Every finding on record at Northwestern Healthcare Center

Based on closed medical record review, staff interviews, interviews with family, family friend, and home health aide, review of Emergency Medical Services (EMS) run report and call transcripts, review of the facility's Self-Reported Incident (SRI) and investigation, and review of facility policies, the facility failed to prevent an incident of neglect involving Resident #87. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 11:30 P.M. when Resident #87 complained of chest pain to Certified Nursing Assistant (CNA) #609 who reported the change to Registered Nurse (RN) #422. RN #422 then failed to timely identify and obtain treatment for Resident #87 following an acute change in condition. In addition, the facility failed to ensure cardiopulmonary resuscitation (CPR) was initiated timely at the time Resident #87 was found unresponsive (without vital signs). On [DATE] at 2:50 A.M., Resident #87 expired with cause of death as cardiopulmonary and pulseless electrical activity with onset of 15 minutes prior to death. This affected one (#87) of three residents reviewed for hospitalization. The facility census was 81. On [DATE] at 10:13 A.M., Regional Director of Clinical Operations (RDCO) #417, the Administrator, the Director of Nursing (DON), and Assistant Director of Nursing (ADON) #813 were notified Immediate Jeopardy began on [DATE] at 11:30 P.M. when Resident # 87, who had advance directives for a full code complained of chest pain. CNA #609 reported the residents' complaint to RN #422. However, RN #422 failed to complete a comprehensive assessment or timely transfer the resident to the hospital for evaluation/medical intervention. The resident was subsequently found unresponsive (no time documented), with bluish-purple lips and fingertips. There was no evidence to support staff immediately initiated cardiopulmonary resuscitation (CPR). The facility failed to conduct a thorough investigation to determine the circumstances of the incident. However, interviews conducted by the State Survey Agency revealed staff did not initiate CPR for approximately seven to twenty minutes per seven staff (two nurses and five CNAs). As a result of Resident #87 not being assessed timely, a code not being called, and CPR not being initiated timely, Resident #87 passed away on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 2:50 P.M., Resident #87 passed away in the facility. On [DATE] at 9:30 A.M., clinical staff reviewing documentation during morning clinical meeting found no documentation of an occurrence with Resident #87. RN #422 was contacted and was instructed to come in and complete documentation immediately. On [DATE] at 11:12 A.M., RN #422 completed a late-entry progress note. From [DATE] to [DATE] staff interviews and statements were obtained by the Administrator, ADON #813 and Acting DON #424 regarding occurrence with Resident #87. On [DATE], Acting DON #424 educated all licensed nurses on clinical documentation standards, notification of change of condition, CPR/Ohio Do Not Resuscitate (DNR) comfort care (CC) and DNR CC Arrest policies- with emphasis on immediately initiating CPR after verification of a CPR code status, and wound care. All new hire nurses will be educated during the new hire orientation process by DON/designee. All borrowed nurses from sister facilities will be educated prior to shift start by DON/designee. Ongoing education will be completed during quarterly all-staff meetings by Director of Nursing/designee. On [DATE], Acting DON #424 educated CNAs on documentation and CPR with emphasis on their supportive role by the direction of the nurse. On [DATE], Acting DON #424 reviewed all resident's nursing notes for the last 30 days that had a change in condition to validate timely and correct treatment. Timely and correct treatment was based on nursing standards for the specific situation. On [DATE], Acting DON #424 completed whole-house code status audit to ensure orders and care plans were updated and current. All resident code statuses are current and can be found in the resident header of the electronic medical record (EMR). Starting [DATE], DON/designee completed ongoing audit of nurses notes to be reviewed daily (five days per week) during daily clinical meeting to monitor for change of condition, and appropriate assessment/treatment completed, up to and including CPR. Any concerns noted will be addressed immediately. Results will be reviewed at monthly Quality Assurance Performance Improvement (QAPI) meetings. On [DATE], Licensed Practical Nurse (LPN) #503 completed a mock code blue drill which included four other staff during the day shift. On [DATE], RN #422 was terminated for performance and policy violations. Upon investigation, it was determined RN #422 was uncooperative during the investigation process. RN #422 failed to provide an accurate description of what occurred and failed to follow the facility's policies and procedures regarding documentation. On [DATE] at 9:57 A.M., an interview with the Administrator stated the facility had no additional information related to their investigation into Resident #87's change in condition and his death to provide for State Survey Agency review. The facility did not provide any documentation of corrective actions completed by facility after their investigation. On [DATE] an ad hoc QAPI was held to discuss the incident with Resident #87 and reviewed plan for education and ongoing monitoring. Members in attendance included the Administrator, the DON, ADON #813, LPN #410, LPN #503, Social Service Director (SSD) #920, RDCO #417 and Medical Director #435. This will be reviewed at monthly QA meeting for the next six months. By [DATE], the DON educated all licensed nurses on completion and documentation of assessments with emphasis on obtaining current vital signs when assessing resident, CPR policy with emphasis on identifying code status, CPR/Ohio DNR comfort care and DNR CC Arrest policies with emphasis on immediately initiating CPR after verification of a CPR code status, and overhead announcement of code. All new hire nurses will be educated during the new hire orientation process by DON/designee. All borrowed nurses from sister facilities will be educated prior to shift start by DON/designee. Ongoing education will be completed during quarterly all-staff meetings by DON/designee. Starting on [DATE], DON/designee will complete mock code blue audits, three times a week for four weeks across various shifts. Concerns will be addressed in real time and discussed at monthly QA meetings. Starting on [DATE], DON/designee will review three assessments per week for four weeks across various shifts to validate assessment accuracy and completion of vital signs. Starting [DATE], DON/designee will continue ongoing audit of at least five residents' nurse's notes to be reviewed daily for five days/week for 12 weeks during daily clinical meetings to monitor for change of condition, and appropriate assessment/treatment completed, up to and including CPR. Any concerns noted will be addressed immediately. Results will be reviewed at monthly QA meetings. Starting [DATE], when the initiation of CPR is required, a Code Event Minutes form will be completed by a designated scribe with time resident is found and time CPR is initiated. These minutes will be reviewed by DON/designee after the Code Event Minutes form is completed, and any concerns will be addressed as appropriate. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #87's closed medical record revealed an admission date of [DATE] and diagnoses included obstructive sleep apnea, hyperlipidemia, weakness, non-pressure chronic ulcer of other part of left lower leg with other specified severity, peripheral vascular disease, chronic kidney disease stage three, chronic obstructive pulmonary disease (COPD), edema and other acute osteomyelitis to bilateral ankles and feet. Review of Resident #87's plan of care for COPD dated [DATE] revealed Resident #87 had shortness of breath while lying flat. An intervention dated [DATE] included the following: staff were to monitor vital signs, report abnormal findings to medical provider, resident/resident representative, staff were to observe for signs and symptoms of COPD: increased shortness of breath, frequent coughing with and without mucus, wheezing, tightness in the chest and anxiety. Report any abnormal findings to medical provider, resident/resident representative. Resident #87 had a physician order dated [DATE] for an advance directive of CPR (Full Code). Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact and had no behaviors during the review period. Resident #87 utilized a walker for mobility. Resident #87 required substantial/maximum assistance with toileting, partial/moderate assistance with upper body dressing, substantial/maximum assistance from sitting to standing, and partial/moderate assistance for chair to bed and toilet transfers. The discharge MDS assessment dated [DATE] revealed Resident #87 died in the facility. Review of Resident #87's medical record revealed he had wounds to left gluteal fold, left lower extremity, left lateral foot, sacrum/bilateral buttocks and right lateral foot with dressing changes to be done every day and night shift and as needed. Resident #87 received hydrocodone-acetaminophen 5-325 milligrams (mg) every four hours as needed (PRN) for severe pain greater than seven (a pain scale from zero to no pain to 10 the most severe pain). Resident #87 received this pain medication on [DATE] at 8:09 A.M. for a pain level of seven; on [DATE] at 12:32 P.M. for a pain level of eight and on [DATE] at 5:25 P.M. for a pain level of eight. Resident #87did not receive this medication the rest of the night. No administration of hydrocodone-acetaminophen was documented on [DATE]. Resident #87 was not documented as having behaviors during his admission to the facility. Review of Resident #87's vital signs in the medical record revealed the last complete set of vital signs was collected on [DATE] at 8:08 A.M. The following were recorded at 8:08 A.M.: pain at zero; pulse of 79 beats per minute (bpm) (normal resting heart rate); temperature of 97.4 degrees Fahrenheit (F); and blood pressure of 123/67 millimeters of mercury. Review of the skilled assessment dated [DATE] at 8:25 A.M. and authored by LPN #811 revealed no changes since the previous evaluation and indicated Resident #87 was alert and oriented times three. Subsequent vital signs recorded revealed on [DATE] at 8:28 P.M. respirations at 18 breaths per minute (normal resting range for an adult); on [DATE] at 10:59 P.M. oxygen saturation via nasal cannula at 94% (normal range); and on [DATE] at 11:52 P.M. blood glucose at 287 milligrams/deciliter (mg/dL) (blood sugar high (normal range 99 mg/dL or below). Review of an EMS telephone call on [DATE] at 11:49 P.M. revealed Resident #87 stated, I need assistance, I can't stand up. The resident explained he was at the facility and provided his room number and stated he needed lift assistance. The resident explained his former nursing aide for a year and a half came to the facility to change his bandage. When she came and was changing them, the nurse threw her out because she was not an employee. He identified himself as Resident #87. He stated they way he was sitting, it was killing his buttocks, and he can't [unable to determine the rest of what Resident #87 said]. There was no documentation in the resident's medical record this visitor was changing the resident's bandage and was thrown out of the facility. The EMS run sheet dated [DATE] at 11:50 P.M. revealed they were dispatched to the facility for a resident (Resident #87) who cannot stand up. While en route, dispatch updated EMS that a call was placed by the resident, and they will contact the facility to speak with staff. Upon arrival, the scene was determined safe. EMS staff entered the building and met a nurse (not able to be identified) at the front desk who stated the resident does not need to go to the emergency room (ER) and the resident just doesn't want to be here. (This behavior of not wanting to be in the facility was not documented in the medical record and interviews with staff could not corroborate this statement.) The nurse stated Resident #87 had no complaints and they were unaware Resident #87 had called EMS. EMS staff explained to the nurse that this was not an appropriate reason to go to the ER. The nurse agreed and stated she would speak with Resident #87. Resident to be left in care of staff. There was no documentation in Resident #87's medical record of EMS arriving at facility and no nursing assessment including vital signs obtained at this time. Review of a call from Berea Police and Fire Department to the facility on [DATE] at 11:54 P.M. revealed dispatch had gotten a call from Resident #87 for a 911 call from his room. Resident #87 stated he fell and needed assistance getting up, and they do have paramedics en route. LPN #423 answered the facility's telephone and stated she would check to find out what was going on. There was no documentation in the resident's medical record of a nursing assessment including vital signs obtained at this time and the telephone call received by the local police department was not documented in the medical record. Review of an EMS telephone call on [DATE] at 12:02 A.M. revealed Resident #87 called 911 back, the nurse just came in and said he sent 911 away. Dispatch told Resident #87 that staff told EMS they were not needed. Resident #87 stated he had been sitting there for six hours, no pain medications, and the nurse refused to do his bandaging on his feet. A telephone call was then placed to the facility and LPN #423 answered. Dispatch stated Resident #87 called 911 again and was on the other telephone line. LPN #423 stated EMS just left and said they were not going to take him; if they had known he had called they would never have come out. LPN #423 reported that Resident #87 did not fall, he was sitting in a chair, and she was not sure what they could do in that moment. EMS said they would not take him. Dispatch said Resident #87 was on the other line advising he could not stand up for hours. LPN #423 stated Resident #87's nurse [RN #422] was to be in his room with him to do a dressing change. Dispatch said they would talk to Resident #87. Resident #87 stated no nurse was in the room with him. Dispatch stated a male nurse was on his way to him. Resident #87 stated RN #422 has refused to bandage his legs for six hours and now he was gathering supplies, and the resident didn't know how long that takes. Dispatch stated the paramedics were there and staff were advising EMS that Resident #87 did not need transported to the hospital and she called and spoke with staff again. Resident #87 reported no one else was in his room. Dispatch asked to speak to whoever was in the room and RN #422 got on the line and identified himself as Resident #87's nurse [RN #422]. Dispatch told RN #422 that Resident #87 kept calling and he replied, yeah, there was not an emergency. Resident #87 yelled in the background, yes, there is. RN #422 then stated yeah, there's not an emergency, it would be a waste to send people and dispatch indicated EMS just got back in the station. Dispatch stated to advise Resident #87, if he keeps calling, they must send somebody out. RN #422 stated he would try; there was only so much that RN #422 can do and was not able to take Resident #87's telephone (which he implied he could not remove the resident's access to telephone). Dispatch stated at some point they would have to send somebody like police out; they would have to send someone. Resident #87 can be heard in the background saying, if you would do your job. Dispatch started to say, If he is being unreasonable. RN #422 then stated, Well I did not commit a crime. and dispatch indicated per protocol, they would have to send someone out to do a welfare check and she did not indicate anything had been done wrong. There was no evidence this EMS call was documented in Resident #87's medical record. The EMS run sheet dated [DATE] revealed a call received at 1:58 A.M. for a cardiac arrest for Resident #87. EMS was on the scene at 2:05 A.M. Resident #87 was unconscious, drooling, not breathing and had delayed skin capillary refill with pale, cyanotic skin. No blood pressure or pulse could be found. Upon arrival at the scene, Resident #87 was supine on the floor receiving CPR from nursing home staff. Staff stated Resident #87 fell from chair while being changed by nurse and when nurse left to get help to lift him, Resident #87 was found unresponsive and not breathing. No palpable pulse could be felt. Approximate arrest time was 1:55 A.M. Manual CPR was taken over by EMS with ventilations given via bag valve mask ventilation (BVM). Resident #87 was intubated and the cardiac monitor showed asystole (cardiac flatline), then pulseless electrical activity (PEA), then ventricular fibrillation (VFIB) then PEA. Resident #87 was taken to the hospital. Disposition of the call was identified as dead after arrival, resident dead at scene-resuscitation attempted with transport. Review of an EMS call dated [DATE] at 1:58 A.M. revealed a female voice (CNA #620 upon review of the facility's telephone list) was at the facility and they had a resident (Resident #87) that was not responsive and had no pulse or anything and provided the room number. Dispatch asked if a nurse was in there with the resident and CNA #620 indicated RN #422 was in with the resident. Dispatch asked if they were doing CPR. CNA #620 stated yes, they were trying to do CPR now and it looked like the resident fell out of a chair and his back was against the chair, they were trying to lay him down flat on the floor and do CPR. Dispatch stated medics were going to be dispatched and told the caller whoever was performing CPR to keep doing so until the medics got there and to have someone meet the medics at the door. Review of the change in condition evaluation dated [DATE] at 2:40 A.M. and authored by RN #422 revealed Resident #87 was unresponsive and it began this morning [[DATE]]. The assessment stated there were no vital signs obtained after the change in condition occurred, and listed vital signs obtained on [DATE] at 8:08 A.M. which included blood pressure, pulse, heart rate, respirations and temperature. Resident #87's advance directive was listed as CPR and respiratory assessment indicated Resident #87 had apnea (temporary cessation of breathing, preventing the body from getting enough oxygen). The progress note and eInteract Situation, Background, Assessment and Recommendation (SBAR) dated [DATE] at 2:40 A.M. and authored by RN #422 revealed Resident #87 was unresponsive and listed vital signs collected on [DATE] at 8:08 A.M. (blood pressure, pulse, respirations, and temperature), at 8:28 P.M. (blood glucose), at 11:52 P.M. (pulse oximetry). The eInteract transfer to hospital evaluation dated [DATE] at 2:41 A.M. and authored by RN #422 revealed Resident #87 was sent to the hospital at 2:30 A.M. due to unresponsive status. Vital signs (no time listed) were blood pressure at 129/73 mmHg; temperature at 98.7 degrees F; pulse was 68 bpm; respirations were 14 breaths per minute; and oxygen saturation 95%. Review of a death certificate revealed Resident #87's time of death was on [DATE] at 2:50 A.M. with cause of death as cardiopulmonary and pulseless electrical activity with onset of 15 minutes prior to death. No autopsy was performed, and the manner of death was listed as natural. The progress note dated [DATE] at 11:12 A.M. and authored by RN #422 revealed the nurse was performing a dressing change on Resident #87 and needed assistance transferring Resident #87. This writer left the room to get assistance and upon returning, found Resident #87 unresponsive. After a quick assessment, this writer began CPR and instructed nearby personnel to get an automated external defibrillator (AED) and call EMS. EMS arrived and continued CPR and transferred the resident to the emergency room (ER). Family arrived at the scene shortly after. DON and Administrator notified. Review of an e-mail witness statement dated [DATE] at 8:47 A.M. and authored by RN #422 revealed while caring for Resident #87, a CNA began a dressing change without communicating to RN #422 (time not given). At the time, RN #422 was completely unaware of who she was or what her level of licensure was. She repeatedly refused to clarify her identity and level of licensure while making threats to both RN #422 and the facility. Her behavior was extremely aggressive and unprofessional and may even be classified as abuse. Eventually, she explained who she was and her licensure. Upon finally being made aware of her licensure, RN #422 explained how many aspects of the dressing change cannot be performed by CNAs as they were beyond her scope of practice. Namely wound assessment: all assessments cannot be delegated and must be performed by nurses and nurses only. Furthermore, the aspects of the dressing change with which she completed, the dressings were completed incorrectly, putting the resident at risk as well. When explaining the process of a dressing change, the CNA displayed a gross lack of understanding that RN #422, using his clinical judgement, considered unacceptable for practice. Simply put she described a dressing change as ‘just following directions,' when there was such a deeper level of knowledge required. In regard to Resident #87's EMS calls, there were two. During the first EMS call, Resident #87 stated he fell. RN #422 entered Resident #87's room, found him in his chair and asked if he fell. Resident #87 stated he never fell. EMS refused to admit him as an emergency situation was not occurring. EMS was called a second time (time not given) by Resident #87 and refused to travel to the facility. Then RN #422 completed Resident #87's dressing change (time not given). Following the dressing change, RN #422 required assistance with transferring Resident #87 (time not given). RN #422 left the room to get assistance. When RN #422 arrived at Resident #87's room, he was unresponsive (time not given). After a quick assessment (not documented, no time given) RN #422 began CPR and instructed nearby healthcare personnel to get an AED and call EMS. EMS transported Resident #87 to the emergency department (ED). Review of a typed witness statement dated [DATE] for RN #422 revealed on [DATE] (no time given), RN #422 was doing a dressing change to Resident #87's buttocks while he was positioned on walker in front of chair. Resident #87 became weak, and RN #422 had to lower Resident #87 to the floor. RN #422 went to get assistance from other nursing staff (no time given, no staff identified). Resident #87 was responsive at the time (not given) and RN #422 went to get help. Upon arrival at the room with staff assistance (no time given, no staff identified), RN #422 attempted to transfer Resident #87 into bed, he became unresponsive, so the resident was lowered to the floor and CPR was initiated (time not given).Review of RN #422's written witness statement dated [DATE] revealed Resident #87 used his call light and entered the room (time not given). Resident #87 requested to have his dressings changed and RN #422 informed him that RN #422 would gather supplies and change his dressing shortly. Upon re-entering the room (time not given), RN #422 found a home health aide performing his dressing change. RN #422 stopped this home health aide and asked who she was. The home health aide refused multiple times to identify herself, her behavior was very aggressive and unprofessional. Home health aide left with the dressing change incomplete. Resident #87 then called the police stating he fell. EMS arrived and refused to admit him because he was in stable condition. When EMS arrived, Resident #87 stated he did not fall. Resident #87 repeatedly called EMS (times not given) until RN #422 began his dressing change. RN #422 completed the dressing change. After RN #422 completed the dressing change, RN #422 and [Resident #87] were having issues operating his chair (time not given). RN #422 and Resident #87 were unable to bring his chair to a working height, so RN #422 left the room to get assistance transferring Resident #87. When RN #422 looked for help, all the CNAs were not on the floor, and RN #422 was not notified of the CNAs leaving. RN #422 ran to the other side to get CNA #509 (time not given). Resident #87 was not responding to words or stimuli. RN #422 performed an assessment and felt a weak thready pulse (vitals not recorded) and apnea. RN #422 and CNA #509 lowered Resident #87 to the ground and began CPR, called EMS, and instructed a (unidentified) CNA and to get an AED (times not given). No shocks were advised by the AED. EMS arrived and transported Resident #87. Review of CNA #509's typed witness statement dated [DATE] revealed RN #422 came to request her help with Resident #87. When CNA #509 came to the front hall (time not given), Resident #87 was sitting on the floor with his back resting on the chair, unresponsive. Both RN #422 and CNA #509 attempted to arm and arm, two-person assist the resident into the chair. When unsuccessful, RN #422 and CNA #509 went to get a lift sling in attempt to mechanically lift Resident #87 into the chair. Female nurse (not identified) came in to assist (time not given) and observed Resident #87 lying on the floor on lift sling. Female nurse (not identified) questioned RN #422 regarding Resident #87's pulse. CPR initiated (time not given), aide (not identified) was instructed to call 911 by female nurse (not identified) and EMS came in to continue CPR. Review of LPN #423's typed witness statement dated [DATE] revealed Resident #87 had called police/EMS three times that night. First time, EMS stated Resident #87 had fallen. LPN #423 ran to verify Resident #87 was ok and observed him sitting in his recliner chair. LPN #423 advised RN #422 that EMS was called. RN #422 then went to Resident #87's room to observe him in his chair, asked Resident #87 if he had fallen and if he was ok. Once EMS arrived and entered the facility, staff let EMS know Resident #87 had not fallen and he was ok. EMS did not assess or observe Resident #87 and left the scene. RN #422 then advised Resident #87 he was going to dress his wounds. LPN #423 went back to her work area, shortly after she reported back to her own work area, there was a telephone call from EMS a second time. Between 2:00 A.M. and 3:00 A.M., LPN #423 saw RN #422 come to the back for a nasal cannula then go back towards the front. About 20 minutes later, LPN #423 saw RN #422 come to the back of the facility and ask for help because Resident #87 had fallen. CNA #509 went to assist RN #422. Another nurse on shift (not identified) was also prompted to help. Once at Resident #87's room, LPN #423 observed Resident #87 lying on floor on Hoyer (mechanical lift) pad. LPN #423 asked RN #422 if Resident #87 had a pulse. RN #422 stated he checked the pulse (time not given), and a pulse was present (vital signs not recorded); after rechecking the pulse, RN #422 stated no pulse was present, so CPR was initiated (no time given). Review of CNA #620's typed witness statement dated [DATE] revealed on or after 2:00 A.M., CNA #620 was doing rounds. CNA #620 came out of a nearby resident's room and noticed CNA #509 standing by Resident #87's door and he motioned for CNA #509 to come help. CNA #509 asked where RN #422 was, CNA #509 mentioned RN #422 went to get another nurse for help. When LPN #905 and LPN #423 arrived (time not given), CNA #620 and CNA #509 were instructed to clear the room. EMS was called and compressions were started (time not given). Review of LPN #905's witness statement dated [DATE] revealed LPN #905 did not recall much from that night but did remember someone had called the police. LPN #905 ran to the front to observe if Resident #87 was on the floor (time not given). Once LPN #905 noted Resident #87 was not on the floor, she went back to report findings to EMS. LPN #905 stated EMS arrived and stated they could not take Resident #87 if there was nothing reported. EMS never entered Resident #87's room. As the night progressed (time not given), RN #422 stated Resident #87 called the police on him again. When LPN #905 entered the building (time not given), everyone was running towards Resident #87's room and was asking for her help. When LPN #905 ran to Resident #87's room, LPN #905 saw Resident #87 on the floor, his arms were above his head, and he had on a nasal cannula. LPN #905 observed the crash cart outside the door and chest compressions were being performed (staff not identified). After a while EMS ran in (time not given) to continue to assist with CPR. Review of CNA #609's typed witness statement dated [DATE] revealed Resident #87 called EMS around 12:00 A.M. and did not see him go out with EMS upon arrival. CNA #609 asked Resident #87 why he did not go to the hospital, and he responded he did not want to. Later on, that night (no time given), RN #422 informed CNA #609 that Resident #87 was down on the floor. When CNA #609 went into the room to assist, Resident #87 was positioned on the floor with his back against his chair. LPN #905 and LPN #423 arrived (time not given), and CNA #609 got the crash cart to assist. Review of an undated and unauthored document regarding Resident #87 revealed the following information: - On [DATE] (no time listed) RN #422 reported doing a dressing change for Resident #87, went to get assistance and when he returned, Resident #87 was unresponsive. CPR was initiated and continued until EMS arrived and took over CPR. Resident #87 was sent to the ER. - On [DATE] (no time listed) Resident #54 (Resident #87 was his former roommate) said he wanted to talk with the Administrator and the DON. Resident #54 had monitored the care of Resident #87 and reported the approximate time of Resident #87 requesting and receiving pain medications. Resident #54 also believed EMS had been called on two different occasions but believed they had been turned away as they never came into the room. This was concerning to Resident #54, but the concerns reported did not rise to the level of abuse/neglect without further investigation. RN #422 was suspended pending investigation. - No date listed. An investigation was initiated, other residents were assessed with no concerns, staff statements were obtained, and the facility requested the EMS run report.- On [DATE], Admissions #705 called Family Member (FM) #425 to offer condolences. No questions, concerns or requests were made at this time.- From [DATE] to [DATE] (inaccurate dates) it was determined from statements collected that RN #422 stated EMS arrived at the facility because Resident #87 had called them, stating he had fallen. RN #422 had gone to Resident #87's room and talked with Resident #87 who had not fallen and went back to the desk to report this information to EMS. EMS left the facility. Later that night (no time listed) EMS called the facility and stated they received a call from Resident #87; RN #422 talked to EMS and told them Resident #87 was okay. Later than night (no time listed) RN #422 was completing a treatment on Resident #87 when he went unresponsive and was lowered to the floor. RN #422 alerted staff (not specified, no time listed) for additional assistance. At that time (not listed) Resident #87 had a pulse. At some point while trying to place Resident #87 in the bed, he lost his pulse and respirations, and EMS was called, and CPR was initiated. EMS arrived, continued CPR and took Resident #87 to the hospital. A discrepancy was identified regarding RN #[TRUNCA

