Every finding on record at Oaks of Brecksville

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of hospital discharge paperwork, facility policy review and interview, the facility failed to ensure wound care orders were transcribed and implemented per physician's orders to promote healing and prevent infection for a surgical wound Resident #81 had upon admission to the facility. Actual Harm occurred on 05/26/25 when staff identified Resident #81 had not been provided wound care treatments to a surgical wound to the resident's back resulting in the infection. Resident #81 had been admitted on [DATE] with a dehisced surgical wound to the lower back and orders for wound care that were not implemented for six days (until 05/26/25). As a result, Resident #81's surgical wound was observed with purulent drainage (thick, malodorous wound drainage that is indicative of infection) and the presence of slough (dead, non-viable tissue, formed when cells in the wound bed die and accumulate, which impedes wound healing) in the wound bed. The resident was placed on an oral antibiotic on this date to treat the infection. On 05/30/25 the resident was assessed to be lethargic and was transferred to the hospital. The resident did not return to the facility. This affected one resident (#81) of three residents reviewed for wound care. The facility census was 75. Findings include: Review of Resident #81's closed medical records revealed an admission date of 05/21/25. Resident #81 had diagnoses including stable burst fracture of the fifth lumbar vertebra and uterine cancer. Resident #81 was transferred to a local hospital on [DATE] and did not return to the facility. Review of Resident #81's hospital discharge paperwork dated 05/21/25 revealed an order to cleanse Resident #81's right lower back surgical wound with vashe (antiseptic wound cleanser), apply aquacel AG advanced (an antimicrobial dressing with silver, commonly used on wounds that are infected or at risk to become infected), and cover with a mepilex (foam border dressing) daily and as needed . The resident was not on any antibiotic therapy upon admission to the facility. Review of an admission report sheet dated 05/21/25 authored by Registered Nurse (RN) #225 revealed Resident #81 had a surgical incision that had dehisced (incision that had opened after surgery). Review of an admission observation entry dated 05/21/25 authored by RN #225 revealed Resident #81 had a lumbar surgical dehisced wound. Review of Resident #81's physician's orders in the electronic medical record revealed an order dated 05/22/25 to keep the resident's lumbar surgical site clean and dry. The order further stated the site may be covered with a dry dressing and to monitor the site for signs and symptoms of infection once daily. Review of the Medication Administration Record (MAR) dated May 2025 revealed Resident #81's order dated 05/22/25 to keep the lumbar surgical site clean and dry was signed off as completed by nursing staff from 05/22/25 to 05/26/25. Review of the care plan dated 05/22/25 revealed Resident #81 was at risk for skin breakdown. Interventions included to report any signs of red or broken areas. An update to the care plan dated 05/27/25 revealed Resident #81 had an infection and was on antibiotic therapy. Interventions included to monitor the resident's skin site for infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had intact cognition and was dependent on staff for toileting, bathing, and personal hygiene. The assessment revealed Resident #81 was incontinent of bowel and bladder. Review of a progress note dated 05/26/25 timed 4:28 P.M. authored by RN #259 revealed she had entered Resident #81's room and a malodor was detected. RN #259 had assessed Resident #81 and had observed Resident #81's lumbar wound dressing was saturated with a serous (thin, watery wound drainage) and purulent drainage. The progress note further stated RN #259 obtained orders from Resident #81's hospital paperwork, changed Resident #81's dressing, and had placed the wound treatment orders in Resident #81's medical records. RN #259 contacted the nurse practitioner to inform of the malodorous and pale yellow tissue in the wound and had received orders to administer doxycycline (an antibiotic) 100 milligrams (mg) twice a day for seven days . Review of Resident #81's physician's orders in the electronic medical record revealed orders dated 05/26/25 to cleanse the wound to Resident #81's lumbar spine with vashe, apply aquacel AG advanced, and cover with a bordered dressing and for doxycycline 100 mg twice daily for 7 days for a lumbar spine wound. There was no evidence a culture had been ordered prior to initiating antibiotic therapy to determine if the ordered antibiotic was appropriate for Resident #81's infection. Review of a wound observation dated 05/28/25 authored by Licensed Practical Nurse (LPN) #280 revealed to irrigate Resident #81's lumbar wound with normal saline, apply a Dakins solution (an antiseptic used to clean and disinfect wounds and to help prevent and treat topical infections), and cover with a clean dry dressing daily and as needed. Further review of wound observation record revealed the wound measured 14 centimeters (cm) in length and 4.5 cm in width. The wound was open and noted to have sanguineous (bloody) drainage. The surgical wound was noted to have slough covering 90% of the wound bed. Review of a progress note dated 05/30/25 time 3:04 P.M. authored by RN #259 revealed she had entered Resident #81's room to administer afternoon medications and observed Resident #81 lethargic and unable to follow commands or answer questions without being re-directed several times. RN #259 contacted the nurse practitioner who gave orders to transfer Resident #81 to the emergency room for evaluation. The resident did not return to the facility after being transferred to the hospital. Interview on 06/24/25 at 11:45 A.M. with RN #259 revealed when she entered Resident #81's room to provide routine care on 05/26/25 she had observed a foul odor and began attempting to locate the source of the odor. RN #259 stated upon assessment, she observed a dressing to Resident #81's lumbar area that was dated 05/21/25 and was saturated with purulent drainage. RN #259 stated she had attempted to locate physician orders to perform the wound care and stated there were no orders in place at that time. RN #259 stated she located Resident #81's hospital admission paperwork dated 05/21/25 and performed the dressing change according to the hospital orders. RN #259 additionally stated she then placed the wound care orders in Resident #81's electronic medical record. RN #259 further stated Resident #81's lumbar wound appeared to be infected, and she contacted the facility's nurse practitioner who had ordered oral antibiotics. RN #259 stated after 05/26/25, she did not work for a few days and upon her return (on 05/30/25) she had noted Resident #81 appeared lethargic and was not responding to her normally. RN #259 stated she had contacted the nurse practitioner and had received orders to send Resident #81 to the hospital for evaluation. RN #259 stated she had discussed the issue with Resident #81's dressing change orders with Regional Registered Nurse (RRN) #304. Interview on 06/25/25 at 11:50 A.M. with LPN #280 revealed she was the facility's wound nurse. LPN #280 stated she had not been made aware Resident #81 had a wound until 05/28/25, and stated she had assessed and measured the area at that time. LPN #280 noted the presence of significant slough in the wound bed and implemented new treatment orders for Resident #81's lumbar surgical wound. LPN #280 denied being aware of any concerns regarding Resident #81 prior that 05/28/25. Interview on 06/25/25 at 12:35 P.M. with RRN #304 revealed she had reviewed Resident #81's progress note from 05/26/25 authored by RN #259 and stated she began an investigation. RRN #304 confirmed Resident #81's treatment order on her hospital discharge paperwork dated 05/21/25 was not transcribed and implemented until 05/26/25 (five days after admission), despite licensed staff documenting daily the resident's lumbar surgical site was clean and dry . RRN #304 stated she implemented corrective action that included re-education, wound care order and observation audits, and chart reviews for accurate and timely physician orders. Review of the facility policy titled Skin and Wound Care Guidelines revised 10/2015 revealed the admitting nurse would be responsible for obtaining the initial treatment orders. The cardinal rule for an open wound was to keep the exposed tissue moist and the surrounding intact skin dry. The dressing should be maintained as clean, dry and intact to all open wounds. If the dressing was saturated or the dressing is not dry and intact, the policy noted the dressing should be changed. The deficient practice was corrected on 05/28/25 when the facility implemented the following corrective actions: - On 05/26/25, Resident #81's physician was notified of the wound care transcription error and correct wound care orders were obtained and input into the resident's record. - On 05/26/25, the Director of Nursing (DON) performed a head-to-toe assessments on all residents with no negative findings. All areas of skin impairment had an appropriate physician's order for treatment. - On 05/26/25, the DON completed all residents' records for accuracy of transcribed orders for residents who were newly admitted to the facility between 05/21/25 and 05/26/25. There were no additional medication or treatment orders missing or inaccurately transcribed. - Between 05/26/25 and 05/28/25, the DON educated all nurses on accurate transcription of medication and treatment orders. Any new staff would be educated upon hire on the proper order transcription during the orientation process by the DON. - On 05/26/25, the DON or designee began ongoing chart audits of residents' medication and/or treatment orders. The audits consisted of reviewing new orders for accurate transcription five times weekly, for a duration of one month. The results of the audits would be reviewed in the facility's Quality Assurance Performance Improvement (QAPI) meetings. The audits were completed on 06/25/25. - On 05/26/25, the DON or designee began ongoing observational audits of wound care to ensure treatments were completed per physicians' order and utilizing appropriate technique on three residents, five times weekly, for a duration of one month. The results of the audits would be reviewed in the facility's QAPI meetings. The audits were completed on 06/25/25. - On 05/28/25, a QAPI meeting was held to discuss the incident with Resident #81's wound and the subsequent audits, facilitated by the Administrator. In attendance were the Administrator, DON, Medical Director, Social Worker #275, Maintenance Director #274, MDS Nurse #258, and Admissions Director #263. There were no additional concerns identified and no additional recommendations during the QAPI meeting. This deficiency represents non-compliance investigated under Complaint Number OH00166423.