Every finding on record at Ohman Family Living at Briar

Based on record reviews, observations, interviews, review of manufacture's guidelines and facility policy review, the facility failed to clean a glucometer machine (a machine used to check blood sugars utilizing a drop of a person's blood). This affected one resident (#83) of five residents observed for medication administration and had the potential to affect one additional resident (#114) identified by the facility as utilizing the same glucometer. The facility also failed to follow contact precautions for Resident #5. This affected one resident (#5) of eight residents reviewed for infection control and had the potential to affect one additional resident (#60) identified by the facility as being on contact precautions. In addition, the facility failed to follow enhanced barrier precautions (EBP) for Resident #21. This affected one resident (#21) of eight residents reviewed for infection control and had the potential to affect 44 additional residents (#3, #4, #8, #9, #10, #14, #15, #16, #18, #20, #22, #23, #26, #28, #31, #32, #36, #37, #38, #40, #41, #44, #45, #46, #52, #54, #58 #62, #65, #69, #70, #73, #75, #76, #80, #81 #87, #88, #92, #96, #103 , #106, #107, and #110) identified by the facility as being on EBP. The facility census was 92.Findings include:1. Review of the medical record revealed Resident #83 was admitted on [DATE] with diagnosis of diabetes mellitus type II. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for mental Status (BIMS) of 06, indicating Resident #83 had severe cognitive impairment. Resident #83 received insulin injections for seven days during the seven-day assessment period. Review of the Medication Administration Record (MAR) for February 2026 and March 2026 revealed orders for the following: Humalog injection solution 100 units/ml (Insulin Lispro). Inject as per sliding scale: if 0-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10 if blood sugar is greater than 400, please call medical doctor (MD), subcutaneously before meals for blood sugar. Accu-check (blood glucose reading) at HS (bedtime) one time a day for diabetes. Further review of the February 2026 MAR revealed blood sugar checks were performed every evening and before each meal (three times a day scheduled at 7:30 A.M., 11:00 A.M., and 4:00 P.M.) Review of the MAR for March 2026 revealed blood sugars were performed the evening of 03/01/26 and 03/02/26 and before each meal (three times a day scheduled at 7:30 A.M., 11:00 A.M., and 4:00 P.M.) on 03/01/26, 03/02/26, and before breakfast on 03/03/26 when the observation of the blood glucose testing was observed. Review of the care plan revealed a diabetes mellitus care plan with an intervention to administer Accu-checks as ordered and PRN (when necessary) and to document results. Observation on 03/03/26 at 8:00 A.M. during medication administration for Resident #83 by Registered Nurse (RN) #364 revealed one Assure Prism glucometer in the 400 Long Hall medication cart. The Assure Prism glucometer was not labeled with a resident name. Interview of RN #364 at the time of observation revealed it was the only glucometer on the unit for one resident (Resident #83) use. RN #364 verified there was no resident name on the glucometer. RN #364 proceeded to clean the glucometer (after donning disposable gloves) with a fresh alcohol pad over the entire surface prior to entering Resident #83's room to administer the ordered blood sugar test. RN #364 then entered Resident #83's room and completed the ordered glucometer test using appropriate infection control practices during medication administration. After completing the glucometer blood sugar test, the nurse cleaned off the glucometer with a fresh alcohol wipe and returned it to the medication cart drawer. There were no visible blood or debris on the glucometer prior or after blood sugar testing. RN #364 verified that Resident #83 was the only resident on the hall that used the glucometer. Interview on 03/03/26 at 11:27 A.M. with the Assistant Director of Nursing (ADON) #394 verified that the glucometers are shared for blood testing and that Cavi1 (disinfecting towelettes) are used to clean and disinfect the equipment between residents. Review of the facility policy titled, Glucometer Cleaning and Disinfection Policy and Procedure (03/25) revealed to open Cavi1 wipe package, remove one wipe, wipe down the device three times vertically, three times horizontally, and then wrap around entire device and allow to sit for one minute. After one minute is up, may wipe device with a clean dry cloth. Review of the manufacturer Assure Prism reference manual (02/16), revealed the system may be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. Cleaning procedure included wear appropriate protective gear (such as disposable gloves) to wipe the entire surface with an appropriate towelette three times horizontally and three times vertically to clean. To disinfect after cleaning, use another towelette to wipe the entire surface three times horizontally and three times vertically, allowing the exteriors to remain wet for the appropriate contact time. Disinfectant brand name CaviWipes1 had a contact time of two minutes. 