Based on closed record review, staff and family interview and policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure Resident #90 was provided adequate assistance during care to prevent a fall with major injury. Actual harm occurred 02/05/25 when Resident #90, who required substantial/maximal staff assistance with bed mobility (rolling left and right) and was dependent on staff for toileting sustained a fall from an elevated bed during the provision of care. As a result of the fall the resident suffered left and right femur fractures, a fibula fracture and a tibia fracture requiring hospitalization and medical intervention. This affected one resident (#90) of three residents reviewed for falls. The facility census was 81. Findings include: Review of the closed medical record for Resident #90 revealed an admission date 11/15/13 with a discharge date of 02/14/25. Resident #90 had diagnoses including severe obesity, chronic respiratory failure, age related osteoporosis with current pathological fracture and type II diabetes mellitus. Resident #90 had been hospitalized from [DATE] to and returned to the facility on [DATE]. Review of the care plan dated 03/29/22 revealed Resident #90 was at risk for falls related to gait, balance problems, incontinence, weakness, vertigo and dizziness. Interventions included ensuring the bed locks were engaged. Review of the physician's orders dated 02/26/23 revealed an order to place an air mattress to bed and check inflation every shift. This order was discontinued on 01/06/25 when Resident #90 was discharged to the hospital. Resident #90 returned to the facility on [DATE]. Upon re-admission there was no physician order in place for the resident to have an air mattress to the bed. In addition, review of the treatment administration record (TAR) and medication administration record (MAR) revealed no documentation the resident's air mattress was checked for inflation from 01/08/25 to 02/05/25. Review of the admission evaluation dated 01/08/25 revealed Resident #90 was at risk for falls. Review of the plan of care dated 01/10/25 revealed Resident #90 had impaired skin integrity, or was at risk for altered skin integrity related to impaired mobility, incontinence, refusing to get out of bed, morbid obesity, diabetes, dry skin, lymphedema and fragile skin. Interventions included to provide appropriate off-loading air mattress. Monitor inflation every shift. The care plan also revealed Resident #90 had a self-care performance deficit, and required assistance with activities of daily living (ADL) related to impaired mobility, morbid obesity and disease process. Interventions included one person assistance for toileting and bed mobility and mechanical lift for transfers with two persons assistance. Review of a change of condition assessment dated [DATE] at 4:20 P.M. revealed Resident #90 fell out of bed and landed on her knees on the floor, with a complaint of pain. Review of a pain observation tool dated 02/05/25 (following the fall) revealed Resident #90 verbalized severe pain to the left leg and left knee. Review of unusual occurrence documentation dated 02/05/25 at 4:20 P.M. revealed Licensed Practical Nurse (LPN) #614 was called to Resident #90's room by Certified Nursing Assistant (CNA) #432. Resident #90 was observed on floor, facing bed with both legs folded underneath the resident. Resident #90 stated she did not hit her head. Resident #90 complained of pain to bilateral lower extremities. LPN #614 called 911 while two additional nurses remained in the room. The documentation revealed Resident #90 was alert and oriented times three. Review of a witness statement for CNA #432, written by LPN #614 on 02/05/25 at 5:13 P.M. revealed Resident #90 was rolled to right of bed to have brief place under her, during incontinent care of bowel. Resident #90's lower body rolled off the bed. Resident #90 was hanging on to grab bar. Resident #90 did not hit her head. The witness statement did not include any information about the resident's air mattress. Review of a witness statement dated 02/05/25 from LPN #614 revealed she was called into Resident #90's room by CNA #432. Upon entering the room Resident #90 was observed on the floor facing the wall with both legs underneath her. Resident #90's head was at roommate's foot board. Resident #90 complained of pain to both legs. Resident #90 was left in room with two other nurses while LPN #614 went and notified Director of Nursing (DON) and called 911. Resident #90 stated CNA #432 was providing incontinence care and Resident #90 rolled off the bed because CNA #432 moved her too far. Staff assisted Emergency Medical Service (EMS) and Resident #90 was transferred to hospital for evaluation. The witness statement did not include any information about the resident's air mattress. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had intact cognition. The assessment revealed Resident #90 was dependent on staff for toileting and required substantial/maximal staff assistance to roll left and right. Resident #90 was frequently incontinent with bowels and had an indwelling catheter. Review of documentation from Hospital #1 revealed Resident #90 was diagnosed with left femur fracture, right femur fracture, fibula fracture, and tibia fracture. The plan was to transfer Resident #90 to Hospital #2 for level II trauma on 02/06/25. The hospital documentation included Resident #90 told the hospital (staff) she had a bowel movement and was turned on her side to be cleaned up. The resident stated she told the CNA to be careful because she felt she was going to fall. The resident stated she then fell off the bed and injured her bilateral legs and hips. An attempt to receive medical record information from Hospital #2 for review during the survey was unsuccessful. Interview on 08/13/25 at 10:25 A.M. with Corporate Regional Nurse #421 on 02/05/25 at the time of the fall, CNA #432 was trying to put a clean incontinence product (Depends) under Resident #90 and pushed down too hard and Resident #90 fell out of bed. Interview on 08/14/25 at 3:17 P.M. with Resident #90's sister revealed Resident #90 fell out of bed (on 02/05/25) when personal care was being provided by CNA #432. The sister stated Resident #90 told her that CNA #432 kept scooting her closer to the edge of the bed and Resident #90 told CNA #432 to stop. The sister reported the resident's legs were on the edge of the bed and gravity took over and she could not stop her legs from falling. The resident's bed was also in a high position since care was being provided. The sister revealed Resident #90 was holding onto the grab bar, but her legs fell off the bed and she landed on her knees. Resident #90 was taken to the local hospital and had to be transported to a bigger hospital due to her injuries. The resident's sister reported Resident #90 broke both knees, tibias, fibulas and femurs and broke her left ankle. Resident #90's sister stated Resident #90's left ankle was not being fixed until the other injuries could be taken care of. Interview on 08/13/25 at 3:04 P.M. with Registered Nurse (RN) #507 revealed she had provided care to Resident #90 during the resident's stay at the facility. The RN revealed Resident #90 had an air mattress (prior to and following the hospitalization in January 2025), and the mattress was based upon the resident's weight. The nurse was to check every shift the settings on the air mattress and document it on the TAR. The RN revealed this was the policy for any resident (including Resident #90) with an air mattress. Interview on 08/18/2025 at 10:25 A.M. with LPN #614 revealed on 02/05/25 she was the nurse on duty and it was at the end of her shift when Resident #90 sustained a fall. The LPN revealed CNA #432 was providing incontinence care to Resident #90 and the CNA rolled her to far and Resident #90 fell out of bed on to her knees. In regard to the use of an air mattress, the LPN revealed staff were to check the air mattress every shift for proper inflation and if there was an issue with the mattress it would beep to alert staff. Interview on 08/18/25 at 12:00 P.M. with the Director of Nursing (DON) verified Resident #90 was hospitalized from [DATE] to 01/08/25 and upon return the physician orders for the resident's air mattress were not resumed. However, the resident continued to have the air mattress in place. The DON verified there was no documentation of the nurse's monitoring Resident #90's air mattress between 01/08/25 and 02/05/25 to ensure proper inflation was maintained or evidence the functionality of the air mattress was included as part of the investigation of the resident's fall. An attempt to interview CNA #432 during the survey was unsuccessful. Review of the facility's undated policy titled Specialty Mattresses revealed the nurse would validate the bed was functional, plugged into the proper outlet and the cords and bed were in good working condition. Review of the facility's undated policy titled Routine Resident Care revealed the facility would provide routine daily care by a CNA with specialized training in rehabilitation/restorative care under the supervision of a licensed nurse including but not limited to maintaining proper body position and alignment for all residents. This deficiency represents non-compliance investigated under Complaint Number 2574706, Complaint Number OH00165814 (1317322), Complaint Number OH00162622 (1317319), and OH00162278 (1317317).

