Every finding on record at O'Neill Healthcare Middleburg Heights

Based on record review, observation, interview and facility policy review, the facility failed to ensure oxygen tubing was dated for Residents #76 and #36. This affected two residents (#76 and #36) of five residents reviewed for oxygen therapy. The facility census was 65.Findings include:1. Review of Resident #76's medical record revealed an admission date of 11/28/25 with diagnoses of acute respiratory failure with hypoxia and hypertensive heart disease. Review of a physician's order dated 11/28/25 revealed Resident #76 was ordered oxygen at two liters/minute via nasal cannula continuously, and the oxygen tubing was to be changed weekly on Sunday.Observation on 12/01/25 at 12:45 P.M. revealed Resident #76's oxygen tubing was not dated. Interview with Licensed Practical Nurse (LPN) #579 on 12/01/25 at 12:50 P.M. confirmed Resident #76's oxygen tubing was not dated.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating impaired cognition. The MDS also revealed Resident #76 required maximum assistance to total care with all activities of daily living (ADL) but was able to feed herself. Review of the current care plan for altered respiratory status/difficulty revealed Resident #76 was at risk for decreased cardiac output related to acute respiratory failure with hypoxia and hypertensive heart disease. Interventions included oxygen therapy per physician order. 2. Review of Resident #36's medical record revealed an admission date of 09/09/25 with diagnoses of congestive heart failure (CHF), hypoxemia, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment dated [DATE] a BIMS score of 14 out of 15, indicating intact cognition. Resident #36 required substantial/maximum assistance with showering and bathing, moderate/maximum assistance with dressing, and supervision with oral hygiene. Review of the current care plan for altered respiratory status/difficulty revealed Resident #36 was at risk for decreased cardiac output related to CHF. Interventions included oxygen therapy per physician order. Review of the physician order originally dated 10/07/25 revealed oxygen tubing was to be changed weekly every night shift every Thursday, date and initial new tubing and replace bag for tubing. Observation on 12/01/25 at 3:59 P.M. revealed Resident #36's oxygen tubing was not dated. Interview with Registered Nurse (RN) #513 on 12/01/25 at 4:00 P.M. confirmed Resident #36's oxygen tubing was not dated. Review of the facility's undated policy titled Respiratory Therapy Equipment stated oxygen cannula and tubing would be changed as necessary.

