pureed chicken and the mechanically altered chicken were served with a green #12-scoop. Interview on 04/12/22 at 12:08 P.M. with Dietary Manager (DM) #546 verified the mechanically altered chicken and the pureed chicken both were served with a green #12-scoop. DM #546 was made aware during the interview the facility did not follow the menu spreadsheet that showed a larger, #10-scoop should have been used to serve these items during the meal. Review of a diet list as of 04/12/22 revealed 19 residents were on a mechanical soft diet (Resident's #9, #13, #15, #18, #22, #33, #49, #55, #59, #65, #68, #73, #77, #78, #85, #88, #91, #246 and #445), eight residents were on a pureed diet (Resident's #27, #34, #37, #44, #47, #56, #72 and #74) and Resident #345 was ordered nothing-by-mouth (NPO).

Based on observation, interview, and facility policy review, the facility failed to ensure medication stored in the medication carts were not expired and insulin vials were labeled with the date opened. This affected nine residents (Resident #21, #24, #35, #39, #54, #64, #86, #87, and #245) and had the potential to affect all 88 residents residing in the facility. Findings include: Observation on [DATE] at 3:03 P.M. of the medication cart in the 800 hall revealed the following: 1. [MEDICATION(S)] insulin Kwik pen labeled only with room number for Resident #24 and an open date of [DATE] 2. [MEDICATION(S)] insulin 100 units per milliliter (u/ml) for Resident #64 was opened with an unreadable date on bottle 3. Vial of [MEDICATION(S)] insulin 100 u/ml for Resident #54 was not labeled with date opened. A date of [DATE] was only on the opened box without a lid 4. Vial of [MEDICATION(S)] insulin 100 u/ml for Resident #39 was not labeled with date opened. A date of [DATE] was only on the opened box without a lid 5. Vial of [MEDICATION(S)] insulin 100 u/ml for Resident #39 was not labeled with date opened. A date of [DATE] was only on the opened box without a lid 6. Vial of [MEDICATION(S)] insulin 100 u/ml for Resident #87 was not labeled with date opened. A date of [DATE] was only on the opened box without a lid 7. Vial of [MEDICATION(S)] insulin 100 u/ml for Resident #21 was not labeled with date opened. A date of [DATE] was only on opened box without a lid 8. Bottle of [MEDICATION(S)] 0.4 milligrams (mg) sublingual (SL) tablets for Resident #21 with expiration date of ,d+[DATE] 9. A second bottle of [MEDICATION(S)] 0.4 mg SL tablets for Resident #21 was in a bag with an expiration date of [DATE], but the bottle was dated ,d+[DATE] 10. Bottle of Saline nasal spray for Resident #87 with an expiration date of ,d+[DATE] Interview with Licensed Practical Nurse (LPN) #539 during medication storage observation for the 800 hall on [DATE] at 3:23 P.M. verified the above medications were expired or not labeled properly. Observation on [DATE] at 3:30 P.M. of medication refrigerator on the 400 hall revealed the following: 11. Bottle of 100 mg [MEDICATION(S)] Swish and Swallow for Resident #86 with an expiration date of [DATE] 12. Vial of [MEDICATION(S)] insulin 100 u/ml for Resident #35 was not labeled with date opened. A date of [DATE] was only on the box and was after the 28-day use of opened insulin vials. 13. Vial of [MEDICATION(S)] solution 0.1 ml was opened and was not labeled on the vial, nor the box with the date opened. Interview on [DATE] at 3:30 P.M. with Registered Nurse (RN) #602 during the observation of medication storage for the 400 hall verified the above medications were expired or not labeled properly. Observation on [DATE] at 4:05 P.M. of the medication cart for the memory care unit revealed the following: 14. Bottle of Aspirin 81 mg stock medication with an expiration date of ,d+[DATE] 15. Bottle of [MEDICATION(S)] 325 mg with an expiration date of ,d+[DATE] Interview on [DATE] at 4:05 P.M. with LPN #630 during observation of medication storage for the memory care unit verified the above medications were expired. Review of the facility policy titled, Storage of Medications, revised [DATE], revealed drug containers with missing, incomplete, improper, or incorrect labels would be returned to the pharmacy for proper labeling before storing. Discontinued, outdated , or deteriorating drugs or biologicals would be returned to the dispensing pharmacy or destroyed. 16. Observation on [DATE] from 9:00 A.M. to 9:09 A.M. during tour of nourishment refrigerators with Dietary Manager (DM) #546 revealed on the memory care unit there was a box of [MEDICATION(S)] solution inside the door of the nourishment refrigerator. The [MEDICATION(S)] solution was labeled ,d+[DATE]; no specific date of first use was further identified on the label. Interview with DM #546 at the time of observation verified medication was not to be stored in the nourishment refrigerator. Interview on [DATE] at 9:09 A.M. with Licensed Practical Nurse (LPN) #617 revealed she was unaware of the [MEDICATION(S)] solution in the nourishment refrigerator. LPN #617 denied any malfunctions of the medication refrigerator on the memory care unit. Interview on [DATE] at 9:11 A.M. with Director of Nursing (DON) verified the [MEDICATION(S)] solution was not to be stored in the nourishment refrigerator. DON denied any malfunctions of the medication refrigerator on the memory care unit. Follow-up interviews on [DATE] at 10:42 A.M. and 3:00 P.M. with DON verified no date of first use was specified on the opened package of [MEDICATION(S)] solution and should have been. DON identified one resident received [MEDICATION(S)] solution from this package, Resident #245. Review of the facility policy, Storage of Medications, revised [DATE] revealed medications requiring refrigeration were stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.