Based on observation, staff interviews, and review of the facility policy, the facility failed to ensure expired foods were disposed of timely. This had the potential to affect 79 residents who the facility identified receive meals from the kitchen, and Residents #6 and Resident #45 were ordered nothing-by-mouth. The facility census was 81.Findings included: Observation of the kitchen on 08/11/25 starting at 9:28 A.M. with Dietary Manager (DM) #418 revealed the following areas of concern: in the walk-in cooler, there was an expired case of sour cream packets dated 07/14/25 and an expired jar of Dijon mustard dated 03/27/25; in the dry stock room, there was an expired jar of Dijon mustard dated 03/27/25 and an expired container of bread crumbs dated 06/06/25. in the resident refrigerator, there was an expired jug of prune juice dated 07/03/25. DM #418 verified the sour cream packets, jars of Dijon mustard, bread crumbs, and prune juice were expired and indicated he or his staff was to go through food storage weekly and dispose of out of date foods at that time. The facility identified Residents #6 and #45 did not receive food from the kitchen because their diet orders were nothing-by-mouth. Review of the facility's policy titled Receiving revised February 2023 revealed all foods will be stored in a manner that ensures appropriate and timely utilization based on the principles of first-in, first-out (FIFO) inventory management.

Based on record review, staff interview, and facility policy review, the facility failed to implement and maintain a comprehensive Quality Assurance Improvement Program (QAPI) program and plan to address care issues and/or concerns in the facility. This had the potential to affect all 81 residents who reside in the facility. The facility census was 81.Findings included: Review of the Quality Assurance (QA) committee attendance records for the previous 12 months revealed QA meetings were held on [DATE], [DATE], [DATE] and [DATE]. The findings for the annual survey, in conjunction with multiple complaint allegations, dated [DATE] revealed noncompliance in the area of abuse resulting in Immediate Jeopardy, actual harm and death beginning on [DATE] at 11:30 P.M. when Resident #87 complained of chest pain to Certified Nursing Assistant (CNA) #609 who reported the change to Registered Nurse (RN) #422. RN #422 then failed to timely identify and obtain treatment for Resident #87 following an acute change in condition. In addition, the facility failed to ensure cardiopulmonary resuscitation (CPR) was initiated timely at the time Resident #87 was found unresponsive (without vital signs). On [DATE] at 2:50 A.M., Resident #87 expired with cause of death as cardiopulmonary and pulseless electrical activity with onset of 15 minutes prior to death. There was also noncompliance found in the area of quality of care resulting in actual harm to Resident #90, who required substantial/maximal staff assistance to roll left and right and was dependent on staff for toileting was improperly rolled from the elevated bed and Resident #90 fell to the floor, sustaining multiple fractures including left and right femur (leg bone between your hip and thigh, the longest, heaviest, and strongest bone in the body and it takes a tremendous force to break your femur) fractures, fibula fracture (smaller out bone of the lower leg) and tibia fracture (shinbone) and required hospitalization on [DATE]. The facility was unable to provide evidence, including documentation, of its ongoing QAPI program's implementation with the neglect of Resident #87 and Resident #90's fall. Interview on [DATE] at 11:52 A.M. with the Administrator confirmed there were no evidence including documentation that the QAPI program implementation with the neglect of Resident #87 and Resident #90's fall. Review of the facility's undated policy titled QAPI (Quality Assurance Performance Improvement) Plan revealed the facility would provide resident centered care that meets the psychosocial, physical and emotional needs of the residents. Safety of residents, staff and visitors is a primary focus of the facility. Regulations require that the facility have an ongoing QA, process improvement plan to monitor the quality of resident care. QAPI data is used not only to identify quality and safety problems, but to also identify other opportunities for improvement, and then setting priorities for action. QAPI focuses on identifying and undertaking systemic change to eliminate problems after the root cause is determined.

Based on record review and staff interview, the facility failed to ensure Quality Assurance (QA) meetings were held at least quarterly with the Medical Director present, to address care issues/concerns in the facility. This had the potential to affect all 81 residents who reside in the facility. Findings included: Review of the QA committee attendance records for the previous 12 months revealed the facility held four QA meetings in four consecutive months on 04/25/25, 05/05/25, 06/02/25, and 07/07/25. The facility had no other records of QA meetings held from 09/01/25 to 03/31/25. Interview on 08/20/25 at 11:52 A.M. with the Administrator confirmed there were no other QA meetings documented, and she had no evidence that the meetings had taken place and if the Medical Director was present. Review of the facility's undated document titled QAPI (Quality Assurance Performance Improvement) Plan revealed the facility had a policy in place that the facility would have a QAPI meeting every month with required members present.

Based on observation, staff interview, and facility policy review, the facility failed to perform hand hygiene between residents and after glove use during medication administration. This affected five residents (#51, #63 #76, #110, and #111) observed for medication administration. The facility census was 81. Findings included: 1. Observation on 08/12/25 at 7:43 A.M. during medication administration revealed Licensed Practical Nurse (LPN) #814 opened the locked medication cart and pulled the medication cards and bottles for Resident #76. LPN #814 then placed each prescribed medication dose into the medication cup. LPN #814 then signed off medications in the electronic medical record and proceeded directly to administer pulled medications to Resident #76. LPN #814 did not perform hand hygiene prior to administering medications to Resident #76, or after contact with Resident #76 and the environment. Additionally, LPN #814 was subsequently observed to administer medication to Residents #111 and #110 without performing any hand hygiene between each resident's medication administrations. Observation on 08/12/25 at 8:06 A.M. revealed LPN #814 was wearing gloves and obtained Resident #63's a blood glucose (accu check). LPN #814 did not perform hand hygiene prior to donning gloves or after removing gloves after the blood glucose check was obtained for Resident #63. Interview with LPN #814 on 08/12/25 at 8:09 A.M. verified she had not performed hand hygiene as required during medication administration to Residents #76, #110, and #111 or during blood glucose check for Resident #63. LPN #110 stated she forgot. 2. Observation on 08/12/25 at 8:20 A.M. revealed LPN #914 did not perform hand hygiene prior to administering Resident #51's medications. LPN #914 was not observed performing hand hygiene prior to or after resident medication administration. Interview with LPN #914 at 8:30 A.M. verified she had forgotten to perform hand hygiene before and after contract with residents and the environment as required. Interview with Director of Nursing (DON) and Regional Director #417 on 08/12/25 at 11:30 A.M. verified all staff were to follow the facility's medication administration policy and complete hand hygiene before and after administering medications, and prior to next resident contact. Review of facility's undated policy titled Medication Administration revealed staff must perform appropriate hand hygiene before beginning medication administration, observe standard precautions including safe sharps use, and perform hand hygiene before and after each resident's medication is administered.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure the residents received quarterly statements for their resident funds account. This affected one (#54) of six residents reviewed for resident trust funds account. The facility identified 38 residents had resident funds account. The facility census was 81.Findings included: Review of the medical record for Resident #54 revealed an admission date of 09/10/24 and was listed as the primary responsible party for billing. Review of the Resident Fund Management Service Authorization Agreement to Handle Resident Funds, revealed Resident #54 signed the document to set up a resident fund account. The document indicated with a signature, the person was authorizing the facility to establish an insured interest-bearing account and the person signing the document would receive a statement at least quarterly.Review of the facility document Resident Fund Statement dated 08/18/25, revealed Resident #54 had a resident fund account with a balance of $300.55. Resident #54's quarterly statements for the period of 04/01/25 through 06/30/25 revealed the resident had a balance of $300.55. Interview with Resident #54 on 08/11/25 at 10:27 A.M. revealed he had not received any quarterly statements and did not know what was in his personal fund account. Resident #54 stated he had asked multiple times to see his balance but was never given a statement as promised. Interview with Business Office Manager (BOM) # 612 stated she was new to the facility and has not provided any of the quarterly statements to the residents or guardians. BOM #612 verified Resident #54 has not received any quarterly statements. Review of the facility's policy titled Resident Trust Fund dated 10/19/17 revealed the purpose was to hold, safeguard, manage, control and reconcile the personal needs funds deposited with the facility by the residents, as authorized, in a manner and in compliance with all laws and regulations to provide the residents with accurate and timely information regarding their personal funds. Employee #1 will mail quarterly Resident Trust Fund Statements once approved by Employee #3.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to notify each resident that received Medicaid benefits when their resident reached $200 less than the Supplemental Security Income (SSI) resource limit. This affected two residents (#28 and #45) of six residents reviewed for resident funds. The facility census was 81.Findings included: 1. Review of the medical record for Resident #28 revealed an admission date of 06/07/23 and Medicaid was a payor source. The resident was the primary financial contact and was cognitively intact. Review of Resident #28's resident fund account's quarterly statement revealed a current balance on 08/14/25 of $2,372.91. The quarterly period statement of 04/01/25 through 06/27/25 revealed a balance of $2,372.91. The facility provided no documentation to prove Resident #28 had received a spend down notification. Interview on 08/18/25 at 10:31 P.M. with Resident #28 revealed he was not aware of how much he had in the account. Interview on 08/18/25 at 11:59 A.M. with Business Office Manager (BOM) #612 confirmed there was no documented proof that spend down letters had been sent to Resident #28. BOM #612 stated she has only been at facility for six weeks and was still catching up from previous manager. BOM #612 verified that extra monies should have been transferred to Resident #28 Qualified Income Trust (QIT) account. 2. Review of medical record for Resident #45 revealed an admission date of 07/20/18 and Medicaid was the payor source. Resident #45 was not interviewable. Review of Resident #45's resident fund account's quarterly statement revealed a balance of $4,186.56 for the period of 04/01/25 through 06/27/25. The current balance on 08/14/25 was $4,186.56. There was no documented evidence that Resident #45 had received a spend down notification. Interview on 08/18/25 at 11:59 A.M. with Business Office Manager (BOM) #612 confirmed there was no documented proof that spend down letters had been sent to Resident #45.BOM #612 stated she has only been at facility for six weeks and was still catching up from previous manager. BOM #612 verified Resident #45 should have received a spend down letter. Review of the facility policy Resident Fund Management (RFMS) Policy, revised 10/13/21, revealed the business office was to notify all Medicaid residents when the asset limit was approaching.

Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to ensure care plans were timely updated and care conferences were held quarterly with the resident and/or family. This affected two residents (#49 and #58) of three residents reviewed for care plans. The facility census was 81. Findings included: 1.Review of the medical record for Resident #49 revealed she was admitted to the facility on [DATE]. Diagnoses that included type II diabetes mellitus with ketoacidosis without coma and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had some cognition impairment. Review of the care plan dated 07/09/25 revealed Resident #49 had an ADL self-care performance deficit due to impaired cognition, weakness and poor safety awareness. Resident #49 was independent with showers and/or bathing with assistance required based on time of day, mood, pain, or fatigue and adjust as indicated. Review of the progress note date 07/16/25 at 1:00 A.M. revealed Resident #49 was confused to the point she would urinate on the floor and was unable to care for herself. Interview on 08/11/25 at 10:34 A.M. stated she was overdue for a shower and needed assistance at this time due to her feet being swollen. Interview and observation on 08/11/25 at 10:36 A.M. with Certified Nurse Assistant (CNA) #520 revealed Resident #49 sitting up in bed with her blood-stained gown. CNA #520 stated she was unsure when Resident #49 was last showered, had a change of clothes, and not sure how long she was in her blood-stained gown. CNA #520 asked Resident #49 if she wanted a shower. Resident #49 replied to CNA #520 stating she has been wanting a shower but needed help because her feet were swollen. Interview on 08/14/25 at 2:21 P.M. with CNA #901 revealed Resident #49 required assistance with ADLs including showers and baths. Interview on 08/14/25 at 2:22 P.M. with CNA #516 revealed Resident #49 always required assistance with her ADLs. CNA #516 revealed she typically provided shower care for Resident #49 when she worked her shift, however, she could not speak to other staff members and on days she did not work. Interview on 08/18/25 at 4:45 P.M. with Licensed Practical Nurse (LPN) #610 during review of Resident #49 electronic medical record (EMR), revealed Resident #49 required assistance with ADLs including showers. LPN #610 stated Resident #49 fluctuated between stand-by assist to one-person assist daily. LPN #610 revealed Resident #49's care plan indicated she was independent with ADLs. LPN #610 confirmed Resident #49's care plan should have been updated to reflect the change in care need assistance. Review of the facility's undated document titled Plan of Care Overview revealed the facility had a policy in place to initiate, review and revise the care plan of residents as the resident's condition warrant. 2. Review of the open medical record for Resident #58 revealed and admission date 09/18/24. Diagnoses included front temporal neurocognitive disorder, depression, anxiety, and altered mental status. Review of the care conference note dated 11/11/24 at 10:40 A.M. revealed Resident #58 and guardian via telephone, social worker and Director of Nursing (DON) who attended the care conference. This was the last time a care conference was provided for Resident #58. Interview on 08/11/25 at 9:41 A.M. with Resident #58 revealed she has not been asked to attend a care conference this year. Interview on 08/14/25 at 9:38 A.M. with Social Worker Designee (SWD) #920 stated care conferences were completed yearly, quarterly and 72 hours on admission. SWD #920 stated the whole 'team', resident and family/guardian are asked if they want to attend the care conference. The SWD #920 verified she could not find any documentation that a care conference was held for Resident #58 after 11/11/24. SWD #920 confirmed there should have been two care conferences completed this year, and none was completed for Resident #58. Review of the facility's undated policy titled Plan of Care Overview revealed care plans would be held quarterly and/or with significant changes in care, support the residents right to participate in treatment and care planning, schedule meeting to accommodate resident's representative and plan adequate meeting time for decision making and discussion.

Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to ensure the residents received proper treatment and assistive devices to maintain hearing abilities. This affected one (#49) of one reviewed for ancillary services. The facility census was 81. Findings included: Review of the medical record for Resident #49 revealed she was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with ketoacidosis without coma and chronic obstructive pulmonary disease. Review of the physician orders dated 12/24/24 revealed a current order for consultations for audiology as needed. Review of the progress note dated 04/15/25 at 1:41 P.M. revealed Resident #49's brother requested appointments for audiology, optometry, and dental appointments. Resident #49 was being put on the list to be seen for these services. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had some cognition impairment and had minimal difficulty related to hearing. Review of the care plan dated 07/09/25 revealed Resident #49 had an activities of daily living (ADL) self-care performance deficit due to impaired cognition, weakness and poor safety awareness and was at risk for communication related to dementia. Interventions included allow adequate time to respond, turn off television and/or radio to reduce environment noise and observe effectiveness of communication. The progress note dated 07/16/25 at 1:00 A.M. revealed Resident #49 stated her mood had not been great due to issues with hearing and vision. Resident #49 stated she was angry due to her hearing and vision not being fixed and being depressed about her limited hearing. The progress note dated 07/28/25 at 1:00 A.M. revealed Resident #49 stated her hearing was bad. The progress note dated 07/29/25 at 1:00 A.M. revealed Resident #49 had vertigo. The progress notes dated 08/08/25 at 1:00 A.M. revealed Resident #49 stated she was unable to hear well and had been self-isolating in her room and sleeping most of the day. Review of the patient list for the last audiology visit dated 01/13/25 revealed Resident #49 was not seen. Interview on 08/11/25 at 10:34 A.M. with Resident #49 revealed her hearing was bad and the facility staff were not doing anything about it. Resident #49 stated sometimes staff ignored her and focused on other residents. Interview and observation on 08/11/25 at 10:36 A.M. with Certified Nurse Assistant (CNA) #520 revealed she was not aware of when the last time Resident #49 was seen by the audiologist. CNA #520 stated Resident #49 was unable to hear that well and staff were required to speak louder when talking to her. Resident #49 stated, during interview with CNA #520, If y'all are talking to me, y'all need to speak up. Resident #49 was also observed placing her right hand behind her right ear and stated, I don't know what y'all are saying, but I hope it's something good. CNA #520 confirmed Resident #49 had hearing difficulty. Interview on 08/12/25 at 3:56 P.M. with Social Service Director (SSD) #920 revealed she was responsible for handling dental, vision, audiology and podiatry appointments. SSD #920 stated staff members consisting of nurses, CNAs, management, or anyone that was aware, would inform her if a resident required or requested ancillary services and she would add them to the list to be seen on the next upcoming visit unless it was an emergency. SSD #920 revealed vision services were every three months, and they had already been into the facility a few weeks ago. Follow-up interview on 08/13/25 at 12:15 P.M. with SSD #920 revealed Resident #49 had no history of being seen by the audiologist and was not on the upcoming list to be seen. SSD #920 stated there were no upcoming dates for the audiologist. SSD #920 confirmed Resident #49 requested and needed to be seen by the audiologist and confirmed Resident #49 had no prior or upcoming appointments scheduled. Review of the facility's undated document titled Resident Rights revealed the facility had a policy in place that residents would receive personal care including, but not limited to, attending to needs in a timely fashion.

Based on record review, resident and staff interviews, and observation, the facility failed to ensure the residents received timely and proper treatments for foot care. This affected one (#49) one resident reviewed for podiatry. The facility census was 81.Findings included: Review of the medical record for Resident #49 revealed she was admitted to the facility on [DATE]. Diagnoses which included type II diabetes mellitus with ketoacidosis without coma and chronic obstructive pulmonary disease. Review of the physician orders dated 12/24/24 revealed a current order for consultations for podiatry as needed. Review of the patient list for the last podiatry visit dated 06/27/25 revealed Resident #49 was not seen. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was alert and oriented with some cognition impairment. Observation and interview on 08/11/25 at 10:34 A.M. revealed Resident #49 was lying in bed in a gown and her toenails on both her left and right feet were long, brittle and brown in color. Resident #49 stated she was overdue for a shower and needed assistance at this time due to her feet being swollen. Resident #49 stated she liked her fingernails long but not her toenails and sometimes staff ignored her and focused on other residents. Interview and observation on 08/11/25 at 10:36 A.M. with Certified Nurse Assistant (CNA) #520 confirmed Resident #49 had long toenails. CNA #520 stated the CNAs were responsible for cutting resident's nails unless they were diabetic. CNA #520 revealed the podiatrist visited the facility and cut the toenails of all residents that required it or requested it. Interview on 08/12/25 at 3:56 P.M. with Social Service Director (SSD) #920 revealed she was responsible for handling dental, vision, audiology and podiatry appointments. SSD #920 revealed staff members consisting of nurses, CNAs, management, or anyone that was aware, would inform her if a resident required or requested ancillary services and she would add them to the list to be seen on the next upcoming visit unless it was an emergency. SSD #920 revealed the podiatrist visited the facility once since 07/30/25 and the next visit was scheduled for 08/20/25. Follow-up interview on 08/13/25 at 12:15 P.M. with SSD #920 confirmed Resident #49 had no history of being seen by the podiatrist and was not on the upcoming list to be seen. Review of the facility's undated document titled Resident Rights revealed the facility had a policy in place that residents would receive personal care including, but not limited to, nail care and/or clipping. Review of the document revealed the facility did not implement the policy.

Based on observation, staff interview and recipe review, the facility failed to prepare purees per standards of practice to ensure nutritional value. This had the potential to affect two residents (#32 and #37) who the facility identified to receive pureed meals at the facility. The facility census was 81.Findings included: Observation and interview on 08/12/25 starting at 10:48 A.M. revealed [NAME] #420 placed four chicken thighs and two, two-ounce ladles of chicken gravy (total of four ounces) into the food processor and blended. [NAME] #420 then added four to eight ounces hot water from a pan on the stove to the mixture in the food processor and blended. [NAME] #420 then added four ounces of thickener to the mixture and blended. [NAME] #420 indicated he needed two purees so prepared two portions. When asked why he added hot water to the puree, [NAME] #420 stated there was no broth to add today and sometimes he would add gravy to thin down the pureed product. Interview on 08/12/25 at 10:55 A.M. with Dietary Manager (DM) #418 verified staff were not to add hot water to purees and confirmed [NAME] #420 did not follow the recipe as written as the recipe stated to add broth or gravy to thin the product if needed. Review of the undated recipe, Chicken, Marinated (Thigh), listed ingredients as chicken and Italian salad dressing. Instructions for pureed directed to measure desired number of servings into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickening. Observation on 08/12/25 starting at 10:56 A.M. revealed [NAME] #420 placed eight cups of corn with milk and butter, and eight cups of water into the food processor and blended. [NAME] #420 added two, four-ounce scoops of thickener to the processor and blended. Interview on 08/12/25 at 10:55 A.M. with DM #418 verified staff were not to add hot water to purees. Review of the undated recipe, Corn, Cream Style, listed ingredients as cream style, canned corn. Instructions for pureed directed to measure out desired number of servings into food processor. Blend until smooth. Add liquid (not specified) if product needs thinning. Add commercial thickener if product needs thickening. Review of a diet list dated 08/11/25 identified Resident #32 and Resident #37 as receiving pureed food.

Based on observation, staff interview, and facility policy review, the facility failed to administer the facility to employ enough laundry staff to the meet the needs of the residents. This had the potential to affect all 81 residents residing in the facility.Findings included: Observation of the soiled linen room on 08/12/25 at 6:28 A.M. with Laundry Aide (LA) #430 present, located on the Back-South hall revealed two yellow bins, uncovered, and overflowing with yellow and brown-stained towels, sheets, gowns, and clothing. Located on the floor, in various areas, there were five open bags, unsealed, of overflowing yellow and brown-stained towels, sheets, gowns, and clothing. LA #430 confirmed the bins were uncovered and overflowing with dirty linens. Observation of the soiled linen room on 08/12/25 at 7:02 A.M. located on the Front-South hall revealed multiple bags of soiled linen, open and unsealed. Interview on 08/12/25 at 7:02 A.M. with LA #430 revealed the soiled linen had not been taken care of in a couple of days. LA #430 stated she could not explain why the soiled linen was in its current state because she was not scheduled to work and was called in to assist the facility with laundry services. LA #430 revealed there was no one scheduled to work the laundry until 2:00 P.M. or 3:00 P.M. LA #430 confirmed the Front-South had multiple bags of soiled linen, open and unsealed. LA #430 stated the certified nursing assistants (CNAs) were having a hard time finding clean linens because of the piled high of soiled linens. Review of the facility document titled Laundry Handling & Processing Policy reviewed 02/01/25 revealed the facility had a policy in place to reduce the risk of disease transmission based on principles of hygiene, common sense, and the Centers for Disease Control (CDC) guidance.

Based on review of facility documents and staff interview, the facility failed to ensure they had a transfer agreement with one ore more hospitals. This had the potential to affect all 81 residents residing in the facility. Findings included: An entrance conference meeting for an annual and complaint survey occurred on 08/11/25 at 8:45 A.M. with the Administrator. At the time of the meeting, various documents were requested including the facility transfer agreement. Review of various documents and continued requests for the transfer agreement during the annual and complaint survey returned no results. Interview on 08/21/25 at 12:30 P.M. with the Administrator confirmed the facility did not have a transfer agreement with one or more hospitals.

Based on observation, interview, and record review, the facility failed to complete personal laundry and return it to residents in a timely manner. This affected three of three residents (#49, #74, and #80) reviewed and had the potential to affect all 81 residents in the facility who had their laundry done by the facility. The family did the laundry for six residents (#2, #11, #22, #51, #55, #74). The facility census was 87. Findings include: Interview on 12/03/24 at 8:18 AM through 10:41 A.M. with Licensed Practical Nurse (LPN) #101, LPN #104, Certified Nursing Assistant (CNA) #114, and CNA #115 revealed there had been some issues with laundry. The staff members reported they had received complaints from residents and families about missing clothes or clothes that had not yet returned from laundry. Interview on 12/03/24 at 11:49 A.M. with Resident #49 revealed it took two weeks for him to get his clothing back from laundry. Interview on 12/03/24 at 12:03 P.M. with Resident #79 stated residents did not get their laundry back in a timely manner. Resident #79 stated in the last resident council meeting a bunch of residents complained. An unnamed staff member at the meeting took the residents' names and wrote down what was missing. Resident #79 stated she went down to the laundry room and asked them to look for her missing items. Sometimes laundry is able to locate some missing items. Resident #79 reported names were in every item that was lost. Resident #79 stated the laundry department was bad, had gotten better, and now it is bad again. Interview on 12/03/24 at 11:45 A.M. with Resident #80 revealed the laundry was not done promptly and that items were not always returned. Resident #80 estimated that sometimes it was a couple weeks before he got his laundry back. Interview on 12/03/24 at 12:55 A.M. with the Laundry Account Manager (LAM) #111 revealed CNAs pick up all of the laundry and put it in bins in the soiled room. Laundry aides pick up the laundry from the soiled room. Laundry is collected three times a day. Staff tried to work four hours a day on residents' personal laundry. Linens were done separately. Laundry aides sorted items and placed personal clothes in a bin. The facility had two medium washers which only held up to 45 pounds of laundry, and two dryers. Observation on 12/03/24 at 12:59 P.M. of the soiled-side of the laundry room revealed a large bin of residents' dirty personal clothing. The pile was over five feet tall. Interview on 12/03/23 at 2:46 P.M. with the Administrator revealed she was going to go look at the laundry room. The Administrator stated two weeks was not an acceptable turnaround time for laundry to be returned to the residents. Interview on 12/03/24 at 3:05 P.M. with the Administrator verified that the amount of residents' dirty personal clothing awaiting to be laundered was a problem. Interview on 12/04/24 at 5:56 P.M. with Regional Environmental Services Manager #120 revealed they had hired two people since 12/02/24. The company had people at the facility all night on 12/03/24 and throughout the day on 12/04/24 doing laundry. They laundered all the residents' personal laundry and delivered it back to all of the residents. Review of the facility's Resident Council Minutes dated 11/30/24 revealed residents reported at the meeting reported the facility's laundry service was poor. Review of the facility's Grievance/Complaint Log from 08/18/24 through 11/04/24. revealed 16 separate complaints of residents with missing clothing. This deficiency represents non-compliance investigated under Complaint Number OH00159778.