Based on closed medical record review, Emergency Medical Service (EMS) run sheet review, hospital record review, review of Medscape guidance, facility policy review and interview, the facility failed to ensure comprehensive monitoring and timely identification of a change in Resident #80's condition related to the use of an indwelling urinary catheter. This resulted in Immediate Jeopardy, actual harm and subsequent death beginning on [DATE] at approximately 7:00 A.M. when Resident #80 had decreased urine output with only a total of 200 milliliters (ml) over three nursing shifts. However, the nursing staff did not follow up to comprehensively assess the resident during this time period or follow up with State tested Nursing Assistant (STNA) staff to inquire about the resident's urine output during their shifts. The nursing staff did not notify the physician Resident #80 had zero to 100 ml of urine output each nursing shift. On [DATE] at 11:25 P.M., the resident's family requested the resident be transferred to the emergency room . Upon arrival at the hospital, the resident was assessed to have a firm abdomen, abdominal distension and pain in the lower stomach region with the resident moaning and wincing in pain on palpitation of lower abdomen. The resident's indwelling catheter was replaced and began draining dark, thick, purulent urine. The resident had 2000 ml of urine output after the indwelling catheter was replaced. The resident was diagnosed with altered mental status, a urinary tract infection (UTI) and septic shock. Resident #80 was subsequently discharged to an inpatient hospice center and expired on [DATE]. The resident's death certificate noted cause of death was bacteremia due to septic shock and heart disease. This affected one resident (#80) of three residents reviewed for catheter care. The facility identified seven additional residents (#17, #42, #45, #47, #55, #57, and #62) with urinary catheters. On [DATE] at 2:18 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #325 were notified the Immediate Jeopardy began on [DATE] at approximately 7:00 A.M. when Resident #80 had decreased urine output with only a total of 200 ml over three nursing shifts. However, the nursing staff did not follow up to comprehensively assess the resident or follow up with STNA staff to inquire about the resident's urine output during their shifts. The nursing staff did not notify the physician Resident #80 had zero to 100 ml of urine output each nursing shift. On [DATE] at 11:25 P.M., the resident's family requested the resident be transferred to the emergency room . Upon arrival at the hospital, the resident was assessed to have a firm abdomen, abdominal distension and pain in the lower stomach region with moaning and wincing in pain on palpitation of lower abdomen. The resident was diagnosed with a UTI and septic shock. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: On [DATE], the facility identified two charge nurses, LPN #307 and LPN #308 who failed to identify the resident's condition and assess Resident #80 appropriately and timely. LPN #307 and LPN #308 received disciplinary action and education regarding urinary devices, output monitoring, resident assessments, interventions, notification to family and physician, and documentation. STNA #315 and STNA #312 were identified as the STNAs involved in Resident #80's care on [DATE] and [DATE]. STNA #315 and STNA #312 were educated on notification of change in resident urine output including amount, color, odor, or complaints of pain from resident. On [DATE], RDCS #325 provided education to the DON regarding urinary devices, output monitoring, resident assessments, interventions, notifications to family and physician/nurse practitioner (NP) and documentation. Education was completed to include monitoring of resident with urinary devices related to change in urinary output (decreased ml out, change in characteristics such as color/odor), completing focused urinary assessment (obtaining vital signs, checking abdomen for distention/tenderness, asking resident if any complaints of pain in abdomen, flank, or back, checking condition of catheter drainage for tubing for clot, kinks, sediment, and initiating interventions as needed. The DON educated the two Unit Managers (LPN #301 and #309) on the same above topics. The DON and Unit Managers educated all 26-nursing staff on the above topics. On [DATE], the facility identified seven residents (#17, #42, #45, #47, #55, #57, and #62) with urinary devices. The DON assessed the seven residents for signs and symptoms of dehydration, urine output outside of resident baseline parameters, and complaints related to urinary status, and reviewed their medical records. Residents #17, # 42, #57, and #62 were stable and no interventions were indicated. Residents #45, #47, and #55 had no urine output documented, and a physician order was obtained to document urine output on each shift. Residents #45, #47, and #55 had sufficient urine output and no other interventions were indicated. On [DATE], the DON/Unit Mangers educated all 31 STNAs on urinary devices, output monitoring, and notification to the charge nurse of any observed change in resident's baseline status. On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) was held to review the findings of Resident #80's change in condition and decreased urine output. Beginning [DATE], the DON/designee would review all new physician orders and notes to ensure any change in condition or potential risk of infection were addressed appropriately and notifications were completed. Audits would be completed daily for four weeks and randomly thereafter for a total of four months to ensure appropriate assessment, documentation, and notification. Beginning [DATE], the DON/designee would complete audits on all residents with an indwelling urinary catheter weekly for a period of four weeks and randomly thereafter for a total of four months to ensure appropriate assessment, documentation and notification. This audit would include physical assessment of catheter, documentation review of urine output, monitoring of signs and symptoms of infection including urine color being collected. All findings will be reviewed by the QAPI committee with the Medical Director weekly (if necessary) or on a monthly basis. Although the Immediate Jeopardy was removed on [DATE], 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 the closed medical record for Resident #80 revealed an admitted [DATE] with diagnoses including history of UTIs, low back pain, hematuria, retention of urine, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had intact cognition and had an indwelling urinary catheter. Resident #80 required one assistance from staff for toileting. Review of the plan of care dated [DATE] revealed Resident #80 was at risk for infection and/or trauma related to the use of Foley (indwelling urinary) catheter related to urinary retention. Interventions included to assess the resident for pain/discomfort every shift, check Foley catheter for patency, kinks in tubing, urinary output every shift, monitor and record output every shift and notify nurse if no output noted and monitor for signs and symptoms of UTI (burning on urination, flank pain, hematuria, decreased urinary output, change in mental status, change in behavior, fever, change in color, clarity and odor of urine). Review of Resident #80's physician orders dated [DATE] revealed an order for Foley catheter care every shift, monitor Foley patency every shift, may irrigate Foley catheter per house protocol, as needed if leaking or obstructed. Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #80 refused his lidocaine patches (pain patch) to his bilateral hips on [DATE] and [DATE]. Record review revealed the resident also had physician orders for Tramadol 50 milligrams (mg) every 12 hours as needed for pain and Acetaminophen 325 mg (for mild pain) two tablets every four hours as needed for pain. Neither medication was documented as being administered to Resident #80 on [DATE] or [DATE]. Review of the meal and supplement intake for [DATE] and [DATE] revealed Resident #80 consumed 100 percent (%) of a magic cup supplement (high calorie supplement) four ounces (oz) at lunch on [DATE] and [DATE]; 100% of Boost glucose control (high calorie nutritional supplement) eight oz on [DATE] and [DATE] in the morning and 50% in the evening on [DATE] and 25% in the evening on [DATE]. Resident #80 was to receive a four oz house nutritional supplement if he consumed less than 50% of his meal. Resident #80 consumed the following meals: on [DATE], breakfast was zero % of meal and supplement, lunch was zero % meal and 100% of the four oz supplement and for dinner was 50% meal intake and 100% of the four oz supplement. On [DATE], breakfast was 100% meal intake and 100% four oz supplement, lunch was 50% meal intake and zero % supplement, and dinner was 25% meal intake and 100% of the four oz supplement. Review of Resident #80's Treatment Administration Record (TAR) for [DATE] revealed on [DATE] from 7:00 A.M. to 7:00 P.M., there was zero urine output documented under catheter care. On [DATE] from 7:00 P.M. to ([DATE]) 7:00 A.M., the record included the resident had 100 ml urine output for the shift. On [DATE] from 7:00 A.M. to 7:00 P.M., there was 100 ml of urine from the Foley catheter documented. On [DATE] from 7 P.M. to 7 A.M., it was marked with an X, and no urine output was noted. This was a total of 200 ml urine output in approximately 36 hours. Monitoring of the catheter's patency was documented as completed. Review of the progress note dated [DATE] at 11:25 P.M. revealed the nurse noticed a blue tint to the resident's outer extremities. The nurse assessed Resident #80's pulse ox (pulse oximetry is to monitor blood oxygen saturation) and it was unobtainable. After applying warm towels to the resident's hands and applying oxygen, his pulse ox was low at 67% at three liters per minute (LPM) via nasal cannula. Residents #80 was shivering, temperature was 98.3 Fahrenheit (F), blood pressure had been elevated ,d+[DATE] and started to come down after applying oxygen to ,d+[DATE]. The nurse contacted the primary care physician and was told if the family wished to send the resident to the hospital, follow their wishes. After speaking with the resident's grandson, Resident #80 would be sent to the hospital. On [DATE] at 1:00 A.M., Resident #80 was sent to the hospital via 911 due to all other transportation companies being unavailable until morning. Resident #80 was unresponsive to conversation or stimulation when leaving the facility, pulse ox was 88% on three LPM via nasal cannula, blood pressure was ,d+[DATE], heart rate was 96 beats per minute and respirations were 20. There was no documentation of issues with the Foley catheter or decreased urine output reflected in the documents reviewed. Review of the Emergency Medical Service (EMS) run sheet dated [DATE] at 1:30 A.M. revealed per staff, Resident #80 was normally alert and oriented times two with baseline confusion but starting yesterday evening, his mental status became more altered than normal with drops in his pulse ox saturation. Staff stated Resident #80 has also been refusing to eat or allow staff to care for him properly for several days. Staff stated the resident's family wished for him to be sent to the emergency room for evaluation. Staff stated they attempted to contact multiple private ambulance agencies prior to calling the fire department EMS. Review of the hospital records dated [DATE] revealed Resident #80 was brought into the hospital for altered mental status and low blood pressure. Chief complaint was sepsis/blood culture gram negative bacillus, acute kidney injury, leukocytosis (increase white blood cells), urinalysis showing pyuria (puss in urine) likely indication UTI and altered mental status. No fever, blood pressure was ,d+[DATE] (hypotensive) and pulse ox at 68% (low). Hospital diagnoses included altered mental status, UTI, and septic shock (when a bacterial infection causes low blood pressure and organ failure). On exam, Resident #80's abdomen was distended and firm below the umbilicus. Resident #80 moaned and winced in pain to palpation of lower abdomen. Resident #80 had an indwelling Foley catheter which was noted to be dry with no drainage. The nurse replaced the Foley catheter and Resident #80 began to drain dark, thick, purulent urine; 2,000 ml urinary output was obtained. Resident #80 became slightly more alert, and he said he felt better. Sepsis alert was called. Resident #80 was started on Zosyn (intravenous (IV) antibiotic) and IV fluids bolus. Resident #80's blood pressure initially responded to fluids and his blood pressure went up but once the fluids were finished, his blood pressure dropped again. Due to Resident #80 being comfort care (advance directive), status pressors (blood pressure medications) were not started. On re-examination, systolic blood pressure was critical (,d+[DATE]) (hypotensive), temperature 99.7 F (elevated), respirations 39 breaths per minute (elevated), pulse ox was 95% on four LPM. Resident #80 has persistent high lactate levels (body tissues are not getting enough oxygen), hypotension (low blood pressure), and remained obtunded (diminished responsiveness to stimuli). Prognosis was poor. On [DATE], Resident #80 was discharged to an inpatient hospice care center. Review of the death certificate dated [DATE] revealed Resident #80 passed away on [DATE] at 9:30 P.M. The cause of death was bacteremia (bacteria in the blood) due to septic shock and due to heart failure. The death certificate was signed by Physician #320 on [DATE]. Interview on [DATE] at 12:11 P.M. with Resident #80's daughter denied knowledge of any family member or friend emptying Resident #80's Foley catheter while he was at the facility. Interview on [DATE] at 12:28 P.M. with Resident #80's grandson verified the cause of death on the resident's death certificate was bacteremia, septic shock and heart disease. Resident #80's grandson denied knowledge of any family member or family friend of emptying Resident #80's Foley catheter at any time. Interview on [DATE] at 2:57 P.M. with the DON revealed there was no facility protocol on what the nurse should do if a resident had no urinary output or low output through the catheter. However, there were orders as needed to flush the Foley catheter, change the catheter and notifying the physician that there were concerns with the Foley catheter. The DON stated LPN #307 told her the family was in and that they emptied the catheter bag. The DON verified LPN #307 and #308 should have assessed Resident #80's Foley catheter due to low urine output and not assumed he did not have any output because he was not drinking water. The DON verified LPN #307 and #308 should have notified the physician of Resident #80's decreased urine output. The DON also revealed the facility had a bladder scanner (device) at the nurse's station and it was working properly, and it could have been used for Resident #80 although nurses have to call the physician to get an order to use the bladder scanner. Interview via telephone on [DATE] at 3:00 P.M. with LPN #307 revealed when she went in to empty Resident #80's Foley catheter on [DATE], it was approximately 6:45 P.M. and his catheter bag was empty. She stated she thought it looked like it had been emptied and thought that the family or STNA had emptied the Foley catheter. LPN #307 stated had it been in the middle of her shift when she went to empty the catheter bag, she would have flushed his catheter or called the physician to do a bladder scan. No one was in the room to ask if someone had emptied the catheter bag. LPN #307 stated Resident #80 appeared to be at his baseline and did not have any more abdominal distention than normal. LPN #307 stated she told LPN #308 that Resident #80 had no output. On [DATE], LPN #307 worked her nursing shift from 7 A.M. to 7 P.M. Resident #80 had 100 ml of urine output but the LPN did not know what the urine looked like. LPN #307 felt this was accurate urine output because Resident #80 was not drinking much. The LPN stated Resident #80 was alert and oriented with confusion, did not show signs or symptoms of infection and did not have any complaints. LPN #307 stated she does not recall if LPN #308 told her about Resident #80 having a decrease in urine output. LPN #307 verified she did not call the physician related to Resident #80's decreased urinary output. Interview on [DATE] at 3:19 P.M. with LPN #308 revealed she worked the night shift on [DATE], [DATE], and [DATE] from 7 P.M. to 7 A.M. LPN #308 confirmed Resident #80 was on her assignment during these shifts. She stated Resident #80 was fine, asking about candy. The LPN stated Resident #80 did not like to drink water and would only drink water when he took his medications, and he would not drink his supplement drinks. LPN #308 stated she spoke to the STNAs regarding Resident #80's low urine output and to encourage fluids. The LPN stated the 100 ml urine output on [DATE] was accurate, but she could not remember what the urine looked like in appearance. The LPN also stated staff did encourage him to drink more water. LPN #308 stated on [DATE], Resident #80 did complain of back pain, but stated he always complained that his back was hurting all the time. On [DATE], LPN #308 did not remember what time he started with a change of condition, or his outer extremities started turning blue. She stated she seen him early in the shift, he was confused and did not want his candy. LPN #308 stated she called the physician related to Resident #80's mental status change but verified she did not inform the physician of any decreased urinary output. Interview via telephone on [DATE] at 9:40 A.M. with STNA #312 revealed she was assigned to Resident #80 on her night shift assignments on [DATE] and [DATE]. STNA #312 stated it was normal for Resident #80 to have 100 to 200 ml urine output on nights. When she did her check and change and repositioned him, he would complain of back pain. She does not recall any abnormal pain. STNA #312 stated the family did not come in much and denied knowledge of anyone other than staff emptying his Foley catheter. STNA #312 stated she told the nurse that Resident #80 only had 100 ml out and did not tell her anything about what the urine looked like. STNA #312 stated she does not remember the appearance of his urine output. Interview on [DATE] at 12:34 P.M. with STNA #315 revealed she was assigned to Resident #80 on her day shift assignments on [DATE] and [DATE]. The STNA revealed Resident #80 was not acting different, but he was not putting out urine. STNA #315 stated she overheard the night shift nurse say Resident #80 was not putting out urine, so she was offering him fluids throughout the night. STNA #315 stated she offered fluids throughout the day. STNA #315 stated Resident #80 was a little agitated for the whole shift, more than usual. He said his back was hurting, but that was his usual. STNA #315 stated she told the nurse that he was complaining of pain. Resident #80 had no urine output on Saturday ([DATE]). STNA #315 stated she did not see any other family members. Interview on [DATE] at 3:40 P.M. with Physician #320 revealed he reviewed Resident #80's hospital record and tried to figure out how long the resident had been sick for. Physician #320 stated it was only an estimate of two weeks that Resident #80 was sick with bacteremia and sepsis. Bacteremia usually comes on slowly and is not identified until outward symptoms show. Review of the facility's undated policy titled Catheter Care, Urinary, revealed under general guidelines to observe the resident's urine level for noticeable increases or decreases, check the urine for unusual appearance (color, blood, sediment). Maintain an accurate record of the resident's daily output. Observe the resident for signs and symptoms of UTI and urinary retention. Under the area of documentation revealed the date and time that catheter care was given, all assessment data obtained when giving catheter care, character of urine such as color, clarity and odor. If the resident refuses the procedure, the reason why and the interventions are taken. Under reporting stated notify the supervisor if the resident refuses the procedure and reports other information in accordance with facility policy and professional standards of practice. Review of Medscape guidance titled Septic Shock dated [DATE] revealed sepsis was defined as life-threatening organ dysfunction due to dysregulated host response to infection. In sepsis, symptoms may include decreased urine output. This deficiency represents non-compliance investigated under Control Number OH00158291.