Based on interview and record review, the facility failed to ensure resident funds were disbursed in a timely manner for Resident #94 after death as required, and failed to provide a spend-down letter for Resident #6 when she was over the resource limit. This affected two residents (Resident #6 and Resident #94) of five residents reviewed for resident funds. The facility census was 88 residents. Findings include: 1. Review of Resident #94's closed medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a significant change minimum data set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively impaired. Review of nurses' notes revealed Resident #94 expired in the facility on [DATE]. Review of Resident #94's funds authorization revealed it was signed and witnessed on [DATE]. Review of Resident #94's funds transaction report indicated a final dispersal was not completed until a check was sent on [DATE]. Interview on [DATE] at 4:28 P.M. with Business Office Manager (BOM) #566 verified Resident #94's final disbursal exceeded the 30 day time limit. 2. Review of Resident #6's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE] revealed Resident #6 was cognitively impaired. Review of profile data indicated Resident #6 had a guardian. Review of Resident #6's funds authorization revealed it was signed on [DATE]. Review of Resident #6's funds transaction report revealed a closing balance of $5548.20 as of [DATE]. No spend-down letters were available for surveyor review. Interview on [DATE] at 4:28 P.M. with BOM #566 confirmed she did not have any spend-down letters for Resident #6 available for review. BOM #566 indicated Social Service staff assisted residents with spending resident funds. BOM #566 was asked for a facility policy on resident funds during the interview. Interview on [DATE] at 4:41 P.M. with Director of Social Services (DOSS) #577 indicated she also did not provide residents and/or their representatives with spend-down letters. The above findings were also verified with the Administrator and Assistant Administrator (AA) #547 during an interview on [DATE] at 4:45 P.M. No policy regarding resident funds was available during the survey.

Based on closed medical record review, medication administration procedure review, Medication Error/Narcotic Discrepancy form review and staff interviews, the facility failed to ensure a resident received the correct amount of the pain medication liquid [MEDICATION NAME] as ordered by the physician. Facility nurses failed to check liquid [MEDICATION NAME] medication labels to determine the correct dose prior to administering narcotic medication which resulted in Immediate Jeopardy for Resident #143, who required [MEDICATION NAME] for pain management. Resident #143 received five 100 milligram (mg) doses of [MEDICATION NAME] instead of the ordered 5 mg dose of [MEDICATION NAME] between [DATE] and [DATE]. Resident #143 expired in the facility on [DATE] at 12:20 P.M. This affected one of three residents reviewed for death. The facility census was 142. The Administrator and Director of Nursing (DON) were notified on [DATE] at 3:12 P.M. that Immediate Jeopardy began on [DATE] at 5:30 P.M., when Licensed Practical Nurse (LPN) #11 administered 100 milligrams (mg) of [MEDICATION NAME] Concentrated Solution orally to Resident #143 instead of the ordered dose of 5 mg. Resident #143 received four more doses of 100 mg of [MEDICATION NAME] on [DATE] and [DATE]. The medication error was discovered on [DATE] at 7:30 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective measures. · On [DATE] at 8:30 A.M., the day shift nurse, LPN #13, calculated and administered the accurate [MEDICATION NAME] medication dose of 5 mg. to Resident #143. · On [DATE], the DON completed a narcotic audit of Resident #143 and the other four facility residents with liquid narcotics ordered, Residents #57, #16, #116 and #47, to ensure the correct dose was identified and administered. No similar dose discrepancies or errors were found. · On [DATE] the DON inserviced 30 of 34 LPNs and Registered Nurses (RNs) on medication administration, medication errors, types of narcotics and reading and writing telephone orders. · On [DATE] Pharmacist #3 provided training to 25 of 34 LPNs and RNs on medication administration, medication errors, types of narcotics and reading and writing telephone orders. All 10 RNs and 24 LPNs on staff attended one or both of the [DATE] and [DATE] inservice trainings. · Medication Administration Audits and Medication