Based on observation, interview, and record review, the facility failed to arrange for an escort to an outside appointment for Resident #80, who at previous appointments had always had an escort. This affected one Resident of three residents reviewed for transportation arrangements. The facility census was 87. Findings Include: Review of the medical record for Resident #80 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, legal blindness, glaucoma, and schizophrenia. Review of Resident #80's appointment orders revealed an escort needed for appointments scheduled for 09/24/24, 09/27/24, and 10/01/24. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #80 had intact cognition. Resident #80 had highly-impaired vision and used a wheelchair for mobility. Review of the nurse's note on 10/24/24 at 3:01 P.M. revealed for upcoming appointments, an escort was needed. Review of Resident #80's appointment order for 11/05/24 does not mention the need for an escort. Interviews on 12/03/24 at 8:18 A.M. and 1:12 P.M. with LPN #101 and LPN #104 revealed nurses are responsible for setting up appointments and will arrange for an escort if needed when arrange for transportation. Interview 12/03/24 at 11:45 A.M. with Resident #80 staff usually escorted him to appointments since he was blind. There was only one time they didn't. That was on 11/05/24. Interview on 12/04/24 at 11:21 A.M. with the Director of Nursing (DON) confirmed an escort was not sent to the appointment with Resident #80 on 11/05/24. This deficiency represents non-compliance investigated under Complaint Number OH00159778.

Based on interview, record review and review of facility policy, the facility failed to ensure Resident #89 was free from significant medication errors when Resident #89's admission orders were not timely transcribed, resulting in a delay in the resident receiving his ordered medications. This affected one Resident (#89) out of three residents reviewed for medication administration. The facility census was 87. Findings included: Review of the closed medical record for Resident #89 revealed an admitted [DATE]. Medical diagnoses included paraplegia, fractures to vertebra, seizures, diabetes, gout, depression, and hypertension. Resident #89 was discharged to the hospital on 10/30/24. Review of hospital discharge orders dated 10/09/24 revealed Resident #89 was to receive the following orders: acetaminophen 975 milligram (mg) tablet by mouth three times a day for pain, allopurinol 300 mg tablet by mouth every day for gout, amlodipine 10 mg tablet by mouth every day for hypertension, aspirin enteric coated (EC) 81 mg tablet by mouth every day for cardiac prevention, atorvastatin 40 mg tablet by mouth every day for high cholesterol, baclofen (muscle relaxant) 5 mg tablet by mouth every night, bisacodyl suppository 10 mg per rectum every night for constipation, cholecalciferol (vitamin D supplement) 25 mg tablet by mouth every day, cyanocobalamin (vitamin B12 supplement) 1000 microgram (mcg) tablet by mouth every day, dextrose 15 gram (gm) per 37.5 gm orally if blood sugar was less than 70 or symptomatic and give 30 gm if blood sugar less than 54 as needed for diabetic management, give dextrose 50 percent in water injection 25 gm per 50 milliliter (ml) as needed if unconscious or unable to swallow as needed, diclofenac one percent gel 4 gm topically to left shoulder four times a day, diclofenac one percent gel 4 gm topically to knuckles, elbows, and shoulders four times a day as needed for pain, docusate sodium 100 mg capsule by mouth every day for constipation, furosemide (hypertension/ diuretic) 20 mg tablet by mouth every day, gabapentin (seizures) 600 mg capsule by mouth three times a day, glucagon injection (diabetic management) 1 mg per ml subcutaneous (SQ) as needed if patient was unconscious and unable to swallow, hydroxyzine hydrochloride (HCL) (hypertension) 20 mg tablet by mouth every night, lactobacillus acidophilus (probiotic) chewable tablet every day, lamotrigine (seizures) 250 mg tablet by mouth twice a day, levetiracetam (seizures) 1250 mg tablet by mouth twice a day, lidocaine five percent topical patch one patch every day applied to chest and remove after 12 hours for pain, lidocaine patch five percent topically apply two patches every day to back for pain, losartan (hypertension) 50 mg tablet by mouth every day, meloxicam (anti-inflammatory pain medication) 15 mg tablet by mouth every day, metformin (diabetes) 750 mg tablet by mouth twice a day with meals, methocarbamol (muscle relaxant)1000 mg tablet by mouth three times a day, and oxycodone 2.5 mg tablet by mouth every six hours as needed for pain. Review of nursing note dated 10/10/24 at 3:51 P.M. and authored by the former Assistant Director of Nursing (ADON)/ Registered Nurse (RN) #117 revealed Resident #89 was admitted to the facility. There was no documentation regarding medication administration orders. Review of nursing note dated 10/10/24 at 5:33 P.M. and authored by Licensed Practical Nurse (LPN) #116 revealed Resident #89 had arrived at the facility at 2:00 P.M. and the note revealed the nurse practitioner and physician were notified regarding his admission. The note revealed the ADON RN #117 had verified the physician orders and pain medications. There was nothing in the nursing note regarding discontinuing or not following any of the orders listed on the discharge hospital orders. Review of physician orders dated 10/10/24 for Resident #89 revealed the only medication order that was transcribed on the date of admission was Oxycodone 5 mg give one half tablet by mouth every six hours as needed for mild to moderate pain for two weeks and Oxycodone 5 mg give one tablet by mouth every six hours as needed for moderate to severe pain for two weeks. There were no orders discontinuing, holding, or providing clarification to of any of the orders per the hospital discharge orders. Review of Nurse Practitioner (NP) #105's progress note dated 10/11/24 at 9:18 P.M. revealed she had evaluated Resident #89 and revealed per the note there were no hospital records available. The progress note that Resident #89's medication list included the following: Tricor 48 mg tablet by mouth at bedtime for elevated triglycerides, lidocaine patch four percent apply to right lumbar area topically one time a day for back pain and remove the patch every 12 hours, cyclobenzaprine HCL 10 mg tablet by mouth three times a day for muscle spasm relief, amlodipine 10 mg tablet by mouth one time a day for hypertension, diclofenac sodium topical gel one percent apply to anterior thorax topically every six hours as needed for pain, tramadol 50 mg tablet by mouth every six hours as needed for moderate to severe pain, diclofenac sodium gel one percent apply to top of left hand, right hand and left shoulder topically every 12 hours as needed for pain. The note revealed to restart his home medications: metformin, Norvasc, and losartan. Review of October 2024 Physician Orders and October 2024 Medication Administration Record (MAR) revealed Resident #89 had not received and/or his order was not transcribed timely per hospital discharge orders including: allopurinol 300 mg tablet by mouth every day was (not transcribed or administered) until 10/18/24 A.M. dose (eight days after admission), Aspirin 81 mg chewable tablet by mouth every day was (not transcribed or administered) until 10/18/24 A.M. dose (eight days after admission), atorvastatin 40 mg tablet by mouth every day was (not transcribed or administered) until 10/17/24 bedtime dose (seven days after admission), bisacodyl suppository 10 mg per rectum one suppository at bedtime every Tuesday, Thursday, and Saturday was (not transcribed or administered) until 10/15/24 bedtime dose (five days after admission), cholecalciferol 1000 unit tablet by mouth every day was (not transcribed or administered) until 10/19/24 A.M. dose (nine days after admission), furosemide 20 mg by mouth every day was (not transcribed or administered) until 10/18/24 (eight days after admission), lactobacillus acidophilus chewable tablet every day was (not transcribed or administered) until 10/18/24 A.M. dose (eight days after admission), gabapentin 600 mg capsule by mouth three times a day was (not transcribed or administered) until 10/12/24 at A.M. dose (two days after admission), lidocaine four percent topical patch one patch every day applied to left chest and remove at night was (not transcribed or administered) until 10/15/24 at 9:00 A.M. (five days after admission), lidocaine patch four percent topically apply to right chest one every day and remove at night was (not transcribed or administered) until 10/16/24 at 9:00 A.M. (six days after admission), lidocaine patch four percent apply to right lumbar area topically every day and remove 12 hours later was (not transcribed or administered) until 10/12/24 at 9:00 A.M. (two days after admission), methocarbamol 1000 mg tablet by mouth at bedtime was (not transcribed or administered) until 10/19/24 U.S. dose (nine days after admission), methocarbamol 1000 mg tablet by mouth in the afternoon was (not transcribed or administered) until 10/19/24 afternoon dose (nine days after admission), methocarbamol 1000 mg tablet by mouth in the morning was (not transcribed or administered) until 10/19/24 A.M. dose (nine days after admission), losartan 50 mg tablet by mouth at bedtime was (not transcribed or administered) until 10/18/24 bedtime dose (eight days after admission), amlodipine 10 mg tablet by mouth every day was (not transcribed or administered) until 10/12/24 A.M. dose (two days after admission), levetiracetam 1250 mg tablet by mouth twice a day was (not transcribed or administered) until 10/17/24 BEDTIME dose (seven days after admission), lamotrigine 250 mg tablet by mouth twice a day was (not transcribed or administered) until 10/17/24 BEDTIME dose (seven days after admission), metformin 750 mg tablet by mouth twice a day before breakfast and dinner was (not transcribed or administered) until 10/12/24 at 9:00 A.M. (two days after admission), cyanocobalamin 10 mg tablet by mouth three times a day was (not transcribed or administered) until 10/12/24 A.M. dose (two days after admission), colace 100 mg capsule by mouth as needed was (not transcribed or administered) until 10/15/24 (five days after admission). Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #89 had intact cognition. He received one injection in the last seven days during the assessment period. He was on hypoglycemic medications. There was no documentation he was on diuretics. Review of care plan dated 10/22/24 revealed Resident #89 was at risk for dehydration or potential fluid deficit related to diuretic use. Interventions included administering medications as ordered, and nutritional consultation on admission, quarterly and as needed. An additional care plan focus revealed Resident #89 had diabetes and was on hypoglycemic medication. Interventions included observe for signs of hypoglycemia and hyperglycemia. Resident #89 also had a neurological disorder related to thoracic fractures sustained after a fall down the stairs at home resulting in paralysis. Resident #89 also had a seizure disorder. Interventions included administer medications per orders, observe for side effects and effectiveness of the medications, observe for changes in mental status, and altered neurological status. Attempted interviews on 12/04/24 at 1:39 P.M., 12/04/24 at 1:40 P.M. and 12/05/24 at 11:13 P.M. with the former ADON RN #117 were unsuccessful. There was no answer and ADON RN #117's voicemail box was full. Interview on 12/04/24 at 2:14 P.M. with LPN #116 (nurse assigned when Resident #89 was admitted ) revealed that she did not recall Resident #89's name or any details regarding his admission. LPN #116 revealed she was unsure why the orders were not transcribed but stated the former ADON RN #117 usually handled transcribing the admission orders into the electronic medical record. Interview on 12/04/24 at 1:01 P.M. with Regional Director of Nursing (RDN) #99 verified Resident #89's discharge orders from the hospital were not transcribed the day he was admitted , and he was not administered his medications as ordered. Interview on 12/04/24 at 3:26 P.M. and 12/05/24 at 11:18 A.M. with the Director of Nursing (DON) revealed she was new to the facility and was not working at the facility when Resident #89 was admitted . She verified Resident #89's discharge orders from the hospital were not transcribed as well as Resident #89 did not receive his medication in a timely manner as some of the orders were not transcribed for up to nine days after Resident #89 was admitted . The DON revealed, upon review, she was not able to explain why the orders were not transcribed the day he was admitted as there was no documentation to explain the reason in the medical record. She revealed former ADON RN #117 no longer worked at the facility and she had attempted to contact her to see if there was a reason but was unable to reach her. The DON revealed if the facility was not to transcribe an order from the discharge instructions on admission there should have been an order from a physician discontinuing the order and/or documentation in the medical record as to why the medication was not transcribed and administered. Review of the undated facility policy Medication Administration revealed the purpose of the policy was to provide guidance for general medication administration. The policy included administer medications only as prescribed by the provider. There was nothing in the policy in regard to transcribing physician orders including on admission. Review of facility policy Physician Orders dated 4/17/24 revealed the provider may write the order in the medical record or in the electronic medical record. The policy revealed the nurse may receive an order over the phone; the nurse would provide a read-back to the provider for accuracy and transcribe the order into the electronic medical record. The policy revealed the nurse would discontinue any previous contradicting orders. There was nothing in the policy regarding transcribing admission orders. This deficiency represents non-compliance investigated under Complaint Number OH00159560.

Based on observation, record review, and interviews, the facility failed to maintain acceptable infection control practices during medication administration to prevent the spread of infection. This affected one Resident (#39) and had the potential to affect eight residents (Residents #16, # 28, #47, #55, 60, #65, #77, and #87) residing on the Back North Hall. The facility census was 87. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnosis included but not limited to schizoaffective disorder, bipolar type, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), vascular dementia, and repeated falls. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had impaired cognition. Review of the physician's orders for December 2024 revealed Resident #39 was ordered daily accuchecks, (accu-check is a brand of products for people with diabetes to help them monitor and manage their blood sugar levels) without coverage and to notify physician or NP if blood glucose is less than 70 or greater than 400, one time a day for DM. On 12/03/24 at 8:31 A.M. Licensed Practical Nurse (LPN) 100 was observed administering medications to Resident #39. During the medication administration observation, LPN #100 went into the resident room to take a blood sugar test and placed the glucometer on the resident's bed with no barrier. Interview on 12/03/24 at 8:39 A.M. with LPN #100 verified she placed the glucometer on the resident's bed without placing a barrier first. LPN #100 reported she forgot. Interview on 12.03/24 at 10:34 A.M. with the Director of Nursing (DON) confirmed a barrier is to be placed under the glucometer. The DON reported she would provide education to LPN #100. Review of facility policy, Blood Glucose Point of Care Testing, undated, revealed to place a clean barrier under glucometer until disinfected. This deficiency represents an incidental finding of non-compliance identified while investigating OH00157560.