2. A review of medical records for Resident #5 revealed the date of admission as 12/01/25. Significant diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and acquired absence of part of the lung. Significant orders included collect stool sample for clostridium difficile (C-diff) (a highly contagious infection of the large intestine usually after antibiotic use causing mild diarrhea to life threatening inflammation of the colon) 02/18/26 and transmission-based precautions: contact precautions for C-diff 02/18/26. A quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 indicating Resident #5 was cognitively intact. Resident #5 was always incontinent of bowel. A stool sample dated 02/17/26 revealed Resident #5 was positive for c-diff. An observation on 03/04/26 at 8:11 A.M. revealed Agency Licensed Practical Nurse (LPN) #475 in the room of Resident #5. LPN #475 did not have any personal protective equipment (PPE) on. LPN #475 opened a soda for Resident #5 per his request. LPN #475 came out of the room and did not wash her hands. LPN #475 verified she did not have on PPE and did not wash her hands. LPN #475 stated Resident #5 was in contact isolation for C-diff but this is his last day. A review of the facility policy titled; Isolation-Guidelines for Categories of Transmission Based Precautions revised 10/24/24 revealed contact precautions are to be used for patients with known or suspected infections that represent an increased risk for contact transmission examples include diarrhea associated with C. difficile. The policy also revealed staff were to use PPE including gloves and gown for all interactions that may involve contact with the patient or with the patient's environment. The policy further stated to don (put on) PPE upon room entry and properly discarding before exiting the patient room to contain pathogens. 3. A review of medical records for Resident #21 revealed the date of admission as 07/05/25. Significant diagnoses included acute and chronic respiratory failure, chronic kidney disease stage three, dependence upon a respirator, attention for a tracheostomy tube, and personal history of cardiac arrest. Significant orders included transmission-based precautions-enhanced barrier precautions for tracheostomy, percutaneous endoscopic gastrostomy (PEG) tube (a tube for feeding inserted through the stomach) and Foley catheter. A quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 indicating Resident #21 was cognitively intact. A care plan dated 01/21/26 revealed Resident #21 to be on EBP related to tracheostomy, PEG tube, and Foley catheter. Interventions included encourage hand hygiene per Centers for Disease Control and Prevention (CDC) guidelines, PPE donned for any anticipated close physical contact with the resident, and PPE donned for device care such as central line, Foley catheter, feeding tube, and drains. An observation on 03/04/26 at 8:10 A.M. revealed the call light of Resident #21 to be on. Agency Certified Nurse Aide (CNA) #475 entered the room and closed the door. This surveyor knocked on the door and CNA #475 stated resident care. This state surveyor announced herself and opened the door. CNA #475 was rendering care to Resident #21 with no gown or gloves on. LPN #394 who serves as the infection control nurse verified the aforementioned findings at the time of the observation. A review of the facility policy titled; Isolation-Guidelines for Categories of Transmission Based Precautions revised 10/24/24 revealed EBP are an infection control intervention designed to reduce transmission of multi drug resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk for acquisition. All residents with any of the following require EBP: an indwelling medical device such as a central line, urinary catheter, feeding tube, tracheostomy, ventilator etc. The policy further stated gown and gloves are to be used for resident care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting, and/ or care for any wound or skin opening requiring a dressing.