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, review of self-reported incidents (SRI), review of facility incident log, review of a local police report, review of Board of Nursing (BON) records, review of Board of Pharmacy records, and review of facility investigations, the facility failed to ensure residents were free from misappropriation. This affected five residents (#11, #29, #37, #41, and #85) out of five residents reviewed for potential misappropriation. The facility census was 75. Findings include: Review of the facility's incident log for February 2025 revealed there had been possible controlled medication misappropriation for Residents #11, #29, #37, #41, and #85. Review of a police report dated [DATE] timed 11:58 A.M. revealed the facility had notified the police that 13 bottles of morphine solution and one Fentanyl (narcotic pain patch) were reported as missing. Upon police arrival, the former Administrator stated on [DATE] at approximately 12:00 P.M., the former Director of Nursing (DON) was vomiting inside the nursing office, appeared to have been under the influence, and had been taken home by an employee. On [DATE] at approximately 10:30 A.M. the former Administrator had requested the DON come into the facility. Upon the DON's arrival at the facility, she informed the DON there was reasonable suspicion (for substance use) based on her behaviors the prior day, and she would need to submit to a urine drug screen on-site at the facility. The DON complied, and the results of the rapid urine drug screen revealed a positive result was returned for morphine, oxycodone (a narcotic pain medication), and benzodiazepines (a class of anti-anxiety medications). The DON was made aware of the positive result and her employment was suspended at that time. During the suspension the Administrator and Regional Registered Nurse (RRN) #304 conducted an audit of the controlled substance narcotic drawer in the DON's office and discovered empty morphine boxes and narcotic count sheets that were missing the medications themselves. It was determined the [NAME] was the only staff member who had keys to the office where the medications were kept. The police report further stated a follow up call was placed to the police by the Administrator on [DATE] at 9:20 A.M. and the local police had been advised of additional discrepancies that were discovered after the initial report. The report noted the DON was noted to be enrolled at a treatment facility out of state. The police report noted the DON's employment with the facility was terminated on [DATE] with reasons including failed drug screen and theft-misappropriation. The police report referenced files provided by the former Administrator to the local police department via subpoena which revealed missing narcotics from 2023 to 2025, which included in 2023 there were 122 unspecified missing items, in 2024 there were 244 unspecified missing items, and in 2025 there were 55 unspecified missing items. The report further identified that between 2023 and 2025, there were 184 missing doses of oxycodone, 97 missing doses of Tramadol (a narcotic pain medication), and 54 missing doses of morphine. The police report referred to an interview conducted with the former DON on [DATE] which stated a friend had provided her with narcotics, which had then turned into abuse. The DON referenced the availability of narcotics at work and admitted to theft of oxycodone, morphine, and tramadol with the DON having stated she preferred oxycodone. The former DON stated she had obtained the medications from non-active orders from residents and stated she had abused medications at home but denied being impaired at work. The former DON admitted she had falsified destruction records while reporting them to the pharmacy that the destructions had been completed. Review of an email sent from the former DON to the former Administrator dated [DATE] timed 11:57 A.M. revealed on [DATE], the former DON had claimed she was ill; however, it was not related to taking any sort of narcotics. The DON confirmed she had taken narcotics when a resident had been discharged or no longer had an active order and denied taking any medications from active residents. Review of a facility Self-Reported Incident (SRI) dated [DATE] revealed the prior Administrator discovered potential misappropriation by the former Director of Nursing (DON). The SRI noted that on [DATE], a possible instance of drug diversion of Resident #11's morphine sulfate solution (a narcotic pain medication) was identified. The SRI noted the controlled substance record and an empty box of morphine (without the medication itself) was discovered in the former DON's office. Upon further review, the morphine had not been documented as being destroyed per protocol. During the investigation, additional concerns for diversion were identified for four additional residents (#29, #37, #41, and #85), where controlled substance records and controlled substances packaging were located in the former DON's office without the medications themselves. The conclusion of the facility's SRI had a disposition of unsubstantiated due to evidence being inconclusive, but that misappropriation was suspected. Review of a Board of Pharmacy Investigation dated [DATE] revealed the former DON was hired on [DATE]. The investigation stated the former DON had removed discontinued medication cards, deceased residents' medication cards, or discharged residents' medication cards. There was no set schedule as to when the former DON would remove discharged residents' or discontinued medication cards from the medication carts. The investigation noted the DON had signed the shift-to-shift count sheets with another nurse when medication cards were removed from the medication carts, and the pharmacy had requested the drugs to be destroyed within 30 days of removal from the medication carts. The facility was under the impression the pharmacy had been checking the drug destruction logs quarterly to ensure the destruction was completed properly. The investigation revealed a lack of documentation for the drug destruction logs, as the logs were only signed by the former DON and lacked a witness of the medication destruction. At the time of inspection by the Board of Pharmacy, 80 bottles of morphine, 186 medication cards of oxycodone, 21 medication cards of hydrocodone (a narcotic pain medication), 103 cards of Tramadol, and 67 other unspecified controlled substances were suspected to have been diverted due to lack of destruction documentation. Review of the board action by the Ohio Board of Nursing dated [DATE] revealed the former DON's license was suspended as she admitted to diverting and self-administering a lot of controlled substances over approximately the last year while employed as the facility's DON. The board action included the former DON's confirmation that she had falsely notified the pharmacy that medications were destroyed and that she had diverted resident medications for her own personal gain. An interview on [DATE] at 2:12 P.M. with RRN #304 revealed she had been made aware of suspicions of the DON being impaired while working at the facility in February 2025. RRN #304 stated the former Administrator had called her and stated on [DATE], the former DON was observed to have been vomiting in her office, her speech was slurred, and she was unsteady while standing. RRN #304 advised the former Administrator to contact the Human Resources (HR) department for further guidance. RRN #304 stated the DON had returned to the facility the following day ([DATE]), submitted to a urine drug test which came back positive for morphine and other controlled substances. RRN #304 stated the former DON was immediately placed on a suspension and an investigation began. RRN #304 stated the facility had immediately contacted the local police, the nursing board, and the pharmacy board who also began investigations. RRN #304 stated she and the former Administrator observed multiple empty medication cards of tramadol, oxycodone, and empty boxes of morphine. RRN #304 stated during the investigation, the DON may have been taking narcotics since sometime in 2023. RRN #304 stated there had not been any prior suspicions of the DON being under the influence or diverting medications prior to February 2025. RRN #304 stated the facility had not identified or reported any discrepancies related to narcotics. Review of the facility policy titled Disposal of Medications revised [DATE] revealed the facility should destroy controlled substances in the presence of a Registered Nurse and another licensed professional. Controlled medications should be documented on the controlled medication count sheet by the Registered Nurse and witnessed by a licensed professional. The destruction process should include recording the quantity destroyed, date of destruction, and signature of both the Registered Nurse and licensed professional on a medication disposition/destruction form or on the Omniview drug destruction application. The facility should dispose of discontinued medications left in the facility after a resident has been discharged or deceased in a timely manner, no more than 90 days after the date the medication was discontinued. Review of the facility policy titled Ohio Resident Abuse Policy revised [DATE] revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. In the case of staff-to-resident abuse, neglect, involuntary seclusion, or misappropriation of resident property, the facility will follow facility's procedure for disciplining or dismissing an employee depending on the circumstances and results of the investigation. The facility will report the results of the investigation to the appropriate licensing agencies and registries in accordance with the law. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: - On [DATE] at 10:45 A.M., the former DON submitted to an on-site urine drug screen. The urine drug screen came back positive for morphine, oxycodone, and benzodiazepines. - On [DATE] at 11:00 A.M., the former DON was suspended pending the outcome of the investigation by RRN #304. - On [DATE], the pharmacy and the local police department were notified by RRN #304. - On [DATE], the facility's Medical Director was notified by the former Administrator. - On [DATE], RRN #304 audited all current narcotic count sheets. The audits consisted of ensuring narcotics were appropriately secured, accounted for, and doses were signed off on the controlled substance records and recorded on the Medication Administration Record (MAR). There were no additional concerns identified. - On [DATE], RRN #304 completed an audit of all four facility medication carts to ensure medications were appropriately secured and accounted for. There were no negative findings. - On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team to discuss the drug diversion by the former DON. - On [DATE], RRN #304 completed an audit of prior narcotic destruction logs with identified concerns. The concerns were appropriately communicated to the pharmacy and local law enforcement as part of an ongoing investigation by RRN #304. - On [DATE] and again on [DATE], RRN #304 educated the new DON and Assistant Director of Nursing (ADON) on the facility's disposal and destruction of expired or discontinued controlled medications procedures. - On [DATE], RRN #304 and designees completed interviews with all interviewable residents to ensure residents were receiving their medications, including pain medications, as ordered. There were no negative findings. - On [DATE], RRN #304 completed interviews with all interviewable residents on quality of care and services and abuse, neglect, and misappropriation. There were no identified concerns. - On [DATE], RRN #304 and designees physically assessed all non-interviewable residents. The residents were assessed for verbal and/or nonverbal reports of pain with no negative findings. There were no concerns for abuse, neglect, or misappropriation. - On [DATE], RRN #304 and designees completed staff interviews regarding medication storage and administration processes. There were no concerns identified. - On [DATE], RRN #304 and designee educated all licensed nurses on proper destruction of controlled substances, drug diversion, ensuring narcotic count sheets matched quantity on hand and administration record, shift-to-shift narcotic count procedures, and the facility's policy on abuse, neglect, and misappropriation. Ongoing education would be provided to newly hired nurses by the DON or designee. - On [DATE], RRN #304 educated the facility's consultant pharmacist on auditing facility disposal and destruction of expired or discontinued controlled medications. - Beginning on [DATE], the new DON or designee conducted random audits of narcotic sheets to ensure there were no concerns for drug diversion weekly for four weeks, then monthly for two months. The results of the audits would be reported to the facility's QAPI committee for further review and recommendations. - Beginning on [DATE], the new DON or designee conducted interviews with five residents who received narcotic medications to ensure they received their medications appropriately weekly for four weeks, then monthly for two months. The results of the audits would be reported to the facility's QAPI committee for further review and recommendations. - Beginning on [DATE], the Administrator or designee monitored the narcotic drawer in the new DON office to ensure controlled substance destruction was completed timely weekly for four weeks, then monthly for two months. The results of the audits would be reported to the facility's QAPI committee for further review and recommendations. - On [DATE], the consultant pharmacist was present at the facility and destroyed all controlled substances per protocol. - The former DON was formally terminated from employment on [DATE]. This deficiency represents non-compliance investigated under Master Complaint Number OH00166891.