Based on observation of medication pass, staff interview, medical record review, review of manufacturer's instructions, review of medication card instructions and review of facility policy, the facility failed to maintain a medication error rate of less than five percent. The facility medication error rate was calculated to be 10.34 percent (%) and included three medication errors of 29 observed medication opportunities. This affected two residents (#58 and #75) of four residents observed for medication pass. The facility census was 96. Findings include: 1. Review of the medical record for the Resident #58 revealed an admitted [DATE]. Diagnoses included cerebral infarction (stroke), dementia, syncope (fainting), type II diabetes, chronic kidney disease and depression. Review of the September 2024 physician orders revealed an order for potassium chloride extended release (ER) 20 milliequivalent (meq) by mouth, vitamin C 50 milligram (mg), ferrous sulfate 325 mg, losartan 25 mg and a multivitamin. Observation on 09/18/24 at 8:40 A.M. of medication pass with Licensed Practical Nurse (LPN) #250 revealed LPN #250 prepared Resident #58's morning medications, including the potassium chloride ER. Resident #58 requested LPN #250 cut the pill in half due to difficulty swallowing. Resident #58 was unable to swallow the potassium chloride ER. LPN #250 then crushed the potassium chloride ER, mixed the crushed medication in pudding and administered the crushed potassium chloride ER to Resident #58. Interview on 12/08/20 at 8:51 A.M. with LPN #250 verified she crushed the potassium chloride ER and administered the crushed medication to Resident #58. LPN #250 stated the pill was scored and able to be crushed. LPN #250 stated she called the pharmacy about crushing potassium for another resident and was told potassium could be crushed. Review of the manufacture's prescribing instructions for potassium chloride ER revealed the formulation was intended to slow the release of potassium so the likelihood of a high localized concentration of potassium chloride within the gastrointestinal tract is reduced. Potassium chloride ER tablets are to be swallowed whole without crushing, chewing or sucking the tablets. 2. Review of the medical record for Resident #75 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, heart failure, anxiety disorder, peripheral vascular disease, hypothyroidism and constipation. Review of the September 2024 physician orders revealed morning medications included levothyroxine (used to treat hypothyroidism) 50 microgram (mcg) by mouth in the morning, simethicone (used to treat flatulence) 80 mg, Eliquis (anticoagulant) 2.5 mg, aspirin 81 mg, carvedilol (used to treat high blood pressure) 6.25 mg, clopidogrel (used to treat heart problems) 75 mg, gabapentin (used to treat pain) 100 mg losartan 50 mg and omeprazole (used to treat gastroesophageal reflux) 40 mg. Instructions included resident requests not to receive medication before 8:00 A.M. Observation of medication pass on 09/19/24 at 8:30 A.M. with Medication Technician (MT) #240 revealed the MT prepared levothyroxine and simethicone, along with seven additional medications, and administered the medications to Resident #75. Review of the levothyroxine medication card revealed instructions to give the medication on an empty stomach and four hours after receiving an antacid, iron and/or simethicone. Concurrent interview with Resident #75 revealed he had breakfast, including a muffin and cereal, proportionately 20 minutes prior to his medications being administered. Interview on 09/19/24 at 8:45 A.M. with MT #240 revealed she administered Resident #75's medications based on his preference. MT #240 stated she was unaware levothyroxine was to be given on an empty stomach and should not be administered with simethicone. Review of the manufactures prescribing instructions for levothyroxine revealed the medication should be administered on an empty stomach, one-half hour to one hour before breakfast, and administer at least four hours before or after drugs that are known to interfere with absorption, including simethicone. Review of the facility policy titled Medication Administration, undated, revealed follow manufacture's recommendations for medications that note do not crush. This deficiency represents noncompliance investigated under Complaint Number OH00157286 and Complaint Number OH00157231.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #46 from developing pressure ulcers, and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 08/20/24 when Resident #46, who was at risk for developing pressure ulcers, and was dependent on staff for bed mobility and incontinence care was identified to have new areas of in-house acquired skin impairment with no additional assessment or new treatment at that time. On 08/21/24 the facility assessed the resident to have two new, in-house acquired Stage III pressure ulcers (full-thickness loss of skin that extended to the subcutaneous tissue, but did not cross the fascia beneath it) on her proximal and distal right posterior thigh, without proper prevention, treatment, and interventions implemented. The resident reported increased pain to the areas and also voiced concerns staff did not provide timely incontinence care or assistance with turning and repositioning. This affected one resident (#91) of three residents reviewed for pressure ulcers. The facility census was 90. Findings include: Review of Resident #46's medical record revealed an admitted [DATE] and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side, muscle weakness, type two diabetes mellitus, and morbid obesity due to excess calories. Review of Resident #46's care plan dated 04/11/24 included Resident #46 had activity of daily living (ADL) self-care performance due to hemiparesis, history of cerebrovascular accident (CVA), decreased functional mobility, pain, incontinence and other diagnoses. The goal included Resident #46 would maintain current level of function. Interventions included Resident #46 required the use of a mechanical lift with two person support. The resident also had a plan of care reflecting impaired skin integrity or being at risk for altered skin integrity due to hemiparesis, history of cerebrovascular accident and other diagnoses, pain and incontinence, and decreased functional mobility. The goal included Resident #46 would have improved or maintain current skin status through next review date of 10/27/24. Interventions included to complete weekly skin checks; encourage Resident #46 to turn and reposition or assist as needed as resident allows. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had moderate cognitive impairment. Resident #46 was dependent for ability to roll from lying on back to left and right side, and return to lying on back on the bed. Sit to lying, lying to sitting on side of bed, sit to stand, and toilet transfer were not attempted due to medical condition or safety concerns. Resident #46 was dependent for chair, bed-to-chair transfers, and ADL care except for eating. Resident #46 was always incontinent of urine and bowel. Resident #46 was at risk for developing pressure ulcers, injuries and did not have a pressure injury. Review of Resident #46's Nursing Admission Evaluation dated 08/01/24 revealed Resident #46's was evaluated to be at low risk for developing a pressure ulcer or injury, there were no skin areas noted, and to turn and reposition the resident as needed. Review of Resident #46's physician orders dated 08/01/24 revealed an order for a wound care consult. Review of Resident #46's physician orders dated 08/02/24 revealed Triad cream to groin, thighs, buttocks every day and evening shift. Review of Resident #46's physician orders dated 08/01/24 through 08/22/24 did not reveal orders to turn and reposition. Review of Resident #46's medical record including progress notes, Medication and Treatment Administration Records, and aide charting from 08/01/24 through 08/22/24 did not reveal evidence Resident #46 was turned and repositioned. There was no evidence Resident #46 refused to be turned and repositioned. Further review revealed there were no Weekly Skin Checks completed during this time period. During an observation on 08/20/24 at 9:51 A.M. with State tested Nursing Assistant/Power of Attorney (STNA/POA) #279 of Resident #46's incontinence care the resident stated the aides did not complete her incontinence care timely and did not offer to turn and reposition her when she was in bed, and if they did offer to turn and reposition her she would not refuse. Observation of Resident #46's right upper posterior thigh revealed two open areas, one area that was approximately an inch and a half long and a half inch wide, and the second area that was approximately an inch long and a half inch wide. The wound bed of both open areas was a medium red to dark red color, and there was a small amount of serosanguineous drainage. The open areas did not have a dressing on then. STNA #279 stated she was Resident #46's POA and was also an STNA at the facility. STNA/POA #279 stated Resident #46 needed a mechanical lift for transfers and after Resident #46 was transferred to her chair on day shift a lot of the STNAs would not bring her back to her room and transfer her back to her bed so her incontinence brief could be changed, and her skin checked, and would wait for second shift to do it. STNA/POA #279 indicated Resident #46 had the two open areas about two weeks and she told the nurses including Licensed Practical Nurse (LPN) #258 and Wound Nurse/Unit Manager (WN/UM) #271 about the two open areas and they did not do anything except to tell her to put Triad on the open areas, and sometimes they did not even look at the open areas and told her to put Triad on the area. After surveyor intervention, LPN #258 entered Resident #46's room and before she looked at the open areas stated Resident #46 had Triad ordered. After looking at the two open areas LPN #258 stated she was going to have Wound Nurse/Unit Manager (WN/UM) #271 evaluate the open areas because Resident #46 only had Triad ordered. Resident #46 indicated the aides did not change her incontinence brief timely. WN/UM #271 entered Resident #46's room, looked at her two open areas, and said she needed to get supplies, left the room and returned with dressing items. WN/UM #271 cleansed the wounds and Resident #46 cried out and said that hurt, WN/UM #271 finished cleaning the open areas, applied Triad and a border dressing. Resident #46 stated the nurses and WN/UM #271 did not thoroughly evaluate the open areas before today. Interview on 08/20/24 at 11:12 A.M. with WN/UM #271 revealed Resident #46 was admitted to the facility with a wound to her right posterior thigh, it was resolved (date not provided), and today she had a wound on her left side (the two open areas were on Resident #46's right thigh). WN/UM #271 indicated Resident #46's skin was fragile and Triad was ordered on 08/02/24 by facility Nurse Practitioner (NP) #312. WN/UM #271 then stated Resident #46 did not have any wounds from 05/2024 until now. WN/UM #271 stated she looked at Resident #46's skin a lot due to discomfort, the felt the nurses had also seen her skin. Observation on 08/20/24 at 12:00 P.M. of Resident #46 revealed she was lying in her bed, was on her back with the head of bed elevated. No observation of an STNA turning and repositioning Resident #46 or offering to reposition her occurred at that time. Observation on 08/20/24 at 2:00 P.M. of Resident #46 revealed she was lying in her bed, was on her back with the head of bed elevated. No observation of an STNA turning and repositioning Resident #46 or offering to reposition her occurred at that time. Interview on 08/20/24 at 4:02 P.M. with STNA #248 revealed Resident #46 told her she waited long periods of time before the STNAs came into her room to help her. STNA #248 stated quite a few residents told her the STNAs do not go in their rooms to help them. STNA #248 indicated a lot of the STNAs do not like taking care of Resident #46 because she is a bigger lady, was kind of needy and could not do anything for herself. Interview on 08/21/24 at 6:54 A.M. with Wound Nurse Practitioner (WNP) #311 revealed Resident #46's two open areas looked like the open areas were some pressure with pressure injuries. WNP #311 stated she ordered silver alginate with border gauze dressing and Triad to the surrounding tissue. WNP #311 stated she had not seen Resident #46 in quite a while. Review of Resident #46's Wound Assessment Report dated 08/21/24 completed by Wound Nurse Practitioner (WNP) #311 included Resident #46 had a new Stage III pressure ulcer to her right distal posterior thigh. The pressure ulcer was acquired in house on 08/20/24. Measurements were length 1.40 cm (centimeters), width 2.40 cm, and depth was 0.10 cm. The wound had 10 percent epithelial tissue, 90 percent granulation tissue and 0 percent slough. The periwound was fragile with scarring. There was a moderate amount of serosanguineous drainage. Treatment was cleanse the wound with wound cleanser, apply silver alginate, bordered foam dressing, and Triad (wound healing, barrier cream) to periwound daily and as needed. Further Review of Resident #46's Wound Assessment Report dated 08/21/24 completed by WNP #311 included Resident #46 had a new Stage III pressure ulcer to her right proximal posterior thigh. The pressure ulcer was acquired in house on 08/20/24. Measurements were length 0.4 cm, width 4.0 cm, and depth was 0.10 cm. The wound had 90 percent granulation tissue and 10 percent slough. The periwound was fragile with scarring and there was a moderate amount of serosanguineous drainage. Treatment was cleanse with wound cleanser, apply silver alginate, bordered foam dressing, and Triad to periwound daily and as needed. Interview on 08/22/24 at 4:46 P.M. with WN/UM #271 and Regional Director of Clinical Operations (RDCO) #310 revealed Resident #46 returned from the hospital on 08/01/24 and the order for a wound consult was a standing order when a resident was admitted or readmitted to the facility, and to be used as needed. WN/UM #271 stated the Wound Nurse Practitioners did a skin check on all new residents and readmissions to the facility, and did a quarterly skin sweep as well. RDCO #310 stated if there were no wounds the nurse practitioners did not document in the resident records, but would send an email stating the residents they evaluated and whether or not each had a wound. RDCO #310 stated nurses on the floor should do weekly skin checks, and both RDCO #310 and WN/UM #271 confirmed Resident #46 did not have weekly skin checks from 08/01/24 through 08/22/24. WN/UM #271 stated Resident #46 had a previous ulcer that healed back in May, and she was not seen by the Nurse Practitioner until 08/21/24. Review of the facility undated policy titled Skin Care and Wound Management Overview included each resident was evaluated upon admission and weekly thereafter for changes in skin condition. Resident skin condition was also reevaluated with a change in clinical condition, prior to transfer to the hospital and upon return from the hospital. Skin care and wound management program included identification of residents at risk for the development of pressure ulcers, implementation of prevention strategies to decrease the potential for developing pressure ulcers, develop a care plan with individualized interventions to address risk factors, communicate risk factors and interventions to the care giving team. This deficiency represents non-compliance investigated under Complaint Number OH00156946.