Based on interview and record review, the facility failed to ensure appropriate fall interventions were used for Resident #100. This affected one of one resident reviewed for neglect. The facility census was 69 Findings include: A record review for Resident #100 revealed he was admitted on [DATE] with diagnoses of dementia, metabolic encephalopathy, history of urinary tract infections (UTI), and hypotension. His care plan dated 04/20/23 revealed he was at increased risk of falls. Interventions included moving his bed against the wall, a pillow wedge to the bed, and for staff to increase safety monitoring. Review of Self-Reported Incident (SRI) dated 04/25/23 revealed on 04/20/23, it was reported to the Director of Nursing (DON) that Licensed Practical Nurse (LPN) #583 left Resident #100 to lie on the floor after several repeated falls throughout the night. It was Resident #100's first evening at the facility and he was restless and fidgety all evening. The Resident was found on the floor several times throughout the night and placed back in bed by the aides. The interventions were not effective, so the resident was placed in a wheelchair and taken to the common area to be monitored more closely. LPN #583 witnessed Resident #100 lift himself out of the chair and fall on the floor. The intervention initiated at that time was to let him lie on the floor until he calmed enough to be moved back to bed. He was given a blanket and pillow for comfort and monitored by LPN #583. The Resident did calm down and was able to be transferred to the couch in the common area. An interview on 07/06/23 at 12:45 P.M. with the DON revealed the intervention of leaving Resident #100 was not an approved or appropriate intervention. LPN #583 was interviewed multiple times for consistency during the investigation. The nurse thought it was the best solution and would prevent Resident #100 from hurting himself. LPN #583 and the two State tested Nurse Aides (STNA)'s involved were terminated. Review of Fall Prevention and Intervention training for nursing staff on 04/25/23 revealed all nursing staff attended. Review of Falls/Incidences from 04/01/23 through 06/30/23 revealed no other trends or patterns. A record review of the falls policy revised on 10/2021 revealed all fall and safety interventions must be approved and appropriate for each resident.

Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 70 residents currently residing in the facility. Findings include: Review of the nursing staff information and staff schedule for 11/10/22 revealed no registered nurse (RN) was present working in the facility on 11/10/22. Interview on 12/20/22 at 2:30 P.M. with the Director of Nursing (DON) verified no RN was scheduled on 11/10/22. Interview on 12/21/22 at 10:04 A.M. with Scheduler #229 revealed staffing is based on census and uses agency when there is not enough facility staff. Scheduler #229 stated she just learned from the survey, that a RN must be scheduled daily.

Based on observation, record review, interview, and policy review the facility to ensure medications were always secure from unauthorized access. This affected one (Resident #26) of four (Residents #1, #26, #35 and #58) observed for medication administration. The facility census was 70. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including major depressive disorder, pulmonary fibrosis, chronic obstructive pulmonary disease, and hypotension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was severely cognitively impaired. Review of the December 2022 physician's orders revealed orders for Depakote (Divalproex Sodium) 125 milligrams (mg) three times a day for depression. Observation on 12/18/22 at 9:40 A.M. revealed an orange oblong pill with a plastic cup with water in Resident #26's room. Resident #26 could not state what date the pill was from. Observation and interview on 12/18/2 at 9:50 A.M. with Licensed Practical Nurse (LPN) #289 revealed an orange oblong pill with UL-125 on it sitting on Resident #26's nightstand. LPN #289 stated she was passing medications and had not been into Resident #26's room yet, and the pill was probably from last night. Review of the website titled, Medscape (https://reference.medscape.com/drug/depakote) revealed UL-125 was identified as Divalproex Sodium, a mood stabilizer. Review of the facility policy titled Oral Solid Medication Administration, dated 08/11/14, revealed residents should be observed taking medications to ensure the resident swallows all medications given.

Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident received the correct thickened consistency of fluids per physician orders. This affected two Residents (#124 and #129) of two residents reviewed for thickened liquids. The facility identified four Residents (#45, #124, #129 and #130) who received thickened liquids. The facility census was 70. Findings include: 1. Review of Resident #124's medical record revealed and admitted [DATE] with diagnoses including pneumonia, multiple sclerosis, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) 3.0 assessment revealed the assessment was in progress. Review of the physician's orders for December 2022 revealed Resident #124's diet order was a no added salt, mechanical soft with ground meat texture, and nectar thickened liquids consistency. Observation on 12/20/22 at 7:26 A.M. revealed a 16-ounce (oz) Styrofoam cup filled halfway filled with thin liquids on the Resident #124's nightstand. This was verified at the time of the observation by Central Supply #233. 2. Review of Resident #129's medical record revealed and admitted [DATE] with diagnoses including COVID-19, dementia, and depression. Review of the admission MDS 3.0 assessment revealed the assessment was in progress. Review of the physician's orders for December 2022 revealed Resident #129's diet order was two-gram sodium low concentrated sweets, mechanical soft texture, and nectar thickened liquids consistency. Observation on 12/20/22 at 7:34 A.M. revealed regular (thin) water in a plastic mug sitting on Resident #129's nightstand with straw. This was verified at the time of the observation by Licensed Practical Nurse (LPN) #291. Review of the facility's diet list revealed that Resident #124 and Resident #129 were on nectar consistency liquids.

Based on observation, staff interview, review of resident records, review of infection control policy and procedures, review of the facilities Influenza timeline for December 2022, the Center for Disease Control (CDC) Interim Guidance for Influenza Outbreak Management in Long Term Care Facilities, dated 11/21/22, the facility failed to maintain acceptable infection control practices in the area of isolation procedures for influenza outbreaks after Resident #24 tested positive for Influenza A (highly contagious respiratory infection) by placing her in the dining room at the table with Resident #45. This affected two (Residents #24 and #45) and had the potential to affect all 70 residents residing in the facility. Findings include 1. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnosis included dementia, acute kidney failure, and heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was severely impaired cognitively. Resident #24 required one to two staff assistance for activities of daily living (ADL). Further review of the MDS assessment revealed Resident #24 was totally dependent for locomotion, eating, and toileting. Resident #24 required a mechanical lift for all transfers. Review of the physician orders dated 12/18/22 revealed an order to swab for Respiratory Syncytial Virus (RSV) and/or influenza due to cough. Review of the progress note dated 12/18/22 at 5:49 P.M. revealed Resident #24 was placed on isolation precautions pending results of the Influenza/RSV swab. Review of the progress notes dated 12/19/22 at 3:44 P.M. revealed Resident #24's swab returned positive for Influenza A. Review of the physician orders dated 12/19/22 revealed an order to maintain droplet isolation for Influenza A every shift until 24-hours symptom free. Review of the physician orders dated 12/20/22 revealed an order for Resident #24 to receive one capsule by mouth, one time a day, of Tamiflu capsule 75 milligrams (mg) for Influenza A, for five days. 2. Review of the medical record for Resident #45 revealed an admitted [DATE]. Diagnosis included acute kidney failure, Alzheimer's, and vascular dementia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #45 was severely impaired cognitively. Resident #45 required one to two staff assistance for ADL. Further review of the MDS assessment revealed Resident #45 was a totally dependent for locomotion. Review of the progress notes dated 12/20/22 at 3:04 P.M. revealed Resident #45 was swabbed for Influenza/RSV due to cough. Further review revealed Resident #45's results were negative. Observation on 12/18/22 to 12/20/22 from 8:00 A.M. to 5:00 P.M. revealed Resident #24 was observed in her room on isolation precautions. On 12/21/22 at 9:10 A.M., Resident #24 was observed in the dining room sitting across from Resident #45 for the breakfast meal. Resident #24 was observed to be yelling loudly without a protective face covering. Resident #45 was observed to be sitting at the table without a protective face covering. Resident #45 was previously swabbed for RSV and Influenza A on 12/20/22 at 3:04 P.M. and the results were reported as negative. Resident #45 was on oral antibiotics for pneumonia. Interview on 12/21/22 at 9:11 A.M. with Licensed Practical Nurse (LPN) #266 stated she was involved in a medical emergency and did not realize Resident #24 was sitting in the dining area located on the southwest unit. LPN #266 was unaware how Resident #24 had been transported to the location. Interview on 12/21/22 at 9:12 A.M., with State tested Nurse Aide (STNA) #286 revealed she walked into the dining room and found Resident #24 sitting at the table and stated she was unaware of her isolation status and how she got to the dinging area. On 12/21/22 at 9:15 A.M., Resident #24 was observed to be transported back to her room by STNA #286. Interview on 12/21/22 at 9:23 A.M., with STNA #287 stated she did not transport Resident #24 to the dining room. STNA #287 stated it was her first day and she was instructed to feed Resident #24. STNA #287 denied bringing Resident #24 to the dining room. Interview on 12/21/22 at 9:26 A.M., with LPN #228 revealed Resident #24 was not on her assignment but she was aware that she was positive for the Influenza A. LPN #228 stated Resident #24 was seated in the dining area across from Resident #45. LPN #228 was not aware how she was transported there. On 12/21/22 at 9:25 A.M., the Director of Nursing (DON) was informed of infection control concerns. The DON stated residents on isolation precautions who require feeding assistance, are to be fed inside their rooms. Review of the undated facility policy titled Policy for Isolation revealed the policy was to prevent the spread of infection within the facility using isolation precautions. The facility failed to implement this policy for compliance. Review of the CDC guidelines for Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities, dated 2017, revealed droplet precautions should be implemented to prevent further exposure to other residents and should continue for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer.