Based on observation, interview, and record review, the facility failed to ensure glucometer devices were sanitized appropriately between resident use and isolation precautions were maintained appropriately. This affected three residents (Resident #13, #48, and #58) out of seven residents observed for infection control and had the potential to affect all 74 residents residing in the facility. Findings include: 1. Observation of Registered Nurse (RN) #533 on 01/21/25 at 8:49 A.M. during a medication administration procedure for Resident #13 revealed RN #533 used and Assure Prism Multi glucometer to test Resident #13's blood glucose. Following the procedure she wiped the glucometer with alcohol swabs and continued her medication pass. Interview with RN #533 on 01/21/25 at 9:15 A.M. confirmed the above findings. She said she normally disinfected glucometers with bleach or sanitizer wipes but they were currently on-order. Record review of the Assure Prism Multi manufacturer instruction manual revealed the device was to be disinfected after each use by one of a specific list of disinfectants approved for use with the device. This list did not include alcohol swabs. The manual further revealed that blood glucose meters were at high risk of becoming contaminated with bloodborne pathogens such as Hepatitis C and that disinfection of meters between residents could prevent transmission through indirect contact. 51067 2. Review of the medical record for Resident #57 revealed an admitted [DATE] with an admitting diagnosis of intervertebral disc disorders with myelopathy, thoracic region, flaccid neuropathic bladder, heart failure, atrial fibrillation, hypertension, and cystitis with hematuria. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #57 was cognitively intact. The resident was dependent on assistance from staff for a majority of the activities of daily living. Review of the nursing progress notes dated 01/10/25 and timed 15:59 revealed Resident #57 was having complaints of pain when urinating. The resident's tip of his penis as red and open. The resident was repositioned with an order for urinalysis culture and sensitivity, complete blood count with differential, and basic metabolic panel. Review of Resident #57 current physician orders identified an order dated 01/18/25 for Isolation/ Transmission- Based Precautions Contact Precautions (TBP)/ Isolation related to extended- spectrum beta-lactamase (ESBL) in urine., and an order dated 01/21/25 for Cefepime (antibiotic) 1 gram to be administered via intravenous twice daily for seven days for ESBL in urine. Review of the plan of care dated 01/19/25 revealed Resident #57 had was on intravenous (IV) medications related to ESBL. Interventions included transmission-based precautions as ordered, including enhanced Barrier precautions. Observation on 01/21/25 at 11:40 AM of Licensed Practical Nurse (LPN) #529 entered into resident room with no gown on to assess Resident #57 IV and the pump which was alarming. Interview on 01/21/25 at 11:42 AM with LPN #529 revealed that he disconnected the IV infusion from Resident #57 as it was complete. LPN #529 stated he was leaving the room to obtain a cap to cover the entrance of the IV which was in the left peripheral forearm of the resident. LPN #529 confirmed the TBP signage outside of the door and admitted that he wasn't wearing the proper personal protective equipment (PPE) per the signage. Review of the facility signage provided for residents who were on TBP revealed those entering resident rooms were to put on a gown and gloves before entry into the room and discard prior to room exit. Review of the facility document titled Transmission- Based Precautions and Isolation, last revision dated 04/15/24, revealed contact precautions were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or resident environment. The document further stated organisms could be spread by contact with the person or contaminated surfaces. 51073 3. Resident #48 was admitted on [DATE] with diagnoses that included unspecified heart failure, contact with and (suspected) exposure to other viral communicable diseases, anemia, hydronephrosis with renal and ureteral calculous obstruction, unspecified atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder. A review of progress notes from the past month showed that the resident began to feel ill on 01/10/25 at 03:35 A.M. with symptoms of her mouth feeling dry, a temperature of 99.1 degrees temporal. Orders were received for blood work and urine culture and sensitivity in the morning if indicated. Later on 01/10/25 at 11:52 A.M. the resident experienced nausea and vomiting. Labs and urinalysis results remained pending at that time, so the resident was administered Ceftriaxone (antibiotic) gram intramuscularly to be repeated daily for five days. Over the next six days antibiotics were adjusted while final results were pending. A progress note on 01/13/25 at 02:25 A.M. revealed the urine culture results demonstrated possible contamination. The nurse practitioner was notified and an order to change the foley catheter in the resident was received and another specimen to be obtained. The specimen was obtained 01/13/25 at 6:44 A.M. which demonstrated on 01/16/25 at 6:39 P.M. on the final urine culture results the positive Escherichia coli and Enterococcus faecalis growth which could be treated with the appropriate antibiotics to which the microbes were sensitive. Review of a urine culture report reported on 01/16/25 showed positive for Escherichia coli with a growth of greater than 100,000 CFU/milliliter and Enterococcus faecalis with a growth of 50-60,000 CFU/milliliter. This result required treatment with an antibiotic. The culture report also indicated the resident be placed in isolation or cohorted with other vancomycin-resistant enterococci carriers. A progress not on 01/18/25 at 6:45 A.M. verified that the resident was in contact isolation precautions. Review of Resident #48's active physician orders revealed the resident to be placed in contact precautions/isolation due to the ESBL in the urine. The resident was also ordered an antibiotic, Zosyn 3.378 grams/50 milliliters intravenously three times a day, along with a second antibiotic of Cipro 250 milligrams orally twice a day. Review of the care plan included areas of indwelling catheter with the goal of appropriate management to prevent infection. On 01/21/25 at 12:01 P.M. the resident was observed to be in contact precautions for Enterococcus faecalis. The room had an isolation cart outside of the room containing isolation supplies. A sign stating that the resident was in contact isolation precautions was also hanging on the wall next to the door of the room. On 01/22/25 at 08:58 A.M. Nursing Student #625 was observed entering the resident's room without donning gloves or gown. While in the room, the student was observed to be delivering the resident's breakfast tray and assisting with opening items on the tray. Nursing Student #625 worked right next to the bed from both sides assisting the resident. When the student left the room, hand sanitizer was applied. The isolation cart was outside of the room containing supplies and the sign from the previous day was still hanging in the same place as the previous day. Upon exit from the room on 01/22/25 at 08:58 A.M. after delivering and assisting with set up of the breakfast tray to the resident, Nursing Student #625 was interviewed. He verified that he entered the resident's room without gowning or gloving. He also verified that a sign for contact isolation precautions was hanging next to the door and that an isolation cart was also present with items inside of the cart. He stated that he was instructed by his instructor to function as a certified nursing assistant (CNA) today. Normally he would be following the nursing and observing procedure. He then stated that he did not need to wear isolation items since he was not performing patient care. He verified that he had been instructed by the facility regarding personal protective equipment and the various types of isolation precautions. Review of the sign placed outside of a room where contact precautions was listed revealed everyone entering the room of a resident in contact precautions should clean their hands before entering and when leaving the resident's room. Care providers and staff were also required to put on gloves and gown before entering and before exiting the room. The sign also identified the use of dedicated or disposable equipment for the resident and that reusable equipment had been cleaned and disinfected before use on another person. Signage indicated that the appropriate type of precautions along with the need to have visitors stop at the Nurses Station before entering was to be placed outside of the room. Transmission-based precautions were to remain in effect during the period of time the risk of transmission of the infectious agent persists. On 01/22/25 at 09:10 A.M. Licensed Practical Nurse #522 was interviewed. She also verified that a contact isolation sign was hanging next to the door and that an isolation cart was also present with items inside of the cart. She stated that she wanted to stop the student from entering the room since he entered without the proper donning of personal protective equipment. She verified that anytime a caregiver, including CNAs, enters a room that has precautions in place, the identified personal protective equipment needs to be applied. On 01/22/25 at 5:58 P.M. an order to discontinue contact isolation and continue enhanced barrier precautions for the foley catheter was obtained which was after the above cited break in contact isolation precautions. Review of the Transmission-Based Precautions and Isolation policy dated 04/15/24 revealed the precautions are used when discharges from the body that cannot be contained because of an increased potential for environmental contamination and risk of transmission of the pathogen. Personal protective equipment that is recommended includes gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident, and gowns whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surface or equipment in close proximity to the resident.

Based on observation, record review, and interview, the facility failed to ensure insulin multi-dose syringe pens were labeled appropriately with resident identifiers and open dates, and failed to ensure medications were properly stored and secured. These findings affected five (Resident #13, #26, #46, #49, and #50) of eight residents reviewed for medication storage and administration. The total census was 74. Findings include: 1. Observation of Registered Nurse (RN) #533 on 01/21/25 at 8:49 A.M. during a medication administration procedure for Resident #13 revealed the resident had a multi-dose injection pen of Soliqua (a combination medication of insulin Glargine and Lixisenatide) in the [NAME] Northwest medication cart with no open date indicated on the pen or container. Observation of the [NAME] Northwest medication cart following the above observation revealed Resident #50's insulin Lispro and insulin Glargine (Lantus) pens had no open date, Resident #49's insulin Glargine pen had no open date, and two pens of insulin Glargine and Lispro had no name and were labeled B.H. One of these pens had no open date, the other had an open date of 12/02/24. Interview with RN #533 on 01/21/25 confirmed the above findings at the time of observation. She said the insulin pens for B.H. belonged to Resident #46 as they matched her initials. Record review of the facility pharmacy storage recommendations for injectable diabetes medications revealed insulin Lispro, Lantus, and Soliqua were to be only stored for 28 days after opening or when kept at room temperature. 43063 2. Review of the medical record for Resident #26 revealed an admissions date of 10/26/22 with diagnoses including diabetes and hypertension. Review of the physician's orders for January 2025 revealed Resident #26 had an order for Levetiracetam 100 milligrams (mg) per milliliter (mL), administer five mL twice a day for seizures dated 01/27/24. There was no indication the resident could keep medication at bedside or self-administer medication. Observation on 01/21/25 at 9:04 A.M. revealed Resident #26 had a medication cup with five mL of clear liquid in it sitting on a stand by her wheelchair. She stated it was medication and the nurse had forgotten to give it to her when he was in the room. Interview on 01/21/25 at 9:06 A.M. with Licensed Practical Nurse (LPN) #529 verified he had left Resident #26's Levetiracetam in a cup on her stand and forgotten to give it to her. He stated she was not able to administer her own medication. Review of the facility policy titled, General Dose Preparation and Medication Administration, dated 01/01/13, revealed facility staff should not leave medications unattended.