Based on observation, closed medical record review, review of an emergency medical services run report, review of facility witness statements, review of the diet guide sheet and recipes, review of the facility's diet manual, review of employee disciplinary action and interviews, the facility failed to ensure residents with physician orders for mechanically altered diets were provided the correct texture food items to prevent choking and to meet their individual needs. This resulted in Immediate Jeopardy and actual harm/death on [DATE] during the dinner meal when Resident #91, who was ordered a Dysphagia Advanced diet, was edentulous and care planned for oral problems, was served a broccoli salad; the resident was subsequently found unconscious, required cardiopulmonary resuscitation (CPR) and when Emergency Medical Services (EMS) arrived, intubation was initially unsuccessful due to a piece of broccoli being found in the resident's airway. Resident #91 was pronounced deceased as a result of the incident. This affected one resident (#91) and had the potential to affect 15 additional residents (#3, #16, #19, #20, #21, #22, #24, #27, #31, #37, #38, #56, #57, #59 and #61) who the facility identified as being on a Dysphagia Advanced diet ordered by their physician or other delegated provider. The facility census was 90. On [DATE] at 11:28 A.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO) #8 were notified Immediate Jeopardy began on [DATE] at approximately 5:10 P.M. when Resident #91 was served a meal tray with a broccoli salad cut into bite size pieces in his room while sitting on the edge of his bed. At approximately 5:50 P.M., Resident #91 was found unconscious and not breathing, slumped over with his face on his dinner tray and CPR was started by facility staff. EMS was notified and arrived at the facility at 6:00 P.M. Initially, intubation was unsuccessful and [NAME] forceps were used to remove a piece of broccoli from the airway. Resident #91 expired at the facility. According to the EMS run report, the presumed cardiac arrest etiology was possible obstructed airway (broccoli removed). The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:25 P.M., Physician #17 was notified of Resident #91's death by Registered Nurse (RN) #9. At 6:39 P.M., Resident #91's daughter was notified of Resident #91's death by Licensed Practical Nurse (LPN) #10. On [DATE] by 7:00 P.M., LPN/Unit Manager #2 interviewed all residents with Dysphagia Advanced diet orders about their meal consistency for the dinner meal on [DATE] with no additional concerns identified. On [DATE] at 7:00 P.M., the DON and LPN/Unit Manager #2 initiated a house audit to identify any residents on Dysphagia Advanced diet. In addition, Regional Director of Operations Registered Dietitian (RDORD) #13 and RN #1 audited validation diet orders in the electronic medical record to ensure the meal tickets matched. On [DATE], the DON began conducting interviews and obtained witness statements from nursing staff working the time of the event involving Resident #91. All the interviews/witness statements were completed on [DATE] at 4:30 P.M. On [DATE], the DON initiated education with facility staff on Dysphagia Advanced diet, the difference between diets/food textures/thickened liquids/obstructed airway care and meal service policy. Education included dietary staff to serve food consistencies as ordered and nursing staff to validate meal being served to resident matches meal ticket prior to serving to residents. The education was completed on [DATE] at 4:30 P.M. On [DATE] at 7:30 A.M., the DON audited the breakfast meal to ensure Dysphagia Advanced diets were prepared appropriately with no concerns identified. On [DATE] at 12:30 P.M., the Administrator and DON reviewed all notes from Speech Language Pathologist (SLP) #15 and interviewed SLP #15 with no concerns identified. On [DATE] at 1:00 P.M., RDORD #13 reviewed Resident #91's meal ticket and dietary profile. On [DATE] at 1:30 P.M., RDORD #13 audited all diets in the electronic medical record and from the dietary meal tracker master list. Three (Residents #31, #20 and #12) residents' diet orders were fixed due to duplicate orders in the electronic medical record. On [DATE] at 2:00 P.M., the Administrator gave a verbal warning and suspended Cook #5 pending investigation in an effort to investigate the event prior to Cook #5 returning to work. On [DATE] at 2:00 P.M., the DON requested the EMS run report from the City Fire Department. On [DATE] at 5:30 P.M., RN #18 educated all residents/responsible parties with Dysphagia Advanced diets that refused to eat in dining room for potential risks of unsupervised dining. Education record assessment completed, and care plans were updated. On [DATE] at 11:00 A.M., Dietary Manager (DM) #4 educated Cook #5 on preparing a Dysphagia Advanced diet with a return demonstration completed successfully. On [DATE] at 11:50 A.M., the DON conducted an audit of all residents in house to identify residents ordered Dysphagia Advanced diet. The DON assessed all residents ordered a Dysphagia Advanced diet with no concerns identified. On [DATE] at 2:48 P.M., RDORD #19 in collaboration with Regional Speech Therapy Director #20 updated the Dysphagia Advanced diet policy/manual to define the appropriate size of chopped vegetables to be approximately 0.5 inches. There were no food exclusions outside what was listed on the Dysphagia Advanced policy as long as the food items met the size requirement. On [DATE] at 3:08 P.M., the DON conducted education with facility staff related to the updated Dysphagia Advanced policy/manual with the adjusted size of chopped vegetables to be approximately 0.5 inches via electronic communication to be completed on [DATE] by 12:00 P.M. Any staff not able to be educated by that time would be educated prior to the start of their next scheduled shift. On [DATE], DM #4 initiated education with all Cooks related to preparing Dysphagia Advanced diet, including a return demonstration. All additional Cooks would be trained prior to the start of their next scheduled shift. Beginning on [DATE], the Administrator/DON/Designee with support of interdisciplinary team bean audits which will be scheduled to be conducted on meal trays at different mealtimes to ensure correct meal consistencies were being served as ordered. Auditing would occur five times a week for two weeks, then three times a week for two weeks. Results of the audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) committee with additional recommendations as warranted. Beginning on [DATE], Director of Therapy #21 conducted an audit of residents ordered a Dysphagia Advanced diet to identify date of last therapy screen. For any resident not screened in the last 90 days or that have not received speech therapy in the last 90 days, a screen would be completed by [DATE]. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #91 revealed an admitted [DATE] and discharge date of [DATE]. Resident #91 had diagnoses including memory deficit following cerebral infarction, diabetes, peripheral vascular disease, hypertensive heart disease, hepatitis C, and hyperlipidemia. Review of the oral/dental care plan dated [DATE] revealed Resident #91 had oral/dental problems related to (being) edentulous (lacking teeth) and did not wear dentures with an intervention that included provide a mechanically altered diet. Review of the Speech Therapy (ST) evaluation dated [DATE] revealed Resident #91 was referred to ST due to exacerbation of decreased safety awareness during oral intake, increased signs and symptoms of dysphagia (difficulty swallowing) and risk for aspiration (when food or liquid enters the airway and eventually the lungs by accident). Review of the ST discharge summary dated [DATE] revealed Resident #91 had met short- and long-term goals and reached maximum potential with skilled services. Resident #91 was safely consuming the least restrictive diet consistency without overt signs and symptoms of difficulty/aspiration. Resident #91's recommended discharge diet order was mechanical soft textures (Dysphagia Advanced). Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #91 was severely cognitively impaired and was independent with eating. Review of the nutritional assessment dated [DATE] revealed Resident #91 was ordered a Dysphagia Advanced texture diet with good appetite and oral intake. Review of the [DATE] physician orders revealed Resident #91 was ordered a Dysphagia Advanced texture diet and could have regular ground beef (hamburger on bun, patty, meatballs, meatloaf and regular fish). The order had been in place since [DATE]. Review of the nurse's note dated [DATE] timed 6:39 P.M. revealed Resident #91 was noted to be without vital signs, CPR started and 911 (EMS) and Power of Attorney (POA) notified. Continued CPR until EMS arrived and took over care of resident. EMS notified hospital emergency department and physician called time of death 6:19 P.M. Review of the Prehospital Care Report Summary (EMS run report) dated [DATE] revealed dispatch requested a squad for [AGE] year-old male not breathing at [address and name of facility]. Staff performing CPR and respirations on pulseless and apneic (not breathing) patient. Staff stated patient was last known well at 5:45 P.M. while eating dinner. Patient found unresponsive at approximately 5:52 P.M. at which time a Code was called by nurse supervisor. EMS crew took over manual CPR. Attempted intubation - no success. During resuscitation attempt, a piece of broccoli was removed from patient's airway with [NAME] forceps. Patient remained in asystole (without heartbeat) during code. Resuscitation attempt terminated per [name of physician]. Time of death was 6:19 P.M. Presumed cardiac arrest etiology: possible obstructed airway (broccoli removed). Review of a facility witness statement dated [DATE] authored by RN #9 revealed, I was passing dinner trays on [Front North]. I went into [Resident #91's room] and announced that I was bringing in dinner. [Resident #100] (Resident #91's wife/roommate) was sitting on her bed. [Resident #91] was lying down .[Resident #91] sat up and was sitting on the side of his bed like he always does to eat. He was acting his norm. I served [Resident #91] his tray. His tray was consistent with his diet order. Review of a facility witness statement dated [DATE] authored by State tested Nurse Aide (STNA) #15 revealed, I started collecting trays and when I got to [Resident #91's] room, found [Resident #91] slumped over his tray. I yelled for the nurse and the nursing staff came when it was called Code Blue. Review of a facility witness statement dated [DATE] authored by STNA #14 revealed, At approximately 5:50 P.M., I other aides and I went down the hall to collect trays. Upon entering the room, we found resident faced down in his food tray. At that point, we all screamed for help down the nurses station. Review of a facility witness statement dated [DATE] authored by LPN #10 revealed, I was at the nurses' cart charting, when aide called, and I ran down to patients room. Patient was face down in dinner tray. This nurse pushed and assisted patient back on bed to obtain vitals and start CPR . Review of the Diet Guide Sheet for Dinner Day 3, Week 1 on Tuesday revealed ,d+[DATE] cup of broccoli salad, chop for resident's ordered a Dysphagia Advanced diet. Review of the recipe for Broccoli (floret) Salad revealed steam or boil broccoli, cook until tender, drain off excess liquid and chop or slice into pieces. For Dysphagia Advanced: chop to small, appropriate small. Review of the facility's 2019 Diet and Nutrition Care Manual for Dysphagia Advanced diets revealed this diet was used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that were difficult to chew were chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Foods to avoid included cooked rubbery or non-tender cooked vegetables. There was no definition of what the measurement was for small, appropriate size. Review of the Employee Corrective Action Form dated [DATE] revealed Cook #5 was given a verbal warning and suspended pending investigation due to incident that occurred on [DATE]. Review of the Teachable Moment form dated [DATE] revealed RN #9 was educated related to diet consistency and texture types and validating that meal matched diet type prior to serving residents. Interview on [DATE] at 8:05 A.M. with Dietary Manager (DM) #4 revealed broccoli salad was on the menu for dinner on [DATE] and the salad was served cold. DM #4 had observed Cook #5 steam and chop the broccoli; however, DM #4 was not at the facility when dinner was served. DM #4 was told that Resident #91 had received a piece or a couple of pieces of broccoli that were not properly chopped, the resident choked and passed away. Interview on [DATE] at 10:50 A.M. with RN #9 revealed she served Resident #91 his dinner on [DATE] while the resident was sitting on the edge of his bed. RN #9 placed a fork into the broccoli salad and the broccoli was chopped and soft. RN #9 felt the dinner served was consistent with his diet order. RN #9 stated after CPR was completed and EMS called Resident #91's time of death, a paramedic told RN #9 that, we did pull a piece of broccoli out of his airway. Interview on [DATE] at 11:40 A.M. with Cook #5 revealed for dinner on [DATE], he cooked the broccoli in the steamer for approximately 25 minutes, ran the broccoli under cool water to cool it off, then cut up the broccoli in to bite size pieces using a chef's knife. Cook #5 stated if the broccoli salad was served to residents on a Dysphagia Advanced diet, he would have had to chop the broccoli into finer/smaller pieces rather than bite size pieces. During the interview, Cook #5 could not recall if he made a separate broccoli salad for residents on a Dysphagia Advanced diet. Cook #5 did not respond when asked if he referenced the broccoli recipe while preparing the broccoli salad. Observation of the lunch tray line on [DATE] at 12:00 P.M. revealed Cook #6 was serving lunch which included Capri Vegetable Blend which contained cooked, diced carrots. Cook #6 served the Carpi Vegetable Blend to the meal tray intended for Residents #31 and #21 who were ordered a Dysphagia Advanced diet. The diced carrots were approximately the size of a half dollar-sized coin. Interview, during the observation, with DM #4 revealed she trained the cooks to chop food items into ,d+[DATE] inch pieces for a Dysphagia Advanced diet. Review of the recipe for Capri Vegetable Blend revealed Capri Blend included 35% Julienne cut carrots strips, 27% bias cut green beans, 23% half round yellow squash, and 15% crinkle cut zucchini. Steam or boil vegetables until tender, toss lightly with margarine. For Dysphagia Advanced: chop to small, approximate size. Interview on [DATE] at 1:45 P.M. with DM #4, (Dietary District Manager (DDM) #11 and the Administrator were present) verified the Capri Vegetable Blend recipe called for Julienne cut carrots rather than diced carrots and verified the diced carrots in the Capri Vegetable Blend were larger than ,d+[DATE] inch. Interview on [DATE] at 2:20 P.M. with RDORD #13 verified there was no definition for small, appropriate size in the diet manual for a Dysphagia Advanced diet. Interview on [DATE] at 3:05 P.M. with STNA #15 revealed Resident #91 was a good eater and normally cleaned his plate. On [DATE], STNA #15 was assisting STNA #14 with collecting meal trays and STNA #15 began collecting trays from the back of the hallway. STNA #15 arrived at Residents #100 and #91's room, and STNA #15 began to collect Resident #100's tray (Resident #100 was not in the room) when STNA #15 looked up and observed Resident #91 slumped over his overbed table with his face down on his plate. STNA #15 rubbed Resident #91's head stating Resident #91's name. STNA #15 began yelling for LPN #10. Interview on [DATE] at 4:00 P.M. with the Administrator revealed the facility conducted an investigation after Resident #91 expired and the investigation concluded that Resident #91 had choked. Interview on [DATE] at 4:25 P.M. with Speech Language Pathologist (SLP) #16 revealed she worked with Resident #91 in June/[DATE] to determine his diet order. Resident #91 was edentulous. SLP #15 would expect that broccoli be served in ,d+[DATE] inch chopped, soft pieces and soft enough to mash with a fork for resident's ordered a Dysphagia Advanced diet. SLP #15 revealed broccoli stems were not able to be mashed. Interview on [DATE] at 10:15 A.M. with LPN #10 revealed she was Resident #91's nurse on [DATE]. That evening, LPN #10 was passing medications while three STNAs and one nurse passed meal trays to the residents on the hall. At approximately 5:20 P.M. or 5:30 P.M., LPN #10 administered medications to Resident #100 (Resident #91's roommate) in the hallway. At that time, LPN #10 observed Resident #91 sitting on the edge of his bed feeding himself without any concerns. LPN #10 returned to the nursing station and was standing at the medication cart when STNAs alerted the nurses to come to Resident #91's room. LPN #10 ran down the hallway into Resident #91's room and the resident's face was in his tray. A follow-up interview on [DATE] at 2:25 P.M. with SLP #16 revealed she had not screened Resident #91 for swallowing since [DATE] and a therapy screening list including Resident #91 should have been provided to the therapy department in [DATE] but that did not occur. The facility identified 15 additional residents, Resident #3, #16, #19, #20, #21, #22, #24, #27, #31, #37, #38, #56, #57, #59 and #61 who required a Dysphagia Advanced diet ordered by their physician or other delegated provider. The facility's failure to ensure food items were properly prepared and/or served at an appropriate size during the dinner meal on 04//,d+[DATE] and lunch meal on [DATE] placed these additional residents at risk for choking and/or adverse outcomes. Review of the facility's Meal Distribution policy revised [DATE] revealed all meals would be assembled in accordance with the individualized diet order, plan of care and preferences. The nursing staff would be responsible for verifying meal accuracy and timely delivery of meals to residents/patients. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, would assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. This deficiency represents non-compliance investigated under Complaint Number OH00153286 and OH00153283.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID- 19 line list, review of facility infection control policies, interviews with staff and residents, and medical record review, the facility failed to timely and appropriately exclude COVID-19 positive staff from working in the facility with COVID-19 negative residents. This resulted in Immediate Jeopardy on 01/04/22 when Director of Rehab (DOR) #500 tested positive for COVID-19 via a rapid test at the facility. DOR #500 was told by Assistant Director of Nursing (ADON) #501 after talking with the Director of Nursing (DON), he could continue to work the duration of his shift. A polymerase chain reaction (PCR) COVID-19 test was not completed at this time. The lack of effective infection control practice placed three residents, (#16, #62, and #67) at risk for serious life-threatening harm, complications and/or death. The facility census was 95. On 01/06/22 at 10:22 A.M., Clinical Regional Nurse (CRN) #503 and Assistant Director of Nursing (ADON) #502 were notified that Immediate Jeopardy began on 01/04/21 when DOR #500 tested positive for COVID-19 during outbreak testing and was permitted to work by the direction of the DON through ADON #501 and worked with COVID negative residents. The Immediate Jeopardy continued through 01/05/22 when the DOR returned to work positive with COVID-19 and continued to work with COVID negative residents. Through interview on 01/06/22 at 8:45 A.M. with CRN #503 it was revealed DOR #500's PCR COVID-19 test result came back on 01/05/22 and was positive. Also, through record review it was determined Resident #67 was placed in droplet precautions and was waiting PCR test results. The Immediate Jeopardy was removed on 01/06/22 when the facility implemented the following corrective actions: · On 01/05/22 at 1:50 P.M., DOR #500 went home for the day. · On 01/05/22 at 2:00 P.M., CRN #503 contacted DOR #500 via phone that he could not work with COVID negative residents and that he could only continue to work if he wanted to provide therapy on the COVID unit only. DOR #500 opted to complete quarantine at home. · On 01/05/22 at 2:20 P.M., ADON #503 tested all residents that were treated by DOR #500 on 01/04/22 and 01/05/22 and their roommates that were not on the COVID unit. · On 01/05/22 at 2:30 P.M., CRN #503 went through the line list to confirm the working status of all COVID-19 positive staff. At the time there were 11 staff out with COVID-19 and three State tested Nurse Aides (STNAs) working COVID-19 positive and asymptomatic only on the COVID unit. · On 01/05/22 at 2:45 P.M., CRN #503 educated ADON #501 and ADON #502 on the process for approval for staff working COVID-19 positive in a crisis situation. All COVID positive staff must have approval by the regional team prior to working. All positive results must be reported to the regional team. · On 01/05/22 at 4:00 P.M., CRN #503 provided a written discipline and education to the DON on the process and approval for COVID positive staff working during crisis which included the following. · Immediate plan to ensure additional safety measures: DON must report all COVID positive staff to CRN #503 and CRN #503 will then provide the direction of calling the local health department (LHD) and confirming the return-to-work date. The DON will send a daily updated line list to CRN #503 for auditing. · The process to determine if the facility enters crisis staffing mode must include completing all relevant forms (Emergency Staff Checklist) and exhausting all other staffing options prior to requesting approval for crisis mode. Determining factors include census, number of staff out with COVID, number of open positions, direct care staff ratio falling below 2.5 hours per day per resident or at a level where all residents ' needs cannot be met. Contacting the LHD for assistance. · Beginning 01/05/22, CRN #503 will receive a daily line list for all COVID positive in the building and will audit daily for one week and weekly after for three weeks to confirm that only approved COVID positive staff working the COVID unit are in the facility. The medical director will be updated at the weekly Quality Assurance Performance Improvement (QAPI) meeting to be held for four weeks and then monthly thereafter. Any staff approved to work COVID positive, the process to be followed as outlined, the regional team is notified, the current staffing QAPI is reviewed to ensure all resources have been exhausted. The regional team will then notify the divisional team and the LHD. · On 01/06/22 at 7:30 A.M., CRN #503 reviewed the line listing for any changes and confirmed there were no COVID positive staff working that were not assigned to the COVID unit. · On 01/06/22 at 9:30 A.M. full house testing of all staff and residents was completed. Although the Immediate Jeopardy was removed on 01/06/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance. Findings include: Review of Resident #16's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] history of COVID-19, and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, walk in room, and toilet use. Review of the progress notes dated 12/27/21, 12/30/21, and 01/03/21 revealed Resident #16 tested negative for COVID-19 during outbreak testing. Review of Resident #62's medical record revealed a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)], and stroke. Review of the admission MDS 3.0 assessment dated 12/21/21 revealed Resident #62 had impaired cognition and required extensive assistance with bed mobility, transfers, and toilet use and total dependence of one staff for locomotion on and off the unit. Review of the progress notes dated 12/30/21 and 01/03/22 revealed Resident #62 tested negative for COVID-19 during outbreak testing. Review of Resident #67's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] right dominant side, weakness, and dementia without behavioral disturbance. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #67 had intact cognition and required limited assistance of one staff for bed mobility and transfers, independence with ambulation, and supervision of one staff for toilet use. Review of the progress notes dated 12/27/21, 12/30/21, and 01/03/22 revealed Resident #67 tested negative for COVID-19 during outbreak testing. Interview on 01/05/22 at 1:00 P.M. with an anonymous staff revealed there were staff that had tested positive for COVID-19 and were currently working with COVID negative residents. The anonymous staff would not provide any staff names but wrote a note that read Rehab DOR positive working with patients off COVID. Review of the facility's COVID-19 positive line list of residents and staff revealed DOR #500 tested positive for COVID-19 on 01/04/22. Interview on 01/05/22 at 1:15 P.M. with Physical Therapist (PT) #510 and Speech Therapist (ST) #511 revealed DOR #500 was working today and was most likely on the COVID unit about to end his day. PT #510 stated the therapy staff saw the COVID negative residents first and went to the COVID unit last prior to going home for the day. PT #510 brought up DOR #500's case schedule in the computer and stated that DOR #500 was scheduled to see Resident #67 today who was COVID negative and that the rest of DOR 500's case schedule included residents on the COVID unit. Interview on 01/05/22 at 1:25 P.M. with agency Licensed Practical Nurse (LPN) #504 revealed she saw DOR #500 working with Resident #62 who was COVID negative earlier today. LPN #504 stated Resident #62's cognition fluctuated but his wife was in the room with him. LPN #504 stated she did not see DOR #500 working with Resident #67 but the resident was alert and oriented. Interview on 01/05/22 at 1:27 P.M. with Resident #67 revealed he had therapy today with DOR #500. Interview on 01/05/22 at 1:28 P.M. with Resident #62 revealed he did not have therapy yet. Resident #62 ' s wife stated when she arrived Resident #62 told her he already had therapy for the day. Resident #62's wife stated the resident received both physical therapy and occupational therapy and that DOR #500 provided the physical therapy. Interview on 01/05/22 at 1:56 P.M. with Assistant Director of Nursing (ADON) #502 revealed he had not had any correspondence with the LHD outside of emailing them the COVID-19 positive line list and the Ohio Department of Health (ODH) confidential reportable disease forms. ADON #502 stated he was not sure who their contact person was for the LHD and had tried to call them once with a general question, but no one answered the phone. Interviews on 01/05/22 at 2:15 P.M. and 2:30 P.M. with DOR #500 via phone revealed he was told he had to leave the facility and was currently at home. DOR #500 stated he tested positive for COVID-19 early in the morning on 01/04/22. After ADON #501 had a conference call DOR #500 was told by ADON #501 he could stay and work. DOR #500 completed therapy sessions with the COVID negative residents (#16 and #62) and then moved onto the COVID unit before ending his day. While working with Resident #16 and #62 DOR #500 wore gown, gloves, a N95 mask with a surgical mask over the N95 mask, and a face shield. DOR #500 worked with Residents #16 and #62 both in the hall and in their rooms and both residents wore surgical masks only while they were in the hall. DOR #500 stated he did not have any symptoms on 01/04/22. DOR #500 returned to work today (01/05/22) again starting therapy sessions with the COVID negative residents (#62 and #67) before going onto the COVID unit. DOR #500 stated while he worked with both residents, he wore gown, gloves, a N95 mask with a surgical mask over the N95 mask, and a face shield. DOR #500 worked with Resident #67 in the rehab gym and Resident #67 wore a surgical mask. DOR #500 stated when he worked with Resident #62 it was in the hall and in his room and Resident #62 only wore a surgical mask while they were in the hall. DOR #500 stated he felt good today (01/05/22) but had mild congestion but no fever. DOR #500 stated while he was working on the COVID unit on 01/05/22 he was told he had to go home. DOR #500 stated he was given the option to work only on the COVID unit or to take the rest of the week off. DOR #500 decided to take the rest of the week off because the workload was pretty low, and PT #510 was able to cover. DOR #500 was vaccinated with the two step COVID-19 vaccine but had not received the booster. DOR #500 stated he also tested positive for COVID in December 2020 and had to stay home for 10 days. Interview on 01/05/22 at 3:19 P.M. with CRN #503 revealed Residents #16, #62, and #67 were all vaccinated with the two step COVID-19 vaccine. CRN #503 stated she had learned the DON had given permission for DOR #500 to continue to work while COVID-19 positive citing crisis staffing. CRN #503 stated she informed the DON that crisis staffing did not apply to DOR #500. Review of the nurse's note dated 01/06/22 at 11:53 A.M. revealed Resident #67's physician was notified Resident #67 had a positive rapid COVID result, and a PCR test was sent out and pending results. Resident #67 was asymptomatic currently. The note indicated the physician would be updated once PCR results obtained. Observation on 01/06/22 at 12:12 P.M. revealed the doorway to Resident #67's room was covered with clear plastic barrier with a zipper down the middle which was closed. There was a sign on the plastic barrier indicating droplet precautions and a bin filled with gowns, gloves, N95 masks, and surgical masks located outside of the doorway. Interview on 01/06/22 at 12:13 P.M. with agency LPN #512 revealed Resident #67 was on droplet precautions due to a positive rapid COVID-19 test and they were currently waiting for the results of his PCR test. LPN #512 stated Resident #67 had no symptoms and was feeling fine when she assessed him. Interview on 01/06/22 at 12:55 P.M. with CRN #503 revealed Resident #67 was tested today with a rapid COVID-19 test and was positive. CRN #503 stated they completed a PCR test and were waiting for the results. CRN #503 stated Residents #16 and #62 were tested again on this date (01/06/22) with a rapid COVID-19 test and both were negative. Review of DOR #500 ' s PCR test result with collection date of 01/04/22 revealed a positive result for COVID-19, confirming the rapid test taken on 01/04/22. Follow-up interview on 01/06/22 at 2:24 P.M. with CRN #503 revealed they had a process before approving positive staff to work and they were only to work on the COVID unit. CRN #503 stated the process included following the facility ' s policy which included completing a form titled Emergency Staffing Checklist which was to be emailed to CRN #503 and CRN #503's boss, input would be provided from the medical director and then a decision would be made regarding whether the staff would be permitted to work. CRN #503 stated the DON did not follow the process and DOR #500 was not included in crisis staffing. CRN #503 stated they were currently in staffing crisis for nursing but would not approve a COVID positive staff to work with COVID negative residents. Review of the facility's policy titled COVID-19 Employee Testing, Quarantine, Return to Work and LOA revealed if the test result was positive and the employee was asymptomatic (and not severely immunocompromised throughout their infection), they would not be permitted to return to work until at least 10 days have passed since the date of their first positive test. In the event of staffing shortages: The CDC recommended contingency capacity strategies to mitigate staffing shortages. The facility could follow the recommendations in the event there were staffing shortages that could not be otherwise managed. The divisional team had to provide approval before this process could be utilized. Review of CMS memorandum, QSO-20-38-NH revised 09/10/21 revealed staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of testing. Review of the CDC's Strategies to Mitigate Healthcare Personnel Staffing Shortages updated 12/23/21 revealed allowing healthcare personnel (HCP) with [CONDITION(S)]-CoV-2 infection who are well enough and willing to work to return to work as follows: HCP with mild to moderate illness who are not moderately to severely immunocompromised: at least five days have passed since symptoms first appeared (day 0), and; at least 24 hours have passed since last fever without the use of fever reducing medications, and symptoms (e.g., cough, shortness of breath) have improved. Healthcare facilities may choose to confirm resolution of infection with a negative [MEDICATION(S)] test or NAAT*. HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: at least 5 days have passed since the date of their first positive [CONDITION(S)] test (day 0). Review of the facility's policy titled Staffing in a Crisis Situation dated 12/27/21 revealed facilities are required to obtain permission from regional or divisional teams prior to implementing the following strategies. Under contingent capacity staffing strategy, allow employees who have tested positive for COVID-19 to shorten their quarantine time to five days with/without negative test if the employee remains asymptomatic or mildly symptomatic and symptoms are improving. The employee must follow all personal protective equipment (PPE) guidelines. Under the area of crisis capacity staffing strategies the policy indicated if shortages continue despite other mitigation strategies, as a last resort consider allowing employees with suspected or confirmed COVID-19 infection who are well enough and willing to work but have not met all return to work criteria. Duties should be considered in the following order: allow employee with confirmed COVID-19 infection to provide direct care only for patients with confirmed COVID-19 infection, preferably in a cohort setting. Review of an email dated 01/01/22 to the DON and Administrator revealed the facility was approved for crisis capacity staffing by the divisional team. The email listed: 1. Implement regional plans to transfer patients to alternate care sites with adequate staffing. 2. allow employees who are unvaccinated or who have had one or two does vaccine series but not a booster vaccine and have had a higher risk exposure to COVID-19 but are not known to be infected may work without quarantine. Testing may or may not occur based on testing supply. If permitted to work, employee should be monitored for symptoms and follow all PPE guidelines. 3. If shortages continue despite other mitigation strategies, as a last resort consider allowing employees with suspected or confirmed COVID-19 infection who are well enough and willing to work but have not met all return-to-work criteria. Duties should be considered in the following order: allow employee with confirmed COVID-19 infection to provide direct care only for patients with confirmed COVID- 19 infection, preferably in a cohort setting; allow employee with confirmed Covid- 19 infection to provide direct care only for patients with suspected Covid-19 infection; as a last resort, employee with confirmed Covid-19 infection to provide direct care for patients without suspected or confirmed Covid-19 infection. If this is being considered, this should be used as a short-term strategy only. Employee should be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology). Patients should wear well-fitting source control while interacting with these employees Employee should be educated on the risk of exposing patients as well as their coworkers. Employee will wear an N95 at all times even when they are in non-patient care areas. Employee must practice social distancing from coworkers at all times and adhere to all PPE guidelines. Employee should self-monitor symptoms throughout shift and notify their supervisor if symptoms recur or worsen. This deficiency substantiates Complaint Number OH 837.