Based on record review, interview review of the Stand Up (Chorus) Patient Lift Manual and facility policy review, the facility failed to provide adequate supervision/assistive devices to prevent avoidable accidents/falls. This affected one resident (Resident #10) out of four reviewed for accidents/falls. This had the potential to affect 48 residents (Resident # #3, #4, #5, #6, #10, #11, #14, #15, #17, #18, #19, #20, #23, #25, #26, #28, #30, #31, #32, #36, #38, #39, #41, #44, #46, #50, #52, #55, #57, #60, #61, #65, #70, #71, #73, #75, #77, #80, #82, #83, #84, #85, #87, #89, #95, #96, #103, #106) that required a Chorus (operated lift designed to safely transition individuals with limited mobility from sitting to standing for transfers) or mechanical lift for transfer. The facility census was 92.Findings include:Record review revealed Resident #10 admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the left buttock, neuromuscular bladder, tremor, unspecified convulsions, repeated falls, mild vascular dementia, and cognitive communication deficit.Review of the physician orders dated 01/12/22 revealed Resident #10 required a Chorus lift with two staff assistance for transfers and a wheelchair for mobility.Review of the Fall Risk Evaluation V2 dated 11/11/25 and completed by Former Licensed Practical Nurse (LPN) #483 revealed Resident #10 was at high risk for falls as he was confined to a chair, unable to stand, had diagnoses that placed him at high risk for falls as well as was on medications that increased his risk of falls.Review of the nurse's note dated 12/01/25 and completed by LPN #318 revealed Resident #10 had a witnessed fall and was lowered to the ground by Agency Certified Nurse Aide (CNA) #480. LPN #318 was informed by Agency CNA #480 that while transferring Resident #10 from the bed to the wheelchair, he lost strength and she was unable to hold him up and had to lower him to the floor. The nursing note revealed he had no injuries and/or signs of pain. Review of the fall investigation dated 12/01/25 and completed by LPN #318 revealed Resident #10 lost strength in his upper extremities during transfer and was lowered to the floor by Agency CNA #480.Review of the Kardex (brief overview of each resident) dated 12/01/25 revealed Resident #10 was to have two staff assist with the Chorus lift transfers.Review of CNA Transfer Inservice dated 12/23/25 and completed by Staff Development/ Registered Nurse (RN) #329 revealed education was provided to follow transfer orders in the Kardex in the electronic medical record or ask the nurse if needed.Review of the nurse's note dated 01/11/26 and completed by LPN #318 revealed Resident #10 had a witnessed fall when Agency CNA #481 lowered him to the floor due to him not being able to maintain balance while using the Chorus lift. The nursing note revealed he had no injuries and/or signs of pain. Review of the fall investigation dated 01/11/26 and completed by LPN #318 revealed Resident #10 was lowered to the floor by Agency CNA #481 due to not being able to maintain his balance. LPN #318 was called to the room and observed the resident sitting on the floor on his buttocks in front of his wheelchair. Resident #10 stated his footing was not correct and while transferring he was unable to hold on.Review of the Kardex dated 01/11/26 revealed Resident #10 was to have two staff assist with the Chorus lift transfers.Review of the email from Assistant Director of Nursing (ADON) #394 to Agency CNA #481 dated 01/12/26 revealed instructions to check the Kardex or ask staff for transfer status of residents. Agency CNA #481 responded she did ask for help, but everyone was busy. ADON #394 replied she would need to wait for help and follow the orders in the Kardex.Review of Physical Therapy Evaluation and Treatment Plan and completed by Physical Therapist (PT) #375 dated 01/29/26 revealed Resident #10 was performing bed mobility with physical therapy; the resident had not attempted out of bed activity.