Based on record review, interview and facility policy review, the facility failed to ensure advance directive orders were consistent across electronic and paper medical records. This affected two residents (#13 and #225) out of 29 resident records reviewed. Facility census was 74. Findings include: 1. Review of Resident #13's medical record revealed an admitted [DATE] and diagnoses including cardiomyopathy, cerebra infarction due to thrombosis of right posterior cerebral artery, left bundle-branch block, dementia with psychotic disturbance and type two diabetes. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact, required set-up for eating and oral hygiene and required partial/moderate assistance for showering/bathing. Review of Resident #13's electronic medical record (EMR) revealed in a green-highlight across the top of the screen that Resident #113 had an advance directive of full code. Review of a physician's orders as of 01/21/25 revealed no order could be located for an advance directive. Review of a care plan dated 03/19/24 and revised 12/10/24 revealed Resident #113 had chosen an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). Review of Resident #113's paper medical record revealed multiple sheets indicating she was to receive full measures and had an advance directive of full code. Interview on 01/21/25 at 4:10 P.M. with the Director of Nursing (DON) verified Resident #13 had an advance directive of full code in her paper chart, did not have an order for any advance directive in her electronic medical record and had a care plan for an advance directive of DNRCCA. The DON indicated an order was to be in place specifying the resident's chosen advance directive and confirmed the paper chart, care plan and EMR did not match as required. 2. Review of Resident #225's medical record revealed an admitted [DATE] and diagnoses including constipation, Parkinson's disease, chronic kidney disease, hypertension, anxiety, unspecified severe protein-calorie malnutrition and low back pain. Review of Resident #225's 5-day MDS 3.0 assessment dated [DATE] revealed Resident #225 had moderate cognitive impairment, was dependent on staff for bathing and toileting and required substantial assistance for upper body dressing and putting on/taking off shoes. Review of Resident #225's EMR revealed in a red-highlight across the top of the screen that Resident #225 had an advance directive of DNRCCA/Do Not Intubate (DNI). Review of a physician's order dated 01/09/25 revealed Resident #225 had an advance directive of DNRCCA/DNI. Review of a care plan dated 01/09/25 revealed Resident #225 had chosen an advance directive of DNRCCA/DNI. Review of Resident #225's paper medical record revealed no evidence of an advance directive could be located. Review of a hospital discharge summary revealed Resident #225 was a DNRCCA/DNI at the hospital but no formal advance directive was noted in the hospital documentation. Interview on 01/21/25 at 4:10 P.M. with the DON verified no written DNR form could be found in Resident #225's chart. The DON indicated the facility process surrounding advance directives included nurses putting the advance directive form in the paper chart, putting an order in in the EMR and then she would get a paper copy of the advance directive form to get signed by the physician. Review of the policy, Advanced Directives Protocol, no date, did not address how advanced directives were to be documented. Review of the facility policy, Advance Care Planning Meeting Protocol, revised 10/01/23 revealed in the event there are legal documents to be obtained, the patient, family and facility staff will coordinate as a team to obtain such documents and place in the clinical record. Results of the advanced care planning will be communicated to the resident's care providers and documented in the medical record.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to maintain resident care equipment in a clean and sanitary condition. This affected three (#4, #75, and #76) of three residents reviewed for environment. The census was 73. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included heart failure, chronic kidney disease, anxiety disorder, depression, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #4 revealed the resident had an intact cognition. Resident #4 required set and clean up assistance with eating. Resident #4 was dependent for all other activities of daily living. Observation during medication administration on 08/26/24 at 8:00 A.M. revealed Resident #4's power wheelchair was dirty. The right arm rest and controller were leaning over the side of the chair. The arm rest had dried food debris caked (approximately six inches in diameter) on the padding located on the top of the arm rest and on the frame/bracket below the arm rest. There was also dried food debris caked on the right front wheel and frame of the wheelchair. Interview on 08/26/24 at 8:05 A.M., with State tested Nurse Aide (STNA) #100 verified the observation of Resident #4's power wheelchair and stated Resident #4 had behaviors including throwing food on floor and on the wheelchair. STNA #100 stated staff must clean Resident #4's wheelchair after every meal. STNA #100 also stated staff place a bag over the right arm rest to prevent food from getting on the chair. Review of the facility policy tilted, Cleaning and Disinfecting of Resident Care Equipment, dated 2024, lacked information directing staff on how and why to clean/sanitize resident wheelchairs. 38091 2. Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, type two diabetes, and atrial fibrillation. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #75 was cognitively intact and required hands on assistance of one staff person for completing activities of daily living. Review of the care plan dated 07/10/24 revealed Resident #75 was at risk for falls related to a right leg amputation with interventions that included a fall mat to the floor to the side of the bed. 3. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included brain aneurysm, dementia, epilepsy, and bipolar disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #76 was moderately cognitively impaired and required hands on assistance for completing her activities of daily living. Review of the care plan dated 03/25/24 revealed Resident #76 was at risk for falls due to impaired cognition and impaired mobility. Review of the care plan interventions revealed a intervention for a mat to floor next to the bed. Observation on 08/26/24 at approximately 11:00 A.M. revealed both Resident #75 and Resident #76's mats used for fall interventions were not clean with various areas of brown and other colored substance on each of the mats. Additionally, Resident #75's mat had significant tears in the exterior. The Administrator verified the conditions of Resident #75 and Resident #76's mats in an interview on 08/26/24 at 11:00 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00156493.

Based on observation, staff interview, resident interview, medical record review, and policy review, the facility failed to ensure a resident was assessed for self-administration of medication and ensure medications were not left unattended at the resident's bedside. This affected one resident (#277) of one observed for unattended medications. The facility census was 72. Findings Include: Review of the medical record for Resident #277 revealed an admitted [DATE] with diagnoses that included dependence on renal dialysis, end stage renal disease, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #277 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #277 required assistance with activities of daily living (ADL). Review of the care plan dated 12/14/23 revealed Resident #277 had an ADL self-care deficit with interventions that included assistance with ADLs as needed. Review of the medical record revealed no assessments for self-administration of medications or no physician orders for medications to be left at the bedside. Observation and interview on 12/19/23 at 9:30 A.M. revealed Resident #277 in bed in her room, with a medication cup that contained two white colored pills, one yellow pill, one maroon/burgundy color pill, and one peach colored pill. The five pills were located on Resident #277's bedside table. Resident #277 revealed she informed Registered Nurse (RN) #567 that she would take them after she finished her breakfast. Observation and interview on 12/19/23 at 9:40 A.M. with RN #567 verified the five pills left at Resident #277's bedside. RN #567 revealed Resident #277's medications were not to be left unattended at her bedside and Resident #277 should have taken them in her presence. Review of the facility document titled General Dose Preparation and Medication Administration revised 01/01/23, revealed staff were to ensure medications were not left unattended and to observe the consumption of the medications.

Based on record review and staff interview the facility failed to ensure the state ombudsman was notified of resident transfers to the hospital and of discharges. This affected four residents (#23, #41, #54 and #69) of four residents reviewed for hospitalization . The facility census was 72. Findings Include: 1. Review of Resident #23's medical record identified admission to the facility occurred on 06/28/23, with medical diagnoses that included chronic obstructive pulmonary disease, methicillin resistant staphylococcus aureus infection, and hypertension. The record identified Resident #23 discharged home on 08/18/23 and subsequently admitted on [DATE], and then had transferred to the hospital on 09/27/23, 10/28/23 and 11/06/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #23's discharge home on 08/18/23 and transfers to the hospital on 09/27/23, 10/28/23 and 11/06/23. Review of the ombudsman notification logs dated June, July, August, September, October, and November 2023 revealed no documented notifications for Resident #23 for 10/28/23 and 11/06/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 2. Review of Resident #54's medical record identified admission to the facility occurred on 10/22/22, with medical diagnoses that included type 2 diabetes, anxiety and hyperlipidemia. The record identified Resident #54 transferred to the hospital on 09/12/23 and 10/06/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #54's transfers to the hospital on 09/12/23 and 10/06/23. Review of the ombudsman notification logs dated June, July, August, September, October, and November 2023 revealed no documented notifications for Resident #54 for 09/12/23 and 10/06/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 45442 3. Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses for Resident #41 included but were not limited to malignant neoplasm of oropharynx, fracture of other specified skull and facial bones, gastro-esophageal reflux disease, severe protein-calorie malnutrition, epilepsy, hypothyroidism, an anxiety disorder. Review of Resident #41's medical record revealed he was transferred to the hospital on 12/26/22, 01/17/23, 01/31/23, 06/09/23, and 07/04/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #41's transfers to the hospital on 12/26/22, 01/31/23, 06/09/23, and 07/04/23. Review of the ombudsmen notification logs dated January 2023 through November 2023 revealed no documented notifications for Resident #41 for 12/26/22, 01/31/23, 06/09/23, and 07/04/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings. 4. Review of the medical record for Resident #69 revealed an admitted [DATE]. Diagnoses included but were not limited to malignant neoplasm of liver and intrahepatic bile duct, malignant neoplasm of rectum, hypothermia, acidosis, acute kidney failure, atrial fibrillation, and depression. Review of Resident #69's medical record revealed he was transferred to the hospital on 10/02/23. Review of the medical record revealed no evidence the state ombudsman was notified of Resident #69's transfers to the hospital on 10/02/23. Review of the ombudsmen notification logs dated January 2023 through November 2023 revealed no documented notifications for Resident #69 for 10/02/23. Interview on 12/20/23 at 3:05 P.M. with Social Services Designee (SSD) #505 confirmed the above findings.