Based on observation, record review, and interview, the facility failed to ensure medications were administered with an error rate of under 5%. This affected two residents (Resident #29 and #66) of three residents observed for medication administration. Findings include: 1. Observation of the morning medication administration by Licensed Practical Nurse (LPN) #301 for Resident #29 and #66 on [DATE] from 8:59 A.M. to 9:29 A.M. revealed neither resident received any acetaminophen (a [MEDICATION(S)] and anti-[CONDITION(S)] medication) with these administrations. Record review of Resident #29 revealed a current order dated [DATE] for two acetaminophen 325 milligram (mg) pills to be given twice per day at 9:00 A.M. and 9:00 P.M. for unspecified [CONDITION(S)]. Record review of Resident #66 revealed a current order dated [DATE] for two acetaminophen 325 mg pills to be given three times per day at 9:00 A.M., 2:00 P.M., and 9:00 P.M. for polyarthritis. Interview with LPN #301 on [DATE] at 10:25 A.M. confirmed she did not give either resident their morning dose of acetaminophen. LPN #301 said the facility was out of the medication and new supply had not yet come in. Interviews with LPN #301 on [DATE] at 1:47 P.M. and 3:49 P.M. revealed the facility was still out of acetaminophen and the medication had not been given to Resident #29 and #66. 2. Observation of medication administration by LPN #301 for Resident #66 on [DATE] at 9:21 A.M. revealed one of the medications to be given was a multivitamin and minerals supplement, which the nurse drew out of a medication bottle with an expiration date of ,d+[DATE] and placed in a medicine cup with Resident #66's other pills. The surveyor intervened and confirmed with LPN #301 that the multivitamin was expired. Following surveyor intervention the nurse discarded the expired pill and drew the medication from a different, unexpired bottle. The above findings identified three errors out of 29 observed opportunities for medication error, creating an error rate of 10.3%. This deficiency substantiate Complaint Number OH 450.

Based on record review and interview the facility failed to consistently assist Resident #6 with brushing her teeth per the resident's plan of care. This affected one out of three residents reviewed for activity of daily living care. Findings include: Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. A plan of care was initiated upon admission and revised on 06/28/20 to address assistance needed with activities of daily living. Interventions on the plan of care indicated to assist Resident #6 with brushing her teeth, rinsing denture and cleaning gums followed by cues to rinse mouth after brushing completed. Resident #6's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 needed extensive assistance of one staff member with brushing her teeth. An interview with Resident #6's family member on 11/12/20 at 12:34 P.M. indicated in early October 2020 Resident #6 was seen by the dentist. The dentist had informed the family member Resident #6 had skin growing over her metal tooth appliance and was unable to clean her teeth due to pain issues. The dentist said Resident #6's teeth were caked with plaque from lack of care and her metal tooth appliance had not been removed in a long time. A interview with Resident #6's dentist on 11/16/20 at 12:20 P.M. indicated he had seen Resident #6 in his office on 10/09/20 and 10/20/20 for her annual cleaning. The dentist indicated Resident #6 was not seen earlier this year as expected due to the cancellation of all appointments due to the pandemic. Resident #6 had an appliance with skin grown over the edges which made it too painful to remove. The dentist indicated for this to happen the appliance had not been removed for a long time. The dentist suspected lack of oral hygiene which was recent as opposed to long term. Resident #6's teeth had soft plaque formed with no tarter or [MEDICATION NAME] present during his assessment. The dentist stated with routine brushing the soft plaque would have been removed. Resident #6 needed a second visit to clean her teeth and remove the appliance for proper cleaning once her gums had time to heal from the initial visit. A review of Resident #6's dental assessment dated [DATE] indicated dental findings of an upper and lower removable bridge appliance. Gingival hypertrophy (overgrowth of gum tissue around teeth) around these appliances suggested the appliances had not been removed in a long time. Heavy plaque levels and material suggest poor or no regular dental hygiene in the past months. Gingival (gums) inflammation and bleeding made the exam difficult. Plaque removed with with a soft brush and light supragingival scaling. Resident #6's partial dental appliances were cleaned in an ultrasonic cleaner. Resident #6 to return on three months for follow-up care. Review of State tested Nursing Assistant (STNA) documentation dated 10/22/20 to 11/15/20 indicated Resident #6 received limited assistance with one staff member providing guided maneuvering of limbs for personal hygiene including brushing her teeth. An interview with STNA #74 on 11/17/20 at 10:31 A.M. indicated she was assigned to care for Resident #6. STNA #74 indicated Resident #6 was able to brush her teeth independently and she set her up with the oral hygiene supplies during her bath care. STNA #6 indicated she did not physically assist Resident #6 with brushing her teeth. A review of the facility policy and procedure titled Mouth Care Level II (undated) indicated the purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. In preparation for mouth care the staff were to review the resident's care plan to assess for any special needs of the resident and then assemble the equipment and supplies as needed. Upon completion of mouth care the staff were to document the completion of mouth care in the resident's record including the date and time the mouth care was provided. The name and title of the individual(s) who provided the mouth care and assessment data obtained concerning the resident's mouth. The nursing assistant should report to the licensed nurse to record in the medical record complaints of pain or discomfort of mouth, if the resident refused the treatment, the reason(s) why and the intervention taken and the signature and title of the person recording the data. This deficiency substantiates Complaint Number OH 043.

Based on record review and interview the facility failed to ensure Resident #67 was free of signficant medication errors; Resident #67's medication were not administered in the evening upon admission to the facility. This affected one of three residents reviewed for significant medication errors. Findings include: Resident #67 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #67's Medication Administration Record (MAR) dated 10/01/20 to 10/31/20 indicated on 10/27/20 the evening medications scheduled to be administered between 7:00 P.M. and 11:00 P.M. were not administered. Resident #67's physician orders indicated the following medications were not entered in to the electronic health record until 10/28/20. 1. [MEDICATION NAME] chloride (Medication used to reduce muscle spasms of the bladder and urinary tract.) extended release 24 hour tablet 5 milligrams (mg) administer orally once a day for [MEDICAL CONDITION]. 2. Apixaban (anticoagulant) 2.5 mg tablet, administer orally twice a day for heart failure. 3. [MEDICATION NAME] (Medication used to treat the symptoms of heart failure) tablet 25 mg administer orally twice a day for heart failure. 4. Entresto (Medication used to reduce the risk of death and hospitalization in adults with long-[MEDICATION NAME] (chronic) heart failure) tablet 97-103 mg (sacibitril-[MEDICATION NAME]) administer one tablet orally twice a day for COVID-19 infection. A review of Resident #67's nursing progress notes dated 10/27/20 indicated Resident #67 was admitted to the facility at 6:45 P.M. Resident #67 was admitted to the COVID-19 isolation unit. A review of Resident #67's hospital record indicated homegoing instructions dated 10/27/20 to continue taking medications as directed. Do not skip a dose of medication. If a medication was missed do not take a double dose. The medication list from the hospital indicated to continue taking in the evening on 10/27/20 the [MEDICATION NAME] chloride, apixaban, [MEDICATION NAME], and Entresto medications at the dosages listed above. An interview on 11/19/20 at 2:38 P.M. with Licensed Practical Nurse (LPN) #80 indicated Resident #67 was admitted to her assigned nursing unit on 10/27/20 at approximately 7:00 P.M. LPN #80 assessed Resident #67 and documented her assessment in Resident #67's clinical record. LPN #80 indicated because she was at the end of her 12 hour shift from 7:00 A.M. to 7:30 P.M. she gave Registered Nurse (RN) #81 report and left the building. LPN #80 indicated she did not administer Resident #67's evening medications on 10/27/20. An interview with RN #81 on 11/20/20 at 6:16 A.M. indicated upon admission the assigned nurse should perform a head to toe assessment and was responsible to enter the physician orders in the electronic record. RN #81 indicated she was assigned to care for Resident #67 on 10/27/20 from 7:00 P.M. to 10/28/20 at 7:30 A.M. RN #81 verified Resident #67's evening medications were not administered on 10/27/20. A review of Resident #3 and Resident #5 indicated they were recently admitted to the facility. On the day of admission all medications were administered as ordered by the physician and as indicated on their homegoing instructions from the hospital. Review of the facility policy and procedure dated 03/01/2007 indicated medications were administered as prescribed , in accordance with good nursing principles and practices by persons legally authorized to do so. The procedure included medications were administered in accordance with written orders of the attending physician. All current medications and dosage schedules were listed on the resident's medication administration (MAR) record. Medications were administered within 60 minutes of scheduled time unless otherwise specified by the physician. The person administering the medications would document their initials on the MAR and verified with a full signature in the space provided. This deficiency substantiates Complaint Number OH 036.