Documentation Audits will be completed weekly by the DON or her designee. Although the Immediate Jeopardy was removed when the facility determined the five residents were being administered the correct dose of liquid medication and nursing staff had calculated the correct dosage, 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). The facility provided education to all of their 34 licensed nursing staff, including ten RNs and 24 LPNs but had not yet conducted ongoing monitoring of medication administration practices to ensure accuracy. Findings include: Closed medical record review revealed Resident #143 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving hospice services. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable, unable to make her needs known, and required one person assist for all activities of daily living. Review of nurses ' notes dated [DATE] at 12:30 P.M. and signed by LPN #14, revealed Resident #143 was observed as pale and lethargic with a pulse oximetry of 80% on room air. Oxygen supplement, laboratory tests and a chest x-ray was ordered by Certified Nurse Practitioner (CNP) #4 at the time of the observed condition. A nurses ' note dated [DATE] at 1:08 P.M. and signed by LPN #14, revealed family refused to send the resident to the emergency room for treatment. A nurses ' note dated [DATE] at 4:15 P.M. and signed by LPN #14, indicated the chest x-ray results revealed pneumonia and were called to CNP #4. A nurses ' note dated [DATE] at 5:00 P.M., and signed by LPN #14, indicated CNP #4 returned the call and ordered the intravenous antibiotic [MEDICATION NAME] 500 milligrams (mg.) once a day for 7 days. Review of CNP #4 ' s untimed note dated [DATE], revealed the family decided the resident was to be treated in the facility rather than in the hospital and the family was meeting with hospice that day. Review of CNP #4 ' s note dated [DATE] revealed the family ' s choice was to keep the resident comfortable and begin hospice when the antibiotics were completed. Review of the [DATE] Medication Administration Record [REDACTED]. On [DATE], a new Hospice consult was obtained and initiated. The Hospice plan of care dated [DATE] included comfort measures to medicate for pain and anxiety, turn and position for comfort every two hours, and the family wished the resident to remain in bed. Review of Hospice Nurse RN #5 ' s note dated [DATE] revealed the resident had irregular respirations, abdominal breathing and slept most of the time. Review of physician orders [REDACTED]. The narcotic pain medication order was updated on [DATE] for [MEDICATION NAME] 5 mg every four hours and 5 mg every two hours as needed for pain or shortness of breath. Review of the MAR for [DATE] revealed LPNs #11 and #12 documented they administered [MEDICATION NAME] 5 mg as scheduled on [DATE] at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M., and on [DATE] at 1:00 A.M. and 5:00 A.M. Review of the Controlled Substance Record for Resident #143 revealed LPN #11 administered 100 mg of [MEDICATION NAME] for the [DATE] scheduled 5:00 P.M. and 9:00 P.M. doses. Documentation on the Controlled Substance Record further revealed on [DATE] at 1:00 A.M., LPN #12 administered 100 mg of [MEDICATION NAME] instead of the ordered 5 mg scheduled dose, and administered 100 mg of [MEDICATION NAME] on [DATE] at 3:15 A.M. when additional pain medication was requested by a family member who was staying with the resident. LPN #12 also administered 100 mg of [MEDICATION NAME] on [DATE] at 5:00 A.M. as the scheduled dose. Nursing notes authored by LPN #12 dated [DATE] at 5:33 A.M., revealed Resident #143 rested comfortably during the night, and took ,[DATE] breaths per minute with periods of apnea (absence of breaths). The note indicated at 4:15 A.M., Resident #143 showed no signs or symptoms of pain. Resident #143 expired in the facility on [DATE] at 12:20 P.M. Review of the facility ' s Continuous Quality Improvement (CQI) Tracking - Medication Errors/Narcotic Discrepancies form, revealed an entry dated [DATE], for the room where Resident #143 resided with the columns Wrong Dose, ,[DATE] and ,[DATE] check marked. During an interview on [DATE] at 1:05 P.M. with the Administrator and DON , the Administrator indicated the specific Med Error Form that contained the details of the [DATE] medication error was part of the facility ' s Quality Assurance and would not be shared with the surveyor. The DON reviewed the Med Error Form for the [DATE] medication error and confirmed