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review and staff interview the facility failed to ensure Resident #70 was properly secured in the facility transportation van to prevent a fall with injury during transport. Actual harm occurred on 04/20/23 when Resident #70 sustained a head trauma/forehead laceration that required hospitalization and multiple stitches/sutures, after being thrown forward and coming into contact with a metal object while being transported to dialysis in the facility transport van. This affected one resident (#70) of three residents reviewed for falls and safe transport. The facility census was 69. Findings include: Review of Resident #70's closed medical record revealed an admitted [DATE] with diagnoses including end stage renal disease, essential hypertension, anemia, and dependence on renal dialysis. Review of the care plan initiated on 04/11/23 revealed Resident #70 had a self-care deficit related to end stage renal disease, received dialysis treatments three times a week, was at risk for falls, had renal insufficiency and was on hemodialysis. Interventions included administer medications and/or treatments as ordered, assist with all mobility as needed, ambulate and/or transfer with assist of two with hoyer, monitor, assess, and report to physician. Review of the physician's orders dated 04/11/23 revealed Resident #70 had an order for dialysis on Tuesdays, Thursdays, and Saturdays with a chair time for 11:00 A.M. located at Centers for Dialysis Care Oakwood. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 that indicated Resident #70 with alert and oriented with cognition impairment. Review of the MDS assessment revealed Resident #70 required two-person physical extensive assist for activities of daily living (ADLs). Review of the progress note dated 04/20/23 at 12:08 P.M. revealed Resident #70 was being transported to dialysis when she had a fall in the facility van. Resident #70 was observed with bleeding to the face but remained alert during the incident. Review of the note revealed emergency services via 911 was called, arrived, and transported Resident #70 to Metro Health Main Campus emergency room . Review of the facility incident file dated 04/20/23 revealed Resident #70 was being transported to dialysis when she had a fall in the facility van. Review of the file revealed Resident #70 remained alert until emergency medical services arrived. Review of the file revealed Resident #70 stated she was feeling tired and leaned forward too much. Review of the file revealed Resident #70 was transported to Metro Health campus emergency room . Further review of the incident file revealed Staff Member (SM) #922 heard Resident #70 call out when he observed her laying face down on the ground. SM #922 revealed as he was slowing down the vehicle, Resident #70 slid out of the wheelchair. Review of the progress note dated 04/21/23 at 7:40 A.M. revealed Resident #70 was admitted to Metro Health hospital for a fall. Review of hospital documentation revealed Resident #70 came to the hospital after a fall and face laceration. The notes reflected the resident had a head trauma. Resident #70 was thrown forward in a braking patient transportation van. The resident had a sutured laceration at mid-forehead to right frontal scalp with no goiter. Hospital records further noted Resident #70 had been sent to Metro Health Hospital just over a week ago. Review of the documentation revealed Resident #70 was being transported to dialysis, was not appropriately strapped in, and suffered a severe injury with a forehead laceration. Resident #70 hurt her forehead with a metal object which then needed multiple stitches. The resident had a large forehead laceration closed with sutures with wound edges well approximated and no signs of infection. An additional hospital note revealed Resident #70 sustained injuries while in transport to dialysis. Resident #70 was in a wheelchair in the transport van, when the van came to a sudden stop, throwing Resident #70 from her wheelchair and causing her to hit her head. Resident #70 had a large laceration to her forehead. Review of the progress note revealed the resident was hospitalized until 05/03/23. Review of the weekly skin evaluation dated 05/04/23 revealed Resident #70 had a suture line, extending from mid forehead to hairline above right eyebrow. Suture line intact and well approximated with no drainage noted. Site without erythema, ecchymosis, induration, or increased warmth to peri wound area. Review of the progress note dated 05/05/23 at 3:56 P.M. revealed Resident #70 sutures were removed from her forehead on this date. Interview on 07/27/23 at 10:19 A.M. with Staff Member (SM) #849 verified Resident #70 had a fall in the transportation vehicle while being transported to dialysis and sustained an injury. Interview on 07/27/23 at 10:40 A.M. with SM #922 revealed he was the facility primary driver and was also a State tested Nurse Assistant (STNA). SM #922 revealed he drove residents to their appointments and was also considered an escort due to his STNA status. SM #922 revealed on 04/20/23 he was transporting Resident #70 to her dialysis appointment, made a left hand turn off the highway, came to a stop, and heard her yell out. SM #922 revealed he looked behind him and Resident #70 was on her knees and stomach area. SM #922 revealed he pulled over, put on his hazard lights, and called 911. SM #922 revealed emergency responders arrived in less than 10 minutes and transported the resident to the hospital. SM #922 revealed he did not know the logistics of what occurred or if she went over the strap that secured her in place. SM #922 revealed he was not aware of Resident #70 sustained any injuries. Interview on 07/27/23 at 11:06 A.M. with the Administrator revealed SM #922 was transporting Resident #70 to her dialysis appointment and called 911 due to Resident #70 coming out of her wheelchair. The deficient practice was corrected on 05/18/23 when the facility completed the following corrective actions: SM #922 was immediately suspended pending investigation and the van was taken out of service until inspection was complete. An Ad Hoc QAPI meeting was held on 4/20/2023. All residents requiring transport via the facility van for appointments were assessed . The Facility also reviewed the incident/accident log and there were no other issues related to falls when transporting residents in the facility van. The Facility's compliance manager performed van inspection on 4/20/2023. The facility re-educated SM #922 on proper securement of wheelchairs and residents in the facility van following the manufacture guidelines. Competency was completed with SM #922 and back-up driver. Drivers completed return demonstration competencies on proper securement of wheelchairs and residents in the facility van and van policy. Future van drivers of this Facility will be trained in safe operation of the transportation van before being allowed to transport residents. Training will be done by Administrator or the Compliance Manager. SM #922 completed a Safety Securement checklist with every resident transport and any negative finding was to be immediately communicated to the facility administrator and addressed immediately. Future van drivers will be required to give the administrator the daily securement checklist at the end of each day. The securement checklist is completed by the van driver before/after each transportation with residents. The checklist was developed by the Manager of OSHA Compliance. The administrator/designee began completing visual audits of the securement of the resident and the safety securement checklist while residents are in the van and prior to being transported, to be done 3x weekly, audits will continue for up to 4 weeks. Audits will be verified by the facilities compliance manager. All audits will be brought to monthly QAPI. The administrator/designee will review weekly the Facility vehicle inspection checklist with van driver. Administrator/designee has verified the proper working condition of the securement and the operations of the van. Any negative findings will be corrected immediately, if unable to correct immediately van will be placed out of service until correction is made. This deficiency represents non-compliance investigated under Complaint Number OH00144572.

Based on interview and record review, the facility failed to provide Resident #64 proper assistance with toileting. Actual harm occurred on 10/06/21 at 1:45 P.M. when Resident #64, who required extensive two person assistance with toileting assistance, was taken off a bed pan by one state tested nursing assistant (STNA) rather than two STNAs. Resident #64 slid to the ground resulting in a fractured femur. This affected one resident (Resident #64) of three residents reviewed for falls. Findings include: Resident #64 was admitted to the facility on [DATE] with diagnosis of muscle weakness, difficulty walking, arthritis, sciatica, chronic embolism and [CONDITION(S)] of other specified deep vein of bilateral lower extremity, and obesity. Review of Resident #64's fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of Resident #64's physician orders revealed on 07/09/21 orders for toileting assistance of two people. Review of Resident #64's annual comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive two person assistance with bed mobility and with toileting. Toileting assistance included the use of a bed pan. Review of Resident #64's nurses notes, dated 10/6/2021 at 7:39 A.M., revealed in follow up to a resident fall, Resident #64 rolled out of bed and a state tested nursing assistant (STNA) assisted to the resident to the floor. Resident #64 complained of right knee pain. Per the family, resident, and physician's order, the resident was sent out to the hospital. Interview on 10/14/2021 at 1:45 P.M. with STNA #189 revealed Resident #64 wanted to get off the bed pan. Resident #64 grabbed the grab bar, pulled herself over, and she removed the bedpan. STNA #189 then told the resident she could let go of the grab bar, but the resident pulled harder on the grab bar and her legs slid from the bed. STNA #189 stated she went to the other side of the bed and grabbed the resident by the waist and slid her to the floor. The nurse assessed Resident #64 and assisted the resident back to bed. STNA #189 revealed as a result of the incident she had to compete competencies. Review of the Witness Statement report dated 10/06/2021 revealed STNA #189 arrived on the unit and Resident #64's call light was on. The resident was placed on the bed pan. Resident #64 then put her call light on to get off the bed pan. The resident rolled over and pulled on the siderail. STNA #189 told the resident that was enough, and the resident pulled harder on the siderail and rolled off the bed. Interview with Director of Nursing (DON) on 10/14/2021 at 12:48 P.M. confirmed Resident #64 received toileting assistance from one STNA, STNA #189. Resident #64 slid to the ground and sustained a right femur fracture. As a result of the incident, STNA #189 was required to complete multiple competencies in which STNA #189 passed all areas. This deficiency substantiates Complaint Number OH 532.

Based on observation, interview record review and policy review, the facility failed to ensure insulin was initialed and dated when it was opened. This affected one resident (Resident #20) of one resident observed for insulin administration. This had the potential to affect nine residents (Resident #52, #36, #7, #20, #16, #12, #50, #51, #35) receiving insulin. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/30/21 at 6:28 A.M. revealed Licensed Practical Nurse (LPN) #602 administered Resident #20's insulin: [MEDICATION(S)] insulin solution 100 units per ml as she administered two units subcutaneously per her sliding scale as her accu check was 200 and she administered her [MEDICATION(S)] insulin solution pen-injector 100 units per ml as she injected 14 units subcutaneously as ordered. Both insulins were not initialed or dated as to when they were opened. Interview on 08/30/21 at 6:34 A.M. with LPN #602 verified both insulins ([MEDICATION(S)] insulin and [MEDICATION(S)] insulin) she had administered to Resident #20 was not initialed or dated when it was opened, and she did not know when they were opened. Interview on 08/30/21 at 12:57 A.M. with the Director of Nursing verified the nurse should have initialed and dated the insulins for Resident #20 when they were opened, and LPN #602 should have checked when the insulin was dated as opened prior to the administration of the insulin. Review of facility policy titled General Dose Preparation and Medication Administration, dated 01/01/13, revealed the facility failed to implement their policy as written as the policy revealed staff should enter the date opened on the label of the medication with a shortened expiration date including insulins and irrigation solutions. This deficiency substantiates Complaint Number OH 042.