Based on interview and record review the facility did not ensure Housekeeper #607 was tested for Covid-19 prior to starting to work on the floor at the facility, and the facility did not have a policy or procedure regarding how they tested their employees, including new hires, for Covid-19. This affected one employee (Housekeeper #607) of 22 employees (Dietary Aides #802, #805, #821, Cook #817, Licensed Practical Nurse (LPN) #801, #811, #814, Staffing Coordinator #820, Administrator, State tested Nursing Assistants (STNA) #803, #806, #807, #808, #813 , #815, #816, #819, Registered Nurse (RN) #804, and Housekeeping #607, #809, #810 and #812 hired after 08/03/20 reviewed for pre-employment Covid-19 testing. This had the potential to affect all 52 residents residing in the facility. Finding included: Interview on 10/19/20 at 9:11 A.M. with Housekeeping #607 revealed she had not been tested for Covid -19. She revealed she recently was hired on 10/13/20 and she was not aware of when she would be getting tested . She revealed she was in housekeeping and had been on all units since hire. Interview on 10/19/20 at 1:15 P.M. with Facility Owner #609 verified Housekeeper #607 was not tested upon hire. She revealed they always test all employees prior to the employee starting on the floor, but Housekeeper #607 fell through the cracks and did not get tested . She revealed they would have her immediately sent out for testing. Review of employee personnel file for Housekeeper #607 revealed a hire date of 10/13/20. Review of undated form, New Hire Covid-19 Testing Log, revealed Housekeeper #607 was hired on 10/13/20 and was not tested prior to starting on the floor. She was tested [DATE]. Interview on 10/20/20 at 9:38 A.M. with Administrator revealed they do not have a specific policy for testing of employees as they just follow Ohio Department of Health guidelines or Center of Disease Control guidelines as well as recommendations from their local health department. Review of facility policy labeled, Covid-19 Residents: Screening and Management, dated 2020, revealed no guidelines or procedures for employee testing including for new hires. This deficiency substantiates Complaint Number OH 697.

Based on interview and record review the facility did not ensure Resident #45 signed a receipt of acknowledgment that he was informed and received his resident rights and facility responsibilities. This affected one resident (Resident #45) of three residents reviewed for being informed of resident rights. This had the potential to affect all 52 residents residing in the facility. Findings include: Review of medical record for Resident #45 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The medical record revealed Resident #45 was his own responsible party. Review of facility census revealed he was admitted to the Covid-19 unit on admission and moved off the Covid-19 unit into room [ROOM NUMBER] on 08/25/20. Review of Resident #45's admission paperwork dated 08/04/20 revealed no signed receipt that Resident #45 received or had his resident rights reviewed with him on admission. Review of five-day Minimum data Set (MDS) 3.0 dated 08/11/20 revealed Resident #45 had impaired cognition. Interview on 10/15/20 at 8:55 A.M. with Resident #45 revealed he did not sign his admission paperwork until he was moved from the Covid-19 unit to his current room of 102 which was several weeks after he was admitted . He revealed he did not receive or have his resident's rights reviewed with him on admission. Interview on 10/15/20 at 12:39 P.M. with Social Service Designee/Admissions #601 revealed she was a little late having Resident #45 sign his admission paperwork. She revealed she thought he had signed the paperwork on admission, but she was not sure. She revealed she had him sign the admission paperwork after he moved off the Covid-19 unit and when he was in room [ROOM NUMBER]. Interview on 10/19/20 at 12:16 P.M. with the Administrator and Social Service Designee/Admissions #601 revealed she did not have the Resident #45 sign off an acknowledgment of receipt for Resident #45 receiving information on his resident rights. Interview on 10/19/20 at 2:49 P.M. with the Activities Director #602 revealed all new admissions get a welcome basket and in the welcome basket is the booklet of Federal and Ohio Resident Rights and Facility Responsibilities. She revealed she gives the basket to the resident or leaves it for them at their bedside, and she does not go over the rights or have the resident sign that they received the resident rights booklet. She revealed she thought Admissions then reviewed the resident rights with the resident when they reviewed the admission paperwork. Interview on 10/20/20 at 9:34 A.M. with the Administrator verified they did not have a resident's acknowledgment of receipt for Resident #45 receiving information on resident rights, and she had Resident #45 sign one today, 10/20/20, and he received the information. Review of facility booklet labeled Federal and Ohio Resident Rights and Facility Responsibilities, dated 11/28/16, revealed in compliance with federal and state regulation the facility must have a signed record stating that a resident has received the specific information and that the residents rights have been explained to the resident in a language that the resident can understand. This deficiency substantiates Complaint Number OH 697.

Based on interview and record review the facility failed to ensure Resident #45's admission paperwork had the accurate date on the paperwork of when Resident #45 signed his admission paperwork. This affected one resident (Resident #45) of three residents reviewed for admission. This had the potential to affect 52 residents residing in the facility. Findings include: Review of medical record for Resident #45 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The medical record revealed Resident #45 was his own responsible party. Review of facility census revealed he was admitted to the Covid-19 unit on admission and moved off the Covid-19 unit into room [ROOM NUMBER] on 08/25/20. Review of Resident #45's admission paperwork revealed the paperwork was signed on 08/04/20 by Resident #45 and Social Service Designee/Admissions #601. Review of five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 had impaired cognition. Interview on 10/15/20 at 8:55 A.M. with Resident #45 revealed he did not sign his admission paperwork until he was moved from the Covid-19 unit to his current room of 102 which was several weeks after he was admitted but did not know the exact date. Resident #45 revealed the facility had placed the date of 08/04/20 on the forms even though this was not the date he signed the forms. Interview on 10/15/20 at 12:39 P.M. with Social Service Designee/Admissions #601 revealed she was a little late having Resident #45 sign his admission paperwork. She revealed she thought he had signed the paperwork on admission, but she was not sure. She revealed she had him sign the admission paperwork after he moved off the Covid-19 unit to room [ROOM NUMBER] on 08/25/20. Interview on 10/19/20 at 12:16 P.M. with the Administrator and Social Service Designee/Admissions #601 revealed she remembers Resident #45 signed the admission paperwork on admission on 08/04/20 but when she completed an audit, she was unable to find his signed paperwork. She revealed she could not remember when she had Resident #45 re-sign the paperwork but it was after he had moved off the Covid-19 unit which would have been sometime after 08/25/20. She had him re-sign the admission paperwork in his current room. She revealed she had Resident #45 re-sign his admission paperwork, and she placed the date of 08/04/20 on all of the forms. She verified this was not the date he re-signed the paperwork as it was after 08/25/20. Interview on 10/20/20 at 9:25 A.M. with the Administrator revealed the facility does not have a policy on signing admission paperwork. This deficiency substantiates Complaint Number OH 697.

Based on record review, observation and interview the facility failed to ensure Resident #68's dignity was maintained. This affected one resident (#68) of one reviewed for dignity. Findings include: Review of Resident #68's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment was in progress. Observation on 02/18/20 at 10:59 A.M. revealed Resident #68 in a wheelchair in the common area wearing a hospital gown, with a blanket laid across his lap, with his feet bare, and his catheter bag, not in a privacy bag. Observation on 02/18/20 at 11:03 A.M. revealed Licensed Practical Nurse (LPN) #430 wheeling Resident #68 from the common area to his room. Interview at that time with LPN #430 revealed Resident #68 was alert to name, but not alert to time. LPN #68 verified the observation and the dignity concerns and stated Resident #68 should have been taken to his room and assisted.

Based on observation, interview, and record review the facility failed to develop comprehensive care plans for Resident #34 related to transmission-based precautions and for Resident #54 related to a wanderguard. This affected two of 18 residents reviewed for care plans. Findings include: 1. Record review of Resident #34 revealed a re-entry date of 01/04/20. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and transfers, and was totally dependent on two staff for toilet use. Resident #34 was always incontinent of bowel and bladder and was not on isolation precautions. Review of the nursing notes dated 01/19/20 at 4:19 P.M. revealed Resident #34 was acting slightly sluggish and eating little. The physician was notified of his condition and tests were ordered including a stool sample. Review of the laboratory results for a stool sample collected on 01/19/20 revealed results dated 01/20/20 indicating Resident #34 was positive for [MEDICAL CONDITION] (C. diff). An inflammation of the colon caused by [DIAGNOSES REDACTED] bacteria. A physician order dated 1/20/20 at 7:27 P.M. revealed [MEDICATION NAME] [MED] solution (an antibiotic), 25 milligrams (mg) per milliliter (ml), 125 mg by mouth four times a day was ordered as an antibiotic for 10 days for the [DIAGNOSES REDACTED]. Review of the physician orders for February 2020 revealed no orders for transmission base precautions, but revealed orders for [MEDICATION NAME] [MED] capsule, 125 milligrams (mg) by mouth, two times a day for diarrhea for seven days until 02/24/20. And a physician order for [REDACTED]. Review of Resident #34's current care plan contained no information related to the need for transmission-based precautions for [DIAGNOSES REDACTED]. Interview of 02/18/20 at 11:06 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #34 was on transmission-based precautions for [DIAGNOSES REDACTED]. Observation at that time revealed a cart with drawers outside of Resident #34's room but no sign indicating transmission-based precautions. Review of Resident #34's care plan on 0[DATE] at 3:25 P.M. with the Director of Nursing verified there was no care plan in place for Resident #34 related to transmission-based precautions for [DIAGNOSES REDACTED]. 2. Record review of Resident #54 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required staff supervision with set-up help only for bed mobility, transfers, and toilet use and used a wander guard alarm daily. Review of the Elopement Data Tool assessment dated [DATE] revealed Resident #54 had a history of [REDACTED]. Review of the nursing notes dated 4/29/19 at 3:21 P.M. revealed Resident #54 was admitted to the facility after being found wandering into her neighbors' yards and was admitted to the hospital for change in mental status and [MEDICAL CONDITION]. Resident #54 was alert and oriented to herself only and very pleasant. Resident #54 has a wander guard in placed to the right ankle to prevent her from leaving the facility unassisted. Review of Resident #54's February 2020 physician orders were silent for the use of a wanderguard. Review of the current care plan revealed no information related to the use of a wanderguard. Observation on 02/18/20 at 2:14 P.M. revealed Resident #54 walking around the facility wearing a wanderguard to her right ankle. Interview on 0[DATE] at 2:50 P.M. with Registered Nurse (RN) #342 revealed he checked to ensure Resident #54's wanderguard was in place and working. RN #342 stated Resident #54 wandered around the facility but did not have exit seeking behaviors. Interview and review of the Resident #54's care plan on 0[DATE] at 3:25 P.M. with the Director of Nursing verified there were no physician orders or care plan for Resident #54's wanderguard.