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. He was dependent on staff for rolling and required maximum assistance for bed mobility. Resident #10 was dependent on staff for sit-to-stand and transfers.Review of the Care Plan dated 02/19/26 revealed Resident #10 was at risk for falls related to impaired mobility, impaired balance, medication use, diagnoses of morbid obesity, COPD, congestive heart failure (CHF), anxiety, depression, and tremors. Interventions included monitoring and medicating for pain, monitoring for signs of dizziness, pharmacy review of medications monthly, referring to physical and occupational therapy to evaluate and treat as needed.Review of Quarterly Fall Risk Evaluation V2 dated 02/19/26 and completed by MDS/ LPN #324 revealed Resident #10 continued to be at high risk for falls, was confined to a chair, unable to stand, had diagnoses that placed him at high risk for falls as well as was on medications that increased his risk of falls.Review of the nurse's notes dated 02/22/26 authored by LPN #318 revealed Resident #10 had a witnessed fall with Agency CNA #482 who yelled for help when attempting to transfer Resident #10 from the bed to the wheelchair. He was unable to stand and began sliding down. Resident #10 was lowered to the ground by Agency CNA #482 and LPN #318. Staff then assisted him off the floor with use of a mechanical lift (used to safely transfer residents who cannot bear weight and limited mobility between positions) into his wheelchair with two staff assist. The nursing note revealed he had no injuries and/ or signs of pain. Review of the fall investigation dated 02/22/26 revealed Agency CNA #482 yelled for someone to assist her. LPN #318 arrived at Resident #10's room and observed the resident on the edge of his wheelchair still attached to the Chorus lift. Agency CNA #482 stated she was attempting to transfer Resident #10 from his bed to his wheelchair when he was unable to continue to stand and began sliding down. LPN #318 and Agency CNA #482 lowered Resident #10 to the ground.Review of the Kardex dated 02/22/26 revealed Resident #10 required two staff assistance for all Chorus lift transfers.Review of the physician's order dated 02/22/26 revealed Resident #10 was changed from a Chorus lift to a mechanical lift for transfers.Review of Physical Therapy (PT), PT Recert, Progress Report and Updated Therapy Plan dated 03/02/26 signed by PT #375 revealed transfers and sit/stand not attempted due to medical or safety concerns. Interview with Resident #10 on 03/02/26 at 10:00 A.M. and on 03/03/26 at 9:16 A.M. revealed he had fallen three times because the agency aides were not locking the wheelchair causing the chair to move back as he went to sit down, and he stated only one staff member assisted him each time instead of two. He revealed he does not want to use the mechanical lift as he wanted to continue to utilize the Chorus lift.Interview with Director of Rehab #466 on 03/03/26 at 11:01 A.M. revealed Resident #10 had always required either a mechanical lift or a Chorus lift to transfer. She verified Resident #10 was to be have two staff assist for both types of transfers for this resident.Interview with the Director of Nursing (DON) 03/03/26 at 12:42 P.M. verified Resident #10 was to have two-staff assist with the Chorus lift. She verified that only one staff member had transferred him on 12/01/25, 01/11/26, and 02/22/26 and that he had fallen and/or was lowered to the floor. Interview with LPN #318 on 03/03/26 at 2:45 P.M. revealed she was working when Resident #10 fell on [DATE], 01/11/26 and 02/22/26 and verified only one aide went into the room to transfer Resident #10 with Chorus lift each time. She verified aides have access to and are supposed to check the Kardex prior to resident care. She stated all three aides were from agency. She revealed she attempted to give report to aides before they do resident care but sometimes, they get into the room before she was done with nursing report from the previous shift. She revealed Resident #10 was lowered to the ground each time and did not complain of any injuries. She stated one of the three incidents was because the aide did not lock the wheelchair. Review of undated facility policy, Falls Prevention Program revealed the purpose of the program is to identify the root cause of a fall, so that an intervention being put in place is effective. Falls risk assessment to be completed and falls weekly meeting held. There was nothing in the policy in regard to the facility monitoring that interventions per physician orders and/ or in their plan were implemented. Review of the Stand Up (Chorus) Patient Lift Manual dated 05/07/18 revealed individuals that use the patient sling must be able to support the majority of their own weight; otherwise injury may occur.This deficiency represents non-compliance investigated under Master Complaint Number 2747582.