Based on record review and interview the facility failed to ensure the services of a Registered Nurse (RN) were maintained for at least eight hours a day seven days a week. This had the potential to affect all 72 residents residing in the facility. Findings include: Review of the daily staffing schedules from 12/01/18 through 01/13/19 revealed that there was not a Registered Nurse (RN) scheduled for eight hours on 12/08/18, 12/09/18, 01/05/19 or 01/06/19. This was verified with Scheduler #100 on 01/24/19 at 11:01 A.M. During an interview on 01/24/19 at 11:15 A.M. with the Administrator and also Human Resources revealed the facility was able to provide evidence of RN services for 12/08/18 (8.25 hours) and 12/09/18 (8 hours). The Administrator revealed the Director of Nursing was present in the building as Manager on Duty (MOD) on 01/05/19 and 01/06/19. However, the facility was unable to provide written evidence that the DON was onsite for at least eight hours on each of those dates.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on review of a Self Reported Incident report, closed record review and interview, the facility failed to ensure resident privacy at all times. This affected one (Resident #4) of four residents reviewed. Findings include: Review of the closed medical record for Resident #4 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to interview on 03/01/18 with the Administrator, on 12/31/17 the facility became aware of a potential breach of privacy and Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. The facility received an anonymous call to the facility's corporate compliance phone number. The caller indicated there was some type of video on the Internet which possibly involved a resident. On 12/31/17, the facility immediately began an investigation and identified State tested Nurse Aide (STNA) #20 as the staff member involved. The investigation found that on 12/30/17, STNA #20 video recorded an incident with Resident #4 and a remote control. According to the facility's investigation, The video was approximately seven seconds in length and showed the left profile side of (Resident #4's) face for approximately less than one second. The remainder of the video included the voice of the aide and a view of the remote control in both the resident's and STNA's hand. The facility interviewed STNA #20 and she admitted the violation. She indicated the resident was holding her remote like a phone to her ear and thought it was a funny moment, and posted the video to Snapchat. STNA #20 acknowledged she did not obtain the resident's permission, and stated she deleted the posted Snapchat video after 20 minutes. STNA #20 was immediately suspended on 12/31/17, and on that day the facility initiated training/education to all staff regarding resident rights, privacy and HIPAA compliance. All three shifts and all disciplines were included in the inservices which were finalized on 01/01/18. STNA #20 was terminated on 01/05/18. On 01/04/18 the facility discovered the resident's identity, and notified Resident #4's family/responsible party the same day. Also on 01/04/18, the facility notified the state and local law enforcement agencies. A follow-up written notification was made to the family on 01/11/18. Follow up audits which included a knowledge-base questionnaire were completed with all staff on 01/03/18 and 01/04/18. The facility's Quality Assurance committee met on 01/30/18 and 02/27/18 to ensure all compliance measures were effective. Random interviews on 03/01/18 with current staff representing various disciplines and departments revealed all were aware of the facility's policy for privacy, resident rights, HIPAA requirements and the facility's Expectations for Technology Use and Confidentiality of Electronic Information Policy. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 02/27/18: · STNA #20 was terminated by the facility. · The medical director was notified. · The family/responsible party was notified in person and by certified mail. · The incident was reported to the local police department. · A Self Reported Incident report was submitted to the Ohio Dept. of Health. · The incident was reported to the State Nurse Aide Registry which included the STNA's name, address, phone number and registry number. · An Incident form was submitted to the Ohio Board of Nursing by the Administrator that indicated the name, address, phone number and license number of STNA #20. · In-services were conducted with all staff, all shifts, and all disciplines on 12/31/17 and 01/01/18 which included education on Resident Rights, Privacy, HIPAA rules and facility expectations. · The administrative staff conducted a facility-wide audit which included a knowledge-base questionnaire to assure staff knowledge of Resident Rights, Privacy, HIPAA rules and facility Policy on Technology Use and Confidentiality of Electronic Information. · The Quality Assessment and Assurance Committee met on 01/30/18 and 02/27/18 with increased review regarding Resident Rights and Privacy and continues to meet on a monthly basis to ensure compliance. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation and interview, the facility failed to ensure expired medications were removed from stock. This affected 17 of 70 facility residents (Residents #36, #27, #47, #57, #124, #125, #126, #127, #51, #46, #12, #40, #128, #43, #130, #131 and #132). Findings include: 1. Observation of the Mulberry medication room on 11/28/17 at 2:20 P.M. revealed two vials of [MEDICATION NAME] Purified Protein Derivative, Diluted Apisol 5 milliliter/50 dose vials dated as opened on 10/12/17. Interview with Licensed Practical Nurse (LPN) #1 at the time of the observation confirmed the [MEDICATION NAME] Purified Protein Derivative multi dose vials were dated as opened on 10/12/17 and therefore expired on 11/11/17, thirty days after opening. Review of the [MEDICATION NAME] Purified Protein Derivative package insert revealed a vial which is entered and in use for thirty days should be discarded. Review of a list provided by the facility revealed Residents #130, #43, #131 and #132 were admitted to the Mulberry unit and received [MEDICATION NAME] testing after the [MEDICATION NAME] Purified Protein Derivative multi dose vials expired on 11/11/17. 2. Observation of the first floor Redwood medication cart on 11/28/17 at 2:30 P.M. revealed a 1000 tablet multi dose bottle of One Daily Multi Vitamin had an expiration date of 07/2017 and a 1000 tablet multi dose vial of Iron tablets had an expiration date of 09/2017. Interview with LPN #2 at the time of the observation confirmed the multi dose bottles of One Daily Multi Vitamin and Iron Tablets had expired. LPN #2 indicated night shift used to be responsible for checking for expired medications in the medication carts. LPN #2 indicated 13 residents received medications from the first floor Redwood medication cart, Residents #36, #27, #47, #57, #124, #125, #126, #127, #51, #46, #12, #40, #128.

Based on observation, interview and record review, the facility failed to provide personal privacy during care. This affected one resident (Resident #127) of 15 residents observed for personal privacy. The facility census was 70. Findings include: Review of Resident #127's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #127's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was an extensive assist of two persons for bed mobility, transfers, dressing, and toilet use. Resident #127 was an extensive assist of one person for personal hygiene and was a set up and supervision for meals. Review of Resident #127's plan of care dated 11/12/17 revealed the resident had a self care deficit and required assistance for all his activities of daily living skills , including privacy. Observation on 11/30/17 at 9:58 A.M. revealed Resident #127's room was located at the end of the hall which also contained the physical and occupational therapy departments. The hallway was heavily used by residents requiring gait training. Further observation revealed the door to Resident #127's room was open approximately six inches and the resident was observed getting a bath from State tested Nursing Assistant (STNA) #10. Resident #12 was uncovered and nude up to his upper chest area with his genitals exposed. The observation was verified with Licensed Practical Nurse (LPN) #11 who instructed STNA #10 to close the door. An interview with STNA #10 on 11/30/17 at 11:10 A.M. revealed he thought the door was shut. STNA #10 stated the door would not close properly but did not realize the door was open while he was providing care.

Based on observation, interview and record review, the facility failed to implement Resident #63 and Resident #6's plans of care related to providing assistance with meals. This affected two of 18 residents whose care plans were reviewed. The facility census was 70. Findings include: 1. Review of Resident #63's clinical record revealed the resident was admitted with [DIAGNOSES REDACTED]. Review of Resident #63's comprehensive assessment dated [DATE] revealed the resident was an extensive of one person for bed mobility, transfers, dressing, and personal hygiene. The resident was assessed as supervision and set up for eating. Review of Resident #63's plan of care dated 11/13/17 revealed the resident had increased nutrition/hydration risks related to being on a mechanically altered diet due to the [DIAGNOSES REDACTED]. Interventions included providing assistance with meals as needed to encourage intake. Observation on 11/29/17 at 12:30 P.M. revealed Resident #63 sleeping at the dining room table from 12:30 P.M. to 1:00 P.M. with her lunch in front of her. Resident #63 was not provided assistance to eat until the surveyor asked Regional Nurse #6 if the resident required assistance. Regional Nurse #6 instructed staff to assist Resident #63 with her meal but the resident ate only a few bites. An interview with Regional Nurse #6 on 11/29/17 at 1:10 P.M. confirmed Resident #63 was at the dining table with her head down, sleeping. Regional Nurse #6 verified the resident's care plan related to nutrition/hydration risks was not implemented as assistance was not provided with the meal to encourage intake. 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of Resident #6's care plan dated 01/27/15 indicated the resident required the assistance of one staff member with eating. Observation on 11/29/17 at 7:55 A.M. revealed Resident #6 in the dining room for breakfast. The resident was not provided assistance for the breakfast meal. Resident #6 was observed to take a bite of food then look as if she forgot she was eating. After the first bite of food, Resident #6 was observed staring out into the dining area making no further attempts to pick up a utensil or eat. Interview on 12/01/17 at 12:48 P.M. with Minimum Data Set (MDS) Coordinator #7 confirmed Resident #6 was a one person assist with meals. Interview on 12/01/17 at 1:45 P.M. with State tested Nursing Assistant (STNA) #9 confirmed Resident #6 did not receive assistance as required in the dining room.

Based on observation, interview and record review, the facility failed to promptly identify and document abrasions/skin tears for Resident #58. This affected one of four residents reviewed for skin issues. Findings include: Resident #58 was admitted to the nursing home on 04/22/14. [DIAGNOSES REDACTED]. Review of a facility Self-Reported Incident (SRI) dated 08/29/16 documented the resident was found with dry scabbed/skin tears on the front of his left lower shin. Review of progress notes dated 08/29/16 at 10:46 A.M. documented a change in condition. Scabbed areas were found on front of his left shin. The documentation under Skin Changes revealed the resident had seven scattered, scabbed areas/abrasions on his lower left shin. Surrounding skin was light pink in color and was listed as being possibly infected. Review of a progress note dated 08/29/16 at 1:20 P.M. documented the immediate intervention was to clean with the areas with normal saline, apply triple antibiotic ointment and leave them open to air. The progress note dated 08/29/16 at 1:54 P.M. documented the physician prescribed [MEDICATION NAME], an antibiotic, 100 milligrams twice a day orally for 10 days for a skin infection. Review of a progress note dated 08/30/16 at 9:13 A.M. revealed the wound type was listed as abrasion/scab/[MEDICAL CONDITION] (skin infection). The wound on his left shin measured 15.0 centimeters (cm) long by 3.0 cm wide by 0.1 cm deep. There was no drainage and the wound bed was black. There was no odor and the periwound was red. This note indicated the wound status was unchanged. There were scattered brown/black scabbed areas with redness noted to surrounding tissue. The area was cool to touch and no swelling was noted. This note indicated Resident #58 was seen in the recliner, rubbing his right heel up and down on his left shin causing the area to be irritated. A new physician order [REDACTED]. Review of the facility SRI revealed the date of discovery was 08/29/16 and the initial report was filed with the State Agency on 08/29/16. Staff statements were obtained. Review of State tested Nurse Aide (STNA) #101's statement indicated she worked the night shift Friday night. She indicated she did not recall, but on one of the nights she witnessed Resident #58 scratching his left leg until it was bleeding. She said another aide saw him scratching as well. Review of STNA #100's statement revealed the first time he/she noticed the scrape and scabs on Resident #58's leg was Saturday, 08/27/16. He/She said the bruises looked like they had been there for maybe a couple days before but had not witnessed it when it happened. Review of STNA #103's statement documented she took care of Resident #58 on Wednesday, 08/31/16. She indicated she took him to the bathroom with another aide an cleaned him up and he was fine. She said he had no bruises or skin tears. Review of STNA #104's statement documented that on 08/28/16, sometime during the second shift, two aides and one nurse transferred Resident #58 from his wheelchair to a recliner. STNA #104 indicted it was a quick and easy transfer. This STNA indicated he/she did recall, around 10:00 P.M., Resident #58 had his pant legs pulled up and he was fiddling with one leg or both, but could not really remember. Resident #58 had some red mark on his shins that could be see from a distance as he/she passed by the TV room area. Review of Licensed Practical Nurse statement dated 08/30/16 revealed she was the nurse caring for Resident #58 over the weekend of 08/27/16 and 08/28/16. She said the resident was not able to transfer on his own and needed the assistance of two staff members. This nurse indicated no injuries were noted during her shifts. She said Resident #58 was agitated on Sunday, 08/28/16, and was yelling out. Review of a shower sheets dated 08/24/16, 08/26/16 and 09/01/16 revealed Resident #58 did not have a rash, bruises, or redness. His skin was documented as intact. All three shower sheets indicated there were no new skin areas. Interview with the DON on 09/14/16 at 5:00 P.M. indicated staff were documenting there were no new areas on 08/24/16 and 08/26/16 and 09/01/16. She verified on 08/29/16 the resident skin was found with scabbed areas on his left leg which was not reflected on the 09/01/16 shower sheet completed by one of the STNA's. Interview with the DON on 09/14/16 at 5:15 P.M. indicated the Power of Attorney (POA) identified the scabbed areas on Resident #58's leg and brought it the staff's attention on the morning on 08/29/16. She verified there was no documentation in the medical record to indicate Resident #58 was scratching his leg causing bleeding or that the scabs observed on 08/27/16 were reported to nursing staff. On 09/14/16 at 2:30 P.M. the resident's left leg was observed with the nurse. The nurse removed the [MEDICATION NAME] the resident was wearing on the left leg. There were multiple pink areas below the knee along the shin. The areas were dry and flaky. Closer to the ankle there were three small areas about the size of pencil tip that had a dark appearance inside the area. Review of Incident/Accident Report policy with a revised date of 02/16 indicated that regardless of how minor the incident/accident may be, including injuries of unknown origin, they must be reported to the Charge Nurse as soon as they are discovered or when information related to the incident/accident is learned. The employee will immediately inform the Charge Nurse or nursing administrative staff so medical attention can be provided if needed. The employee who discovers the incident may initiate the report or it may be initiated by the Charge nurse or nursing administrative staff. This deficiency substantiates Complaint Number OH 690.