Based on observation, record review and interview, the facility failed to ensure accurate and complete documentation in the medical records for Residents #34 and Resident #6[AGE]. This affected two residents (#34 and #6[AGE]) of 18 residents whose medical records were reviewed. Findings include: 1. Record review of Resident #34 revealed a re-entry date of [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and transfers, and was totally dependent on two staff for toilet use. Resident #34 was always incontinent of bowel and bladder and was not on isolation precautions. Review of the nursing notes dated [DATE] at 4:19 P.M. revealed Resident #34 was acting slightly sluggish and eating little. The physician was notified of his condition and tests were ordered including a stool sample. Review of the laboratory results for a stool sample collected on [DATE] revealed results dated [DATE] indicating Resident #34 was positive for [MEDICAL CONDITION] (C. diff). An inflammation of the colon caused by [DIAGNOSES REDACTED] bacteria. A physician order [REDACTED].M. revealed [MEDICATION NAME] [MED] solution (an antibiotic), 25 milligrams (mg) per milliliter (ml), 125 mg by mouth four times a day was ordered as an antibiotic for 10 days for the [DIAGNOSES REDACTED]. Review of notes written by Nurse Practitioner (NP) #454, dated [DATE], revealed Resident #34 was positive for [DIAGNOSES REDACTED] and the plan was to start oral [MEDICATION NAME] for a of 10 days, contact precautions per facility protocol, and monitor closely for resolution of diarrhea. The note dated [DATE] revealed Resident #34 continued on oral [MEDICATION NAME] for [DIAGNOSES REDACTED]icile and nursing reported the diarrhea was resolved. The plan for [DIAGNOSES REDACTED] was to continue oral [MEDICATION NAME]. Review of the physician orders [REDACTED]. And a physician order [REDACTED]. Review of Resident #34's current care plan contained no information related to the need for transmission-based precautions for [DIAGNOSES REDACTED]. Interview of [DATE] at 11:06 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #34 was on transmission-based precautions for [DIAGNOSES REDACTED]. Observation at that time revealed a cart with drawers outside of Resident #34's room but no sign indicating transmission-based precautions. Review of Resident #34's care plan on [DATE] at 3:25 P.M. with the Director of Nursing verified there was no care plan in place for Resident #34 related to transmission-based precautions for [DIAGNOSES REDACTED]. Interview of [DATE] at 11:06 A.M. with Licensed Practical Nurse (LPN) #430 revealed Resident #34 was on transmission-based precautions for [DIAGNOSES REDACTED]. Observation at that time revealed a cart with drawers outside of Resident #34's room, but no sign indicating transmission-based isolation precautions were in place for Resident #34. Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON), stated the nurses were to complete skilled nursing assessments under the assessments tab in the electronic medical record in relation to Resident #34 being on transmission-based precautions for [DIAGNOSES REDACTED]. Review of the skilled nursing assessments dated [DATE], [DATE], and [DATE] indicated Resident #34 was not on antibiotics or on any isolation precautions. There were no other skilled assessments dated after [DATE]. Review of the note by NP #454 dated [DATE] revealed Resident #34 had recently completed treatment for [REDACTED]. The plan for [DIAGNOSES REDACTED] with return of diarrhea was to resume the antibiotics and then go for tapering dose over the next 4 weeks and continue isolation precautions for now. Interview on [DATE] at 9:00 A.M. with NP #454 revealed she could not remember when Resident #54 was first diagnosed with [REDACTED].>Interview on [DATE] at 3:46 P.M. with the DON verified the skill nursing assessments noted above were inaccurate and no further assessments were completed after [DATE]. 2. Review of the closed medical record for Resident #6[AGE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated [DATE] revealed an advance directive for a full code status to be implemented and communicated to staff. Review of the nurse's note dated [DATE] at 7:30 P.M. revealed Resident #6[AGE] was found unresponsive by a State tested Nursing Assistant (STNA). The nurse was unable to get a pulse, heart rate and vitals. A note at 7:45 P.M. indicated the Administrator, physician, Power of Attorney and family were notified. The funeral home was contacted to come for Resident #6[AGE]. The nursing notes lacked pertinent information regarding all care and treatment provided to Resident #6[AGE], including if cardiopulmonary resuscitation (CPR) was initiated, as the resident was a full code. Review of the Physician Discharge Summary dated [DATE] revealed Resident #6[AGE] [MEDICAL CONDITION], multiple hospitalization s and a complicated pressure ulcer. The cause of death was cardiopulmonary arrest (heart stopped) and the resident was discharged to the funeral home. The summary contained no information to indicate resuscitation measures, including CPR, were attempted. Interview with Licensed Practical Nurse #451 on [DATE] at 4:44 P.M. revealed the nurse aide notified him that Resident #6[AGE] was unresponsive. LPN #451 stated he went into the room and immediately started CPR and 911 was called. He said emergency responders took over CPR and care when they arrived at the facility. Interview with the Director of Nursing on [DATE] at 4:54 P.M. verified the above findings and verified the medical record did not accurately reflect all care and treatment provided to Resident #6[AGE], including CPR.

Based on observation and interview and record review the facility failed properly alert staff, visitors and other residents to see nursing staff prior to entering the room of Resident #117, who was on isolation precautions. This affected one of two residents reviewed for isolation precautions. Finding include: Record review for Resident #117 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #117 was cognitively impaired and required extensive assistance from staff for bed mobility, transfers and toileting. The resident was incontinent of bowel and bladder. Review of February 2020 physician orders [REDACTED]. diff) infection, a highly contagious infection which causes diarrhea and inflammation of the colon. Observation on 02/18/20 at 9:30 A.M. of Resident #117's room revealed a cart sitting outside the room containing person protective equipment (PPE), such as gloves, gowns and face masks, used for isolation precautions. There was no sign posted on the doorway or outside the door to alert all staff, visitors or other residents to see the nurse prior to entering the room. Observation of Resident #117's room on 0[DATE] at 10:22 A.M. and 4:30 P.M. revealed sign posted to alert people to see the nurse before entering the room. Interview with License Practical Nurse (LPN) #448 on 2/20/20 at 10:22 A.M. confirmed Resident #117 was in isolation for [DIAGNOSES REDACTED] infection and was on contact isolation precautions. These are precautions used for residents with infections/diseases which are spread to others by touching the person or objects in their room. LPN #448 was unaware there was no sign posted on Resident #117's door to alert visitors, all staff and other residents to see the nurse before entering. LPN #448 verified this concern at that time. Interview with the Director on Nursing (DON) on 02/20/20 at 3:30 P.M. revealed she was unaware the isolation rooms did not have proper signs posted. The DON verified they have signs that are posted on the resident's door to see the nurse before entering the room. The DON said the bottom half of the signs they use identify the type of precautions in effect and the person protective equipment (PPE) needed before entering the room. The DON said they were getting more signs made because housekeeping had been disposing of the signs when cleaning the rooms. Review of the undated facility policy titled, Isolation-Categories of Transmission-Based Precautions, revealed under the category of Contact Precautions, step 8 Signs, the facility will implement a system to alert staff to the type of precaution the resident requires. The facility utilized the following system for identification of Contact Precautions for staff and visitors; there were to two lines left blank for the facility to fill in the type of alert system before entering the room.

Based on interview and record review the facility failed to ensure an allegation of abuse and/or mistreatment of [REDACTED].#2, was investigated to prevent any or further altercations. This affected one of three residents reviewed for allegations of abuse and/or mistreatment by Resident #2. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current plan of care revealed the resident had physical behaviors related to poor impulse control, anger and a history of harm to others. The interventions included assess and anticipate the residents needs, provide physical and verbal cues to alleviate anxiety, monitor, document and report to Clinical Practitioner of danger to self or others and be conscious of residents position when in groups, activities and dining room to promote proper communication with others. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the nursing note dated 02/20/19 by Licensed Practical Nurse (LPN) #107 revealed the resident was brought back to her unit and told she was in an altercation with Resident #2 because Resident #55 unwantingly walked into her room. Resident #55 had scratches on her arm and stomach. Further reveal of the medical record revealed there was no documentation of an investigation, witness statements or reporting of the incident. On 04/29/19 at 1:05 P.M., interview with the Administrator verified she was not aware of the altercation on 02/20/19 between Resident #2 and Resident #55. She verified there was no investigation or reporting of the incident. On 04/29/19 at 3:00 P.M., interview with LPN #107 revealed on 02/20/19 a State tested Nursing Aide (STNA) brought Resident #55 back to her unit and said the nurse had to separate her and Resident #2. LPN #107 verified she did not witness anything and thought Resident #2's nurse would take care of the investigation and reporting and verified she did not report the allegation to anyone. Review of the facility abuse policy and procedure, not dated, revealed the residents had the right to be free from abuse, neglect and/or mistreatment. The staff were to report any such allegations immediately to the Administrator. When investigating resident to resident concerns the facility would refer the matter to the interdisciplinary team to determine the appropriate interventions. This deficiency substantiates Complaint Number OH 832.