Based on record review, observation, interview and facility policy review, the facility failed to ensure comfort measures were utilized for Resident #12. This affected one resident (#12) of three residents reviewed for pain management. The facility census was 92.Findings include:Record review revealed Resident #12 was admitted [DATE] with diagnoses of radiculopathy lumbar region, type II diabetes with diabetic neuropathy, pain in the left ankle and joint, and pain in the right shoulder.Review of the care plan initiated on 10/15/25 and revised on 10/27/25 revealed Resident #12 suffered daily from pain in the legs, toes, right shoulder, and neck and has diagnoses of osteoarthritis and lumbar radiculopathy. Interventions included administering pain medications as order for pain relief, assessing effectiveness of pain medication, and assessing and monitoring for non-verbal signs of pain. The care plan did not include an intervention for an arm sling.Review of the care plan dated 10/15/25 and revised on 02/05/26 revealed resident #12 had an activity of daily living self-care deficit related to diagnosis of cerebral vascular accident (CVA). An intervention included left arm sling for comfort dated 1/18/25. Review of the physician's orders revealed Resident #12 had an order for a left arm sling for comfort every shift with a start date of 11/17/25.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and required maximal assistance with toileting hygiene, showers, and personal hygiene and was dependent on staff for dressing. Section J of the MDS revealed Resident #12 received non-medical intervention for pain.Review of the treatment administration record (TAR) for 03/03/26 revealed it was documented Resident #12 received the arm sling during the day shift. Observations on 03/03/26 at 8:40 A.M., 12:52 P.M., and 3:41 P.M. revealed Resident #12 was not wearing an arm sling as ordered or documented. Interview on 03/03/26 at 12:52 P.M. with Resident #12 revealed she had not yet been given an arm sling but was supposed to have it. Interview on 03/03/26 at 12:55 P.M. with Licensed Practical Nurse (LPN) #402 revealed Resident #12 had frequent complaints of arm pain and the sling was ordered for comfort.Review of the undated Pain Management Policy revealed the policy did not address non-pharmacological treatment interventions but did state that all pain interventions would be documented on the plan of care, the medication administration record/treatment administration record, and/or nurses notes.

Based on observation, interview, review of the facility Controlled Mediation Shift Change Log and facility policy review, the facility failed to ensure accurate records for the receipt and disposition of controlled drugs for one of one medication cart (400 long hall) narcotic records reviewed. This had the potential to affect all residents receiving narcotic medications. The facility census was 92.Findings include:Observation on 03/03/26 at 7:30 A.M. of the narcotic count reconciliation between the night shift Licensed Practical Nurse (LPN) #477 and the day shift Registered Nurse (RN) #364 for the 400 Long Hall, revealed the pharmacy document titled, Controlled Medication Shift Change Log had missing second nurse signatures for the dates of 02/23/26, 02/24/26, 02/26/26, 03/02/26, and 03/03/26.Review of the facility two-sided document titled, Controlled Medication Shift Change Log revealed note additions and deletions on reverse side. Discrepancies are to be reported to nursing administration. There were two signatures required labeled, signature 1 and signature 2 for each entry.Interview on 03/03/26 at 7:30 A.M. with LPN #477 verified the missing signatures on the Controlled Mediation Shift Change Log for the dates of 02/23/26, 02/24/26, 02/26/26, 03/02/26, and 03/03/26. LPN #477 revealed when a nurse accepted a new narcotic or destroyed a narcotic, the nursing supervisor or a second nurse verified the receipt or disposal of a narcotic with a second signature. Interview on 03/03/26 at 7:30 A.M. with RN #364 verified the missing nursing signatures on the Controlled Mediation Shift Change Log for the dates of 02/23/26, 02/24/26, 02/26/26, 03/02/26, and 03/03/26.Interview on 03/03/26 at 11:27 A.M. with Assistant Director of Nursing (ADON) #394 revealed the procedure when accepting or returning a narcotic card from the pharmacy is to have two nurse signatures witness the receipt or removal of the medication. ADON #394 verified the missing signatures on the Controlled Mediation Shift Change Log for the dates of 02/23/26, 02/24/26, 02/26/26, 03/02/26, and 03/03/26 Review of the undated facility policy titled, Dispensing and Narcotic Count Policy, revealed a complete narcotic count must be performed at every shift change between the oncoming and outgoing nurse. Wasted narcotics must be performed by two licensed nurses.