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure interventions were in place to prevent further weight loss. This resulted in Actual Harm for Resident #109 when she sustained significant weight loss over a one month period because the facility did not initiate interventions to address the weight loss. The facility also failed to investigate the cause of an unusual weight loss and failed to implement interventions for weight gain. This affected two residents, Residents #85 and #177. Four residents were reviewed for weight loss. Findings Include: 1. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #109's dietary preference assessment dated [DATE] and completed by Dietary Manager (DM) #75, revealed Resident #109 said she did not drink milk at home. The assessment indicated the resident's weight had been stable for the previous six months. Review of Resident #109's medical record revealed the resident's weight on 07/14/16 was 100.6 pounds; on 07/16/16 the resident's weight was 100.8 pounds; and on 07/17/16 the weight was 98.2 pounds. Review of the admission dietary assessment for Resident #109 dated 07/18/16 and completed by Registered Dietician (RD) #47, revealed 98.2 pounds was listed as the current weight obtained on 07/17/16. The resident's body mass index (BMI) was within normal limits at 20.5 (normal range 18.5 to 24.9). RD #47 wrote the resident was admitted on a mechanically altered diet on 07/14/16 but was upgraded to a regular diet on 07/15/16. RD #47 wrote the resident was at nutritional risk due to anxiety, [MEDICAL CONDITION], advanced age, and a history of a mechanically altered diet. The resident would be closely monitored. Review of Resident #109's nutritional care plan initiated on 07/20/16 indicated the resident had increased nutrition/hydration risk related to anxiety, [MEDICAL CONDITION], advanced age, a history of a mechanically altered diet, and weight gain prior to admission. Interventions listed on 07/20/16 to maintain Resident #109's nutritional status included: encourage adequate fluid intake; encourage compliance with diet guidelines; encourage family to bring in food favorites from home if allowed on the resident's diet; encourage a healthy diet; encourage to eat in the dining room; monitor dietary intake; monitor for dehydration; monitor labs as ordered; offer alternate food if intake was less than 50%; provide supplements as ordered; and review preferences per routine and as needed. On 08/17/16 RD #47 added another risk factor as weight loss in August 2016. No new interventions were added to the care plan. Review of Resident #109's weights revealed the following: 07/24/16 - 97.3 pounds; 07/31/16 - 99.0 pounds; 08/01/16 - 99.0 pounds; 08/07/16 - 94.9 pounds; 08/14/16 - 92.4 pounds (reweight requested but not obtained); 08/21/16 - 85 pounds; 08/22/16 - 83 pounds (reweigh); 08/30/16 - 82.8 pounds. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #109 was moderately cognitively impaired, had no swallowing problems and had sustained an unplanned significant weight loss of 5% or more over the last 30 days. Review of the progress notes revealed a weight warning on 08/12/16 listing Resident #109's weight as 94.2 pounds which was a 5% loss in the previous 30 days. RD #47 indicated it was an expected loss due to weight gain prior to admission and a [DIAGNOSES REDACTED].#47's plan was to encourage eating well at meals, offer alternates and supplements as needed, and to continue to monitor. Review of the progress notes dated 08/15/16 revealed a weight warning was entered by RD #47 who indicated the resident's weight was now 92.4 pounds and requested a reweight be obtained. RD #47 initiated whole milk at all meals to help with weight maintenance. The note indicated RD #47 would follow up if weight loss persisted after the reweight. Review of the progress notes dated 08/22/16 revealed a weight warning was issued when Resident #109's weight was 85 pounds, which was a 5% loss over the last 30 days. RD #47 noted she had requested a reweight. The interdisciplinary team (IDT) discussed the weight loss that day and RD #47 would follow up if the weight loss persisted. Review of the progress notes dated 08/30/16 revealed a weight warning was issued when Resident #109's weight was 83 pounds. RD #47 indicated Resident #109 had shown a weight loss over the previous two weeks and on 08/29/16 RD #47 started the resident on a supplement of a house shake twice a day. RD #47 noted Resident #109 ate in the dining room with variable intakes and she would monitor closely. Review of RD #47's progress notes revealed no indication that Resident #109's physician was notified of the resident's significant weight loss. Review of the physician/certified nurse practitioner (CNP) notes from 07/14/16 thru August 2016 indicated the resident's appetite was poor to fair, was admitted for rehabilitation following surgical repair of a [MEDICAL CONDITION], was anemic, and had weakness. There was no indication either the physician or the CNP was aware of Resident #109's significant weight loss. Interview with RD #47 on 08/31/16 at 5:20 P.M. revealed she said after receiving the weight warning dated 08/12/16, she started the resident on whole milk at each meal to prevent further weight loss. RD #47 reviewed the nutritional care plan with the surveyor and confirmed there was no information about adding whole milk to each meal. RD #47 said the intervention of adding milk to each meal would be covered under the provide supplements as ordered. RD #47 said there were no supplements initiated on 07/20/16. RD #47 confirmed there was no documentation as to how much whole milk the resident drank at each meal. Observation of Resident #109 eating breakfast on 09/01/16 at 8:50 A.M. revealed the resident had scrambled eggs, biscuits and gravy, hot cereal, and chocolate milk. Resident #109 fed herself. Interview with RD #47 on 09/01/16 at 11:15 A.M. revealed the interdisciplinary team (IDT) decided who notified the physician of significant weight loss. RD #47 said she normally did not contact the physician because she was only in the facility two times a week. RD #47 confirmed chocolate milk was not the whole milk supplement ordered. Interview with the Director of Nursing (DON) on 09/01/16 at 2:56 P.M. confirmed she was unable to find any documentation indicating the physician had been notified of Resident #109's significant weight loss. Interview with RD #47 on 09/01/16 at 3:10 P.M. confirmed Resident #109 had been continuously losing weight since 08/01/16. RD #47 said she initiated whole milk with each meal on 08/15/16. RD #47 said she was unaware of DM #75's assessment indicating the resident did not drink milk and instituting whole milk as a supplement was probably not a good choice. RD #47 confirmed she had not notified the physician of the resident's significant weight loss and she had not initiated any supplements until 08/29/16. RD #47 confirmed she had not updated the resident's nutritional care plan and had not put any interventions in place to prevent further weight loss. Review of the facility's Weight Policy, effective May 2015, indicated any resident with a significant weight change (5% or more in one month, 7.5% in three months, or 10% or more in six months) must be weighed weekly until stable and was to be discussed in the Nutrition At Risk committee. RD #47 confirmed on 09/01/16 at 4:00 P.M. that this was also the significant weight change policy. Review of the facility's Notification of Change policy, last revised in July 2015, indicated the facility was to notify the physician with any significant change in the resident's condition. 2. Review of the record revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed she was severely cognitively impaired, and required only supervision and set up for eating. Review of the August 2016 physician's orders [REDACTED]. She was to be weighed daily. An order dated 08/26/16 revealed the doctor should be called if her daily weight increased more than 5 pounds. Review of a nursing note dated 08/21/16 revealed the resident was on an antibiotic for a urinary tract infection and the resident was being encouraged to drink fluids. Review of a progress note dated 08/22/16 from the IDT team (interdisciplinary team) revealed the resident had a weight increase of 5% over 30 days based on a weight on 08/21/16 of 180.4 pounds. The note indicated the resident's weight gain was discussed and nursing was to check resident for [MEDICAL CONDITION] due to weight gain. Review of the resident's weights revealed her weights fluctuated between 170 pounds to 180 pounds between June 2016 and 08/21/16. On 08/21/16 she weighed 180.4 pounds. There was no weight for 08/22/16 and the weight for 08/23/16 was 152.4 pounds. This weight was noted by the dietician and marked as an error on 08/24/16 at 9:04 A.M. A weight for 08/24/16 at 2:36 P.M. was 155 pounds, on 08/25/16 was 156.1 pounds and subsequent weights remained under 156.3 pounds. Review of nursing notes from 08/21/16 through 08/30/16 did not reveal any indication of [MEDICAL CONDITION] (swelling or fluid retention), changes in intake or elimination. The resident remained on the antibiotic, had a swollen finger that was found to be symptoms of gout and had skin impairments on her buttocks and left calf, which were investigated and treated without concern. An IDT note dated 08/30/16 at 12:53 P.M. revealed the weight obtained on 08/28/16 of 154.3 pounds triggered the weight warning and significant weight loss. The note indicated the weight change might be a scale discrepancy. The note indicated the resident's labs on 08/26/16 were relayed to the doctor with no new orders, no changes were noted to the oral intakes and nursing reports decrease in [MEDICAL CONDITION]. There was no documentation in the record that indicated the resident's [MEDICAL CONDITION] had decreased. An interview with RD #47 on 08/31/16 at 3:48 P.M. revealed she was notified of the weight loss on 08/29/16. She said she was told of the low weight obtained on 08/23/16 but assumed it was an error and stated she just asked for a re-weigh of the resident. She verified the resident was reweighed on 08/24/16, which continued to indicate a weight loss of almost 25 pounds in 3 days. She verified she had not been notified of the reweigh weight until 08/29/16 and verified there was no note concerning the large weight loss until 08/30/16. She stated the resident's physician should have been notified of the large weight loss to ensure the resident was medically stable. An interview with the DON on 09/01/16 at 10:15 A.M. verified Resident #85's record did not contain documentation of notification of the resident's physician after an almost 25 pound weight loss was noted in 3 days. She indicated the facility staff most likely thought the scales were incorrect, but verified the low weight continued and no documentation was noted from the reweigh on 08/24/16 until 08/30/16 regarding the change in the resident. She stated the recalibration of the scales in the facility resulted only in differences of about 4 pounds. She verified such a large weight loss, which the facility attributed to [MEDICAL CONDITION], should have had some physical change in the resident documented by nursing. 3. Review of the record revealed Resident #177 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her MDS 3.0 assessment dated [DATE] revealed she was severely cognitively impaired. Review of the resident's initial nutrition assessment dated [DATE] revealed she was on thickened liquids and a mechanically altered diet. The note indicated she was underweight with a [DIAGNOSES REDACTED]. It indicated the resident would be monitored closely. Review of the resident's weights indicated she weighed 99.4 on 07/27/16 and was up to 100.2 pounds on 07/29/16. Review of her daily weights revealed on 08/04/16 she was down 3% from last week with a weight of 95 pounds. There were no new orders noted. Review of an IDT note dated 08/17/16 at 11:37 A.M. revealed the resident was down to 92.2 pounds on 08/14/16 and her weight loss was discussed with staff. The note indicated whole milk would be added to every meal to increase caloric and protein intakes and the resident would be monitored closely. Review of the record revealed no documentation of the resident's intake of the milk. The resident's weight on 08/15/16 was 90.4 pounds and on 08/28/16 was 95 pounds. Review of an IDT note dated 08/30/16 at 1:07 P.M. revealed the resident had a 5% change in weight from admission. The note indicated the resident ate most meals in the dining room for increased socialization and her plan of care was appropriate and adequate to meet needs. The note indicated a weight gain this week after a weight loss this month. Observation of the resident during the lunch meal on 08/31/16 at 12:40 P.M. revealed she did not have milk at her place at the table. This was verified with Licensed Practical Nurse LPN #42, who asked the resident if she would like milk and the resident declined. Review of the dietary slip revealed it listed the milk to be given with each meal. An interview with RD #47 on 08/31/16 at 3:30 P.M. verified Resident #177 was underweight, with a goal on admission to have a slow, steady weight gain to reach her ideal body weight. She verified the resident had sustained a weight loss since admission and the only intervention ordered, the addition of milk for meals, was not provided during a meal observation on 08/31/16. She verified there was no documentation in the record to indicate the resident drank the milk or refused it.