Based on interview and record review the facility failed to ensure a comprehensive interdisciplinary plan of care was in place for Resident #2 to ensure her behaviors were monitored for the safety of the other 66 residents residing in the facility. This affected one of three residents (Resident's #2, #6, and #55) reviewed for comprehensive care planning. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current plan of care revealed the resident had physical behaviors related to poor impulse control, anger and a history of harm to others. The interventions included assess and anticipate the residents needs, provide physical and verbal cues to alleviate anxiety, monitor, document and report to Clinical Practitioner of danger to self or others and be conscious of residents position when in groups, activities and dining room to promote proper communication with others. There was no indications she had altercations with Resident #55 on 02/20/19 or Resident #6 on 04/02/19 nor were there any interventions addressing how to keep other residents safe. Review of the nursing note dated 01/10/19 revealed the resident was mad and was hitting the wall. Review of the social service note dated 01/24/19 revealed the resident was alert and oriented and able to make her needs known. She had behaviors that were usually able to re-direct but had no impulse control. Review of the nursing note dated 02/20/19 revealed Resident #55, who was confused, wandered into the residents room, but the resident did not want her in the room and it resulted in an altercation with Resident #55 having scratches on her arm and stomach. Review of the nursing note dated 04/02/19 revealed Resident #6, who was confused, wandered into the residents room but the resident did not want her in the room, she slammed the door causing Resident #6 to fall on the floor. Review of the 04/10/19 nursing note revealed the resident became agitated when the aide did not perform a task the way she expected. The resident attempted to throw her wheelchair leg rest at the aide and was cursing at the staff. Review of the interdisciplinary team care conference dated 04/15/19 revealed the goal was to reduce outbursts but did not mention any specific plans or evidence anything was discussed with the resident who was present at the meeting. Review of the 04/28/19 nursing note revealed the resident physically attacked an aide. The resident was sent to the emergency room and subsequently admitted to the psychiatric unit for treatment. On 04/29/19 at 10:48 A.M., interview with Licensed Practical Nurse (LPN) #103 revealed she had to stop the resident from attacking an aide on 04/28/19. LPN #103 verified the resident flies off the handle a couple times a week mostly at staff. She was non-verbal but able to express her needs. LPN #103 felt Resident #2 taunted other residents at times. There was no behavior plan for the resident, we just try to re-direct her. On 04/29/19 at 12:50 P.M., interview with Social Service Designee (SSD) #104 indicated the resident did not express any concerns during the care conference on 04/15/19, and there was no discussion of her behaviors or ways to attempt to eliminate the behaviors. She verified there was no behavior modification plan in place. On 04/29/19 at 3:10 P.M., interview with the Administrator verified the concerns and felt it was best for the safety of all the residents if Resident #2 went to a facility that specialized in TBI residents and discussed it with the power of attorney today. Review of the facility abuse policy and procedure, not dated, revealed the residents had the right to be free from abuse, neglect and/or mistreatment. When investigating resident to resident concerns the facility would refer the matter to the interdisciplinary team to determine appropriate interventions. This deficiency substantiated Complaint Number OH 832.

Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessment was coded correctly for three residents (Resident's #11, #55, and #57). This affected three of eighteen residents reviewed for accuracy of assessments. The facility census was 57. Findings Include: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Treatment Administration Record (TAR) for (MONTH) (YEAR), Resident #11 revealed that the received [MEDICAL TREATMENT] on 10/08/18 and 10/10/18 related to a [DIAGNOSES REDACTED]. Review of section O of the MDS 3.0 assessment, dated 10/11/18, revealed the facility answered no to the question is the resident receiving [MEDICAL TREATMENT]? MDS Coordinator #258 verified the inaccuracies in an interview on 01/03/19 at 2:05 P.M. 2. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Pre-Admission Screen and Resident Review (PASRR) level two evaluation from the State Department of Mental Health, dated 05/11/11, revealed Resident #55 had a level two mental illness. Review of section A of the MDS 3.0 assessment, dated 12/06/18, revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental [MEDICAL CONDITION] in federal regulation) or a related condition?. Social Service Designee #300 verified the inaccurate MDS in an interview on 01/03/18 at 12:44 P.M. 3. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the PASRR level two evaluation from the State Department of Mental Health, dated 03/14/16, revealed Resident #57 had a level two mental illness. Review of section A of the MDS 3.0 assessment, dated 12/06/18, revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental [MEDICAL CONDITION] in federal regulation) or a related condition?. Social Service Designee #300 verified the inaccurate MDS in an interview on 01/03/18 at 12:44 P.M.

Based on record review, staff interview, and policy review the facility failed to ensure an antipsychotic medication was administered to the correct resident and failed to ensure insulin and blood pressure medications were administered as ordered resulting in significant medication errors. This affected one of four residents reviewed for significant medication errors (Resident #64). Actual harm occurred to Resident #64 when she was administered a dose of an antipsychotic medication in error resulting in a change in mental status requiring hospitalization for monitoring and treatment. Findings include: 1. Closed record review revealed Resident #64 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 07/29/16 Resident #64 was discharged to the hospital. A review of Resident #64's Resident Occurrence Report dated 07/29/16 revealed an anti-psychotic medication was administered to Resident #64 accidentally at 10:30 A.M. The medication was ordered for another resident who resided in the room next to Resident #64's room. Both residents had similar names and the same initials. Physician #69 and Resident #64's daughter were notified by Registered Nurse (RN) #70 immediately upon finding the error at 11:30 A.M. An intravenous line was initiated and vital signs were obtained every 15 minutes and one-on-one observation of Resident #64 by RN #70 was provided until the ambulance arrived to transport Resident #64 to the hospital. Resident #64 was lethargic and was encouraged to drink fluids and needed the assistance of RN #70 to eat her lunch meal. A review of Resident #64's clinical record revealed progress notes dated 07/28/16 and 07/29/16. The progress notes indicated Resident #64 was alert and oriented and was admitted to the facility for a short term stay for skilled services. Resident #64 was a full code and was anticipating returning home to her previous level of function upon discharge from the facility. On 07/29/16 at 11:30 A.M. nursing progress notes indicated Resident #64's daughter alerted the nurse that Resident #64 was quiet and not answering questions appropriately. Resident #64's daughter wanted to sit with Resident #64 for a while and would notify the nurse if needed. At 12:50 P.M. Resident #64 was lethargic, able to respond to her name and her vital signs were stable. Resident #64 was assisted with her lunch meal. She was unable to lift her utensils and required cues and hand over hand assistance with eating her lunch meal. Resident #64 consumed approximately 50% of her meal and drank 240 cubic centimeters of fluid. Resident #64 remained slow to answer questions. At 1:15 P.M. vital signs were stable, oxygen saturation was within normal limits but Resident #64 remained slow to answer questions. At 1:45 P.M. Resident #64 was transported to the hospital by ambulance. An interview with Physician #69 on 08/02/16 at 9:10 A.M. revealed she was responsible for Resident #64's care while she resided in the facility. Physician #69 stated on 07/29/16 Resident #64 received the wrong medication. Physician #69 stated Registered Nurse (RN) # 70 called her by phone upon realizing he had administered another resident's anti-psychotic medication to Resident #64. Physician #69 stated she immediately contacted poison control and followed their recommendations. Physician #69 stated she directly admitted Resident #64 to the hospital and her partner (Physician #71) cared for the resident while the resident was admitted to the hospital. Physician #69 stated Physician #71 updated her on Resident #64's condition while in the hospital. Physician #69 stated Resident #64 remained groggy and had no memory of the events at the facility, no cardiac issues or other effects were experienced by Resident #64 as a result of the medication error. Physician #69 stated Resident #64 was discharged to another extended care facility upon discharge from the hospital. The above findings were verified by the Administrator during interview on 08/02/16 at 10:30 A.M. An interview with RN #70 on 08/02/16 at 11:33 A.M. revealed he had cared for Resident #64 on 07/29/16. RN #70 admitted he gave an anti-psychotic medication ([MEDICATION NAME]) 100 milligrams orally to Resident #64. RN #70 stated upon the realization he accidentally gave the wrong medication to Resident #64 he contacted Physician #69, notified the Director of Nursing (DON) and Resident #64's daughter who was in Resident #64's room at the time. The antipsychotic medication was ordered for another resident and RN #70 stated he failed to read the name on the medication card correctly. RN #70 stated Resident #64 was alert and oriented at the time he administered the antipsychotic medication. RN #70 stated at the beginning of his eight hour shift he had a conversation with Resident #64 and she was alert and oriented at that time. At approximately 11:00 A.M. he administered pain medication due to her complaints of left knee pain and she was able to converse at that time. After the lunch meal Resident #64's mental status changed. RN #70 stated he monitored Resident #64's vital signs every 15 minutes and checked her blood glucose level. Resident #64 remained lethargic until the ambulance arrived and the resident was transported to the hospital. A review of the facility policy and procedure titled General Guidelines For Medication Administration dated 03/01/07 revealed medications are administered according to the physician order in accordance with good nursing practice and only by persons legally authorized to do so. The procedure for administering medications included the residents were identified prior to the medication administration. Check the identification band, photograph attached to the medical record, call resident by name and if necessary, verify resident identification with other facility personnel. Medications supplied for one resident are never administered to another resident. Prior to administration, the medication and dosage schedule on the resident's MAR is compared to the medication label. If the medication label and MAR do not match the physician order was to be checked to ensure to correct medication was administered. 2. A review of Resident #64's Medication Administration Record (MAR) dated 07/01/16 to 07/31/16 revealed no documented evidence medications were administered per physician orders as evidenced by multiple omitted doses of several different medications as follows: On 07/27/16 at 12:00 P.M. Humalog Insulin (blood sugar medication) 5 units subcutaneously with sliding scale coverage and at 10:00 A.M. a [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) nebulizer one unit dose were not administered. On 07/28/16 at 12:00 P.M. and 5:00 P.M. 5 units of Humalog Insulin subcutaneously with sliding scale coverage, at 9:00 P.M. 40 milligrams (mg) of [MEDICATION NAME] (blood thinning medication) subcutaneously, [MEDICATION NAME] ([MEDICATION NAME]) 600 mg orally at bedtime (9:00 P.M.), [MEDICATION NAME] ([MEDICAL CONDITION] treatment) 0.0005 % one eye drop each eye, at 2:00 P.M. and 10:00 P.M. [MEDICATION NAME] (blood pressure medication) 50 mg orally and at 10:00 A.M., 4:00 P.M. and 10:00 P.M. [MEDICATION NAME] nebulizer unit doses were not administered. During an interview with RN #70 on 08/02/16 at 11:33 A.M., RN #70 verified there were missed doses of several medications on Resident #64's July, 2016 MAR. RN #70 stated when medications were administered, the MAR was initialed with the licensed nurse's initials who administered the medications. There were no initials on the dates and times referenced in the above finding on the MAR and therefore he concluded the medications were not given. An interview with the Administrator on 08/02/16 at 1:30 P.M. verified the above findings. The Administrator stated if the documentation wasn't present on the MAR the medications were not given. A review of the facility policy and procedure titled General Guidelines For Medication Administration dated 03/01/07 revealed medications are administered according to the physician order in accordance with good nursing practice and only by persons legally authorized to do so. The procedure for administering medications included at the end of each medication administration , the person administering the medication reviews the entire MAR to ascertain all medications were administered and all administered dosages were documented on the MAR. The resident's MAR is initialed by the person administering the medication in the space provided under the date and on the line for the specific medication dose administration. Initials were verified on each MAR with a full signature in the space provided. This deficiency substantiates Complaint Number OH 891.