Based on record review, observation and interview, the facility failed to ensure an accurate medical record for Resident #34. This affected one resident (#34) of five residents reviewed for medication orders. The facility census was 92.Findings include: Resident #34 was admitted on [DATE], with diagnoses of hemiplegia (loss of muscle function) and hemiparesis (weakness), dysarthria (speech disorder), diabetes mellitus type two, dysphagia (difficulty swallowing), hypertension (high blood pressure), major depression disorder, insomnia, and anxiety disorder.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #34 had a Brief Interview for mental Status (BIMS) score of 13, indicating intact cognition.Review of the electronic medical record Skilled Nurses Progress Note authored by Licensed Practical Nurse (LPN) #441 dated 02/19/26 at 5:00 P.M., revealed the gastrostomy tube was removed by the physician that day.Review of Resident #34's electronic medical record Order Summary Report and medication administration record (MAR) for March 2026, revealed medications Ambien (sedative) 5 milligrams (mg) 0.5 tablet as needed (PRN) via gastrostomy tube (g-tube), Ambien 5 mg at bedtime via g-tube, Amlodipine Besylate (beta blocker to treat hypertension and chest pain) 10 mg one time a day via g-tube, Carvedilol (lowers blood pressure and heart rate) 6.25 mg twice a day via g-tube, Escitalopram Oxalate (antidepressant) 5 mg one time a day via g-tube, Hydralazine HCL (vasodilator) 25 mg three times a day via g-tube, Lisinopril (treats high blood pressure and heart failure) 20 mg two times a day via g-tube, Melatonin (supplement to aid in sleep) 3 mg one time a day via g-tube, Senna S (laxative) 8.6-50 mg two tablets one time a day for constipation, and Silodosin (treats benign prostatic hypertrophy) 4 mg one time a day via g-tube. Oral medications included Acetaminophen (analgesic) 650 mg by mouth every six hours PRN, Chloraseptic mouth throat liquid (topical anesthetic) one spray by mouth every eight hours PRN, hydrogen peroxide mouth/through solution 5 milliliters (ml) by mouth every eight hours PRN, and Lidocaine Viscous HCL (topical anesthetic) 5 ml by mouth very eight hours PRN.Observation of medication administration on 03/03/26 at 8:55 A.M, revealed Resident #34 received the following medications orally by Registered Nurse (RN) #364: amlodipine 10 mg, carvedilol 6.25 mg, escitalopram 5mg, lisinopril 20 mg, and silodosin 4 mg. Interview at the time of the observation with RN #364 verified she gave the medications orally, verified the medication order route was via g-tube on the MAR, and that Resident #34 had the g-tube discontinued a few weeks ago and had been taking the medications by the oral route since the g-tube was discontinued. Interview on 03/03/26 at 8:57 A.M. with Resident #34 revealed that she had been taking her medications by mouth for quite some time. They took out my tube a long time ago.Interview on 03/03/26 at 11:27 A.M. with the Assistant Director of Nursing (ADON) #394 verified Resident #34's March 2026 MAR medication orders for the g-tube route. ADON #394 verified the g-tube was discontinued for Resident #34, and the facility procedure is to correct the orders in the electronic medical record to the correct route, so the MAR reflects the correct administration route.