Based on observation, interview and record review, the facility failed to ensure accurate assessments regarding activities of daily living for Residents #25 and #50, regarding hearing for Resident #94 and regarding medications for Resident #79 and #123. This affected five of 16 residents reviewed for assessments. Findings include: 1. Review of the record revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance to transfer and total assistance for dressing. The assessment also indicated, under eating and toileting, that those activities had not occurred. Review of the MDS 3.0 assessment dated [DATE] revealed the resident was total assistance for transfer, extensive assistance for dressing, supervision for eating and total assistance for toileting. An interview with the MDS assessment nurse, Licensed Practical Nurse (LPN) #40, on 08/31/16 at 3:30 P.M. revealed the assessment completed on 07/11/16 was correct. She stated there had been no changes in the resident's activities of daily living and the entries noted for 04/15/16 for transfers, dressing, eating and toileting were entered incorrectly. 2. Review of the record of Resident #94 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her nursing admission assessment revealed she had hearing and vision problems. Review of the MDS 3.0 assessments dated 06/03/16 and 08/05/16 indicated the resident's hearing was adequate and no hearing aids were used. Review of psychologist notes dated 07/05/16 and 08/23/16 indicated the resident was hard of hearing and would benefit from hearing aids. The note on 08/23/16 indicated the resident had not had a hearing assessment and an improvement in her hearing could improve her communication and socialization. Observation and interview with Resident #94 on 08/30/16 at 10 :55 A.M. revealed she had much difficulty hearing the surveyor ask questions. When an activity staff member entered the room to announce an activity starting, and was noted to be talking to her roommate, Resident #94 had increased difficulty hearing the surveyor, and was confused as to who was talking to her, stating her hearing was very poor. She stated she would like a hearing aid and thought she was on a list for one. Interview with the MDS nurse, LPN #40, on 09/01/16 at 12:30 PM. revealed she conducted her assessment of the resident for the MDS 3.0 assessment dated [DATE] in a quiet room and she did not note any hearing difficulty so she did not mark it as a concern on the MDS. She verified the [DIAGNOSES REDACTED]. She verified the MDS 3.0 assessments did not contain accurate information regarding the resident's hearing. 3. Review of the medical record revealed Resident #123 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 physician orders [REDACTED]. Review of the August 2016 Medication Administration Record [REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed it was coded to indicate that the resident received no anticoagulant medication, antianxiety medication on three days and hypnotic medication on seven days. An interview with LPN #40 on 09/01/16 at 8:47 A.M. verified the MDS 3.0 assessment dated [DATE] had been incorrectly coded for the anticoagulant, antianxiety and hypnotic medications received during the seven days. 4. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the physicians orders for August 2016 revealed the resident had an order for [REDACTED]. Review of the August 2016 MAR for Resident #79 revealed the resident received an antidepressant medication on 08/13/16 thru 08/19/16. The resident received an antibiotic on 08/15/16, 08/17/16 and 08/19/16. Review of the MDS 3.0 assessment dated [DATE] indicated the resident received antibiotics on seven days and no antidepressant medication during the seven day reference period of 08/13/16 thru 08/19/16. An interview with LPN #40 on 09/01/16 at 9:49 A.M. verified the MDS 3.0 assessment was incorrectly coded. She verified the resident received an antidepressant on seven days during the assessment reference period and an antibiotic on three days during the assessment reference period. 5. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact, and needed extensive assistance of one to two people to eat, bathe, dress, transfer, bed mobility, and toileting. Review of the MDS 3.0 assessment dated [DATE] showed a decline in the resident's ability to provide self care. The assessment indicated the resident was totally dependent of one to two people for all self care. An interview with Resident #50 on 08/30/16 at 9:46 A.M. revealed she said she needed assistance with almost all of her daily care needs because she was only able to use her hands and nothing else. An interview with LPN #40 on 08/31/16 at 3:32 P.M. revealed she said she was unaware of any decline in Resident #50's ability to perform self care and she would review the assessments to determine what had happened. After reviewing the assessments, LPN #40 said the 08/11/16 MDS 3.0 assessment had been incorrectly coded and a correction would be submitted. Resident #50's self care abilities had not changed.

Based on medical record review, staff interview and policy review, the facility failed to ensure the physician was notified of significant weight loss. This affected two (Residents #109 and #85) of four residents reviewed for weight loss. Findings Include: 1. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #109 was moderately cognitively impaired, had no swallowing problems and had sustained an unplanned significant weight loss of 5% or more over the last 30 days. Review of Resident #109's medical record revealed the following weights: 07/14/16 - 100.6 pounds; 07/16/16 - 100.8 pounds; 07/17/16 - 98.2 pounds; 07/24/16 - 97.3 pounds; 07/31/16 - 99.0 pounds; 08/01/16 - 99.0 pounds; 08/07/16 - 94.9 pounds; 08/14/16 - 92.4 pounds; 08/21/16 - 85 pounds; 08/22/16 - 83 pounds (reweigh) 08/30/16 - 82.8 pounds. Resident #109 had a 17.6% significant weight loss from 07/14/16 to 08/30/16. Review of Resident #109's record revealed no documentation of Resident #109's physician being notified of the resident's significant weight loss. Review of the physician/certified nurse practitioner (CNP) notes from 07/14/16 thru August 2016 indicated the resident's appetite was poor to fair and there was no indication either the physician or the CNP was aware of Resident #109's significant weight loss. Interview with Registered Dietician (RD) #47 on 08/31/16 at 5:20 P.M. confirmed she had not notified the physician. Interview with RD #47 on 09/01/16 at 11:15 A.M. revealed the interdisciplinary (IDT) team decided who notified the physician of significant weight loss. RD #47 said she normally did not contact the physician because she was only in the facility two times a week. Interview with the Director of Nursing (DON) on 09/01/16 at 2:56 P.M. confirmed she was unable to find any documentation indicating the physician had been notified of Resident #109's significant weight loss. Review of the facility's Notification of Change policy, last revised in July 2015, indicated the facility was to notify the physician with any significant change in the resident's condition. 2. Review of the record revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed she was severely cognitively impaired, and required only supervision and set up for eating. Her August 2016 orders indicated she was to be weighed daily. Review of the resident's weights revealed her weights fluctuated between 170 and 180 pounds between June 2016 and 08/21/16. On 08/21/16 she weighed 180.4 pounds. There was no weight marked for 08/22/16. The weight for 08/23/16 was marked 152.4 pounds. This weight was noted by the dietician and marked as an error on 08/24/16 at 9:04 A.M. Weight on 08/24/16 at 2:36 P.M. was 155 pounds, on 08/25/16 was 156.1 pounds, and subsequent weights remained under 156.3 pounds. Review of nursing notes from 08/21/16 through 08/30/16 did not reveal any indication of [MEDICAL CONDITION] (swelling), changes in intake or elimination. An IDT note dated 08/30/16 at 12:53 P.M. revealed the weight obtained on 08/28/16 of154.3 pounds triggered the weight warning and significant weight loss. The note indicated the weight change might be a scale discrepancy. The note indicated the resident's labs on 08/26/16 were relayed to the doctor with no new orders, no changes were noted to the oral intakes and nursing reports decrease in [MEDICAL CONDITION]. An interview with RD #47 on 08/31/16 at 3:48 P.M. revealed she was notified of the weight loss on 08/29/16. She said she was told of the low weight obtained on 08/23/16 and on 08/24/16 but assumed it was an error and stated she just asked for a re-weigh of the resident. She verified the resident was reweighed on 08/24/16, which continued to indicate a weight loss of almost 25 pounds in 3 days. She stated the resident's physician should have been notified of the large weight loss to ensure the resident was medically stable. An interview with the DON on 09/01/16 at 10:15 A.M. verified the record did not contain documentation of notification of the resident's physician after an almost 25 pound weight loss in three days. She verified such a large weight loss, which the facility attributed to [MEDICAL CONDITION], should have had some physical change in the resident documented by nursing.