the Resident #143 received five doses of [MEDICATION NAME] 100 mg on [DATE] and [DATE] instead of the prescribed dose of 5 mg. The DON revealed that on [DATE], Registered Nurse (RN) Supervisor #10 removed a prefilled bottle of [MEDICATION NAME] Concentrated Solution 20 mg/ml from the facility ' s medication storage ' MedLocker ' to have available for Resident #143 as the family stated that the previously ordered tablet medication form was ineffective. The physician (MD #1) order dated [DATE] was for [MEDICATION NAME] 5mg/5ml; give 5 mg every four hours as needed. On [DATE], the pharmacy sent the prescribed medication in a concentration of 5mg/5ml as ordered. Nursing staff administered 5 ml of the pharmacy-dispensed 5mg/5ml [MEDICATION NAME] medication from [DATE] until the bottle was empty on [DATE]. Beginning on [DATE] at 5:30 P.M., LPN #11 administered doses from the higher concentration solution in the narcotic drawer for Resident #143. The DON confirmed LPN #11 and LPN #12 did not read the labeled medication to ensure the required dose was prepared but administered 5 ml without any calculation. The DON confirmed the medication errors were significant and could put a resident at risk for respiratory arrest or even death. The DON stated MD #1 was immediately notified of the errors, and CNP #4 examined the resident on [DATE] at 8:00 A.M. and explained the incidents to the family. An interview was conducted with LPN #11 on [DATE] at 4:30 P.M. During the interview LPN #11 revealed she worked second shift and regularly cared for Resident #143. LPN #11 stated on [DATE] at 5:30 P.M. and again at 9:00 P.M., she administered the scheduled [MEDICATION NAME] pain medication to Resident #143 . LPN #11 stated she read the name of the medication and administered 5 ml of the medication because she had been giving the resident 5 ml prior to [DATE]. LPN #11 revealed the resident was occasionally restless in bed but did not appear in any acute distress before or after the administration of the [MEDICATION NAME] medication on [DATE]. LPN #11 revealed she became aware a medication error had occurred when she was notified by the DON on [DATE] that each administered dose was 100 mg and not the 5 mg as ordered. LPN #11 confirmed she had administered the wrong dose to Resident #143 because the concentration of the [MEDICATION NAME] medication solution had changed and she did not confirm the correct dose was prepared. LPN #11 confirmed that with any medication administered, the nurse was required to ensure the correct medication and dose was administered. LPN #11 confirmed she received additional training on medication administration on [DATE] in the facility and on [DATE] with the consultant pharmacist, Pharmacist #3. An interview was conducted on [DATE] at 4:50 P.M. with LPN #12. During the interview, LPN #12 revealed she cared for Resident #143 on third shift on [DATE] and administered [MEDICATION NAME] to the resident during the night shift. LPN #12 stated she confirmed the type of medication and administered 5 ml of the narcotic medication on [DATE] at 1:00 A.M. and 5:00 A.M. as scheduled and an additional dose at 3:15 A.M. at the request of the family, for symptoms of pain. LPN #12 stated the resident appeared comfortable during the night, with no noticeable change in status. LPN #12 revealed the medication error was discovered on [DATE] at 7:35 A.M. when the day shift nurse, LPN #13, prepared an as needed dose requested by the family for Resident #143 and calculated the correct dose as 0.25 ml, not 5 ml as previously administered by LPN #11 and LPN #12. LPN #12 stated it was discovered that the resident had been administered 100 mg of [MEDICATION NAME] instead of 5 mg when LPN #12 did not calculate the correct amount to give. LPN #12 confirmed she immediately notified the physician, MD #1, the DON, Hospice Nurse RN #5 and CNP #4 of the errors. LPN #12 confirmed she received additional training on medication administration on [DATE] from the DON and on [DATE] with Pharmacist #3. Neither LPN had been reported to the Ohio Board of Nursing. Review of the facility ' s Medication Administration Procedure, revised [DATE], revealed the nurse was to read the medication order on the MAR; remove the correct medication from the drawer; check the name and dosage of the medication with the MAR; pour medication into a medication cup; and to recheck the medication, dosage and administration time, and the resident ' s name. This deficiency substantiates Complaint Number OH 157.