Based on interview and medical record review, the facility failed to ensure that a resident received water flushes through her gastrostomy tube as ordered by the physician. This affected one (Resident #76) of one resident who was reviewed for hydration. Resident #76 was admitted to the hospital for treatment after she developed a urinary tract infection, dehydration [MEDICAL CONDITION] in the facility. Findings include: Resident #76 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She received all fluids and nutrition through a gastrostomy tube. Resident #76 also had a suprapubic catheter that drained urine from her body into a collection bag. A physician's orders [REDACTED]. Review of Resident #76's November 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This would provide Resident #76 with six water flushes with a total of 960 cc of water each day. A handwritten entry next to the order directed the water flushes to be administered only four times per day, at 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Four 160 cc water flushes per day provided Resident #76 with 640 cc of water each day, 320 cc less than what was ordered by the physician. Review of Resident #76's November 2012 MAR indicated [REDACTED].M. revealed that no additional water flushes were administered to Resident #76 in November 2012. The DON revealed Resident #76's urinary output was to be measured every shift and documented on the Resident Daily Record. Review of Resident #76's Resident Daily Record for November 2012 revealed her urinary output was not documented eight times on day shift, 24 times on evening shift, and six times on night shift. The DON confirmed that the documentation of Resident #76's urinary output in November 2012 was inconsistent, and did not provide an accurate indication of her hydration status. Dietary progress notes dated 11/29/12 revealed Resident #76 did not have signs or symptoms of dehyration, and current water flushes through the gastrostomy tube should be continued. Nursing progress notes dated 12/02/12 at 3:00 P.M. revealed Resident #76 was somewhat lethargic and minimally responsive to verbal stimuli. The physician was notified and ordered the resident to be transferred to the emergency room for an evaluation. Resident #76 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. A hospital laboratory report dated 12/02/12 at 5:15 P.M. revealed Resident #76's Blood Urea Nitrogen (BUN) was very high and measured 109 milligrams per deciliter (mg/dl). A normal BUN level ranged between 10-20 mg/dl. Resident #76's creatinine level was high and measured 1.8 mg/dl. A normal creatinine level was between 0.6-1.3 mg/dl. Abnormally high BUN and creatinine levels in the blood could indicate dehydration.

Based on record review and interview the facility failed to ensure adequate supervision and/or assistive devices were in place and provided to Resident #76 to prevent falls. Resident #76 sustained seven falls between 01/08/11 and 06/03/11 while residing in the facility. A fall on 02/13/11 resulted in a laceration and hematoma to her left eye and bruising and swelling to her left wrist. A fall on 06/03/11 resulted in a fractured right hip. This affected one resident (Resident #76) of three residents reviewed related to fall risk. The facility census was 74 residents. Findings include: Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Fall risk assessments, dated 01/07/11, 01/11/11, 02/03/11, 04/02/11, and 05/03/11, revealed the resident was at high risk for falls. A plan of care, initiated on 01/07/11, revealed the resident was at high risk for falls related to decreased mobility and dementia. The goal developed was for the resident to remain free of falls and/or injury related to falls. Interventions included to ensure call light was within reach, anticipate and meet needs, the use of a bed and chair alarm and provide activities that minimize the potential for falls while providing diversion and distraction. Review of the initial Minimum Data Set 3.0 comprehensive assessment with an assessment reference date of 01/13/11 revealed the resident exhibited long and short term memory loss, no recall ability and severely impaired decision making skills. The assessment revealed the resident was non-ambulatory and required extensive assistance from staff for transferring and bed mobility. Review of facility fall documentation and interview with the assistant director of nursing (ADON), director of nursing (DON), administrator and staff development registered nurse on 08/02/11 beginning at 2:58 P.M. revealed the resident sustained [REDACTED]. Record review revealed no written evidence the resident's fall care plan was updated to reflect the falls that occurred or to determine that any new interventions were initiated to prevent additional falls following each incident. The following falls were reviewed with administrative staff during the interview on 08/02/11 at 2:58 P.M. On 01/08/11, Resident #76 was lowered to the floor by her family after attempting to stand independently from the wheelchair. The resident had a personal alarm that was changed to a sensor pad alarm at that time. On 01/11/11 at 9:25 (no A.M. or P.M. noted) the resident was found on the floor after staff responded to her alarm sounding. The resident was found on the floor between her wheelchair and a chair on the carpeted area near the nurse's station. The resident was assessed to have a one centimeter open area to her forehead that was slightly bloody. There was no documentation contained in the medical record to determine if staff were in the area when the fall occurred and/or evidence that the resident was being adequately supervised. Record review revealed there was no written documentation to determine that the resident's safety needs had been reassessed or that any new interventions were considered to prevent additional falls following this incident. On 01/18/11 at 6:50 P.M., nurse's notes revealed the resident stood up from the chair, her alarm sounded and she lost her balance and fell to the floor hitting her posterior head on the over bed table in the television room by the southwest desk. The resident complained of pain to her head. No new orders or treatments were obtained at that time. Record review revealed there was no written documentation to determine that the resident's safety needs had been reassessed or that any new interventions were considered to prevent additional falls following this incident. On 02/12/11 at 10:15 A.M., the resident sustained [REDACTED]. There was no documentation completed to determine whether the alarming devices ordered were in place and properly functioning at the time the fall occurred. No statements from staff were available to review to determine the specific circumstances of the fall. Record review revealed there was no written documentation to determine that the resident's safety needs had been reassessed or that any new interventions were considered to prevent additional falls following this incident. On 02/13/11 at 10:00 P.M., nursing staff noted the resident was attempting to get out of bed and her bed alarm was sounding. Staff assisted the resident to the wheelchair and then proceeded to bring the resident out to the nurse's station. At 10:30 P.M. the resident attempted to get out of the wheelchair and fell sustaining a laceration and hematoma to her left eye and bruising and swelling to her left wrist. The exact location of staff at the time of the fall occurred could not be determined. Additionally, it could not be determined how, once identified to require additional supervision, after attempting to get out of bed, the resident sustained [REDACTED]. Record review revealed there was no written documentation to determine that the resident's safety needs had been reassessed or that any new interventions were considered to prevent additional falls following this incident. On 05/30/11 at 11:30 A.M., Resident #76 was found on the floor when staff responded to her alarm sounding. The resident stated she wanted to get into bed at that time. No injuries were noted. Record review revealed there was no written documentation to determine that the resident's safety needs had been reassessed or that any new interventions were considered to prevent additional falls following this incident. On 06/03/11 at approximately 8:00 A.M., an ambulance driver onsite in the facility to pick up another resident, saw Resident #76 on the floor. The resident fell from her wheelchair. Record review revealed no written documentation that the resident's alarm was in place and properly functioning at the time the fall occurred. At the time of the incident, the nurse assigned to the unit had left the facility and gave the keys to her medication cart to the ADON. There was no nurse assigned on the unit at the time the fall occurred. The ambulance driver alerted a state tested nursing assistant (STNA) who then notified the ADON of the incident. The resident was transferred to the hospital where she was diagnosed and surgically treated for [REDACTED]. Based on the documentation reviewed and interview with administrative staff the facility failed to ensure comprehensive and adequate interventions and supervision were provided to Resident #76, who was assessed to be at high risk for falls. Additionally, the facility failed to provide written evidence to determine that comprehensive re-assessments were completed to reassess the resident's safety needs following the falls that occurred at the facility. This deficiency substantiates allegations contained in Complaint Number OH 531.