Based on record review, observation, interview and facility policy review, the facility failed to ensure a call light was functioning for Resident #26. This affected one resident (#26) of one resident who was investigated for a functioning call light. In addition, the facility failed to ensure the call light was within reach for Resident #3. This affected one resident (#3) of one resident who was investigated for call lights within reach. The facility census was 92. Findings include:1. A review of Resident #26's medical record revealed an admission date of 08/05/25 and pertinent diagnoses included diabetes mellitus type II, chronic pain syndrome, hemiplegia and hemiparesis following cerebral infarction, Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed) of the left heel, Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining) of the right heel, Post-Traumatic Stress Disorder (PTSD), major depressive disorder, generalized anxiety disorder and insomnia. A review of Resident #26's Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Further review of the MDS revealed Resident #26 required set-up and clean up with oral hygiene and eating, substantial to maximum assistance with toileting, bathing, upper body dressing, and was dependent on staff with lower body dressing and partial to moderate assistance with personal hygiene. Resident #26 required substantial to maximum assistance with bed mobility and was dependent on a mechanical lift for safe transfers. An observation on 03/03/2026 at 11:26 A.M. revealed Resident #26 sitting up in bed, awake and watching a movie. He stated he pressed his call light so that he could be helped into his chair and go to therapy, but no one was coming in to help him. This observation also revealed Resident #26 was holding his call button and pressing it with his thumb, but the indicator light above his door in the hallway was not activated or enabled. This was verified with Activities Aide #322. An interview on 03/04/26 at 11:14 A.M. with Plant Operations and Maintenance Director #339 revealed routine audits to check for functioning call lights were not conducted and further stated he was notified of issues through electronic work orders or by word of mouth. Plant Operations and Maintenance Director #339 further stated the turnaround time for call light repairs is quick because the residents can't be without a call lights. A review of the facility's policy titled Call Light Policy and dated 03/2025 revealed if a Resident's call light is not functioning it will be replaced with an alternative means of notifying staff until it is repaired. Maintenance will be notified through TELS or verbally of the nonfunctioning call light. 2. Review of the medical record for Resident #3 revealed a date of admission of 03/15/24. Significant diagnoses included Multiple Sclerosis, chronic respiratory failure, diabetes mellitus type two, dependence on respirator ventilator and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #3 was cognitively intact. The MDS also indicated impairment to both upper and lower extremities. Resident #3 was noted to be dependent on staff for all activities of daily living and always incontinent of bowel. A care plan dated 01/05/26 revealed Resident #3 had a communication problem related to inability to speak due to having a tracheostomy. It indicated that she could mouth words and nods her head. Interventions included keeping call light under her hand. Observation on 03/02/26 at 9:57 A.M. revealed a push pad call light activation devise in the center of Resident #3's chest. Resident #3 was noted to have bilateral upper extremity contractures. A care sign was noted over Resident #3's bed stating to keep call light under hand. Resident #3's spouse was in the room at the time and stated keeping the call light in reach was an issue. When Resident #3 was asked if there were any issues with her care, she mouthed the words call light. Observation on 03/03/26 at 9:54 A.M. revealed the push pad call light activation devise in the middle of Resident #3's chest. Resident #3 was asked if she could reach her push pad call activation signal. Resident #3 moved her right contracted arm in an attempt to activate push pad and was unable to do so. Certified Nurse Aide (CNA) #371 verified the push pad call activation devise was in the middle of Resident #3's chest at the time of the observation. CNA #371 placed the push pad call activation devise partially under the hand of Resident #3 and verified the sign over the bed stating to keep call light under hand. Resident #3 was asked to activate her call light and she could not. CNA #371 then asked Resident #3 if she needed the call light placed deeper. Resident #3 mouthed the word yes. The push pad call light activation devise was then placed completely under the right hand of Resident #3. Resident #3 was able to activate the call light. Observation on 03/04/26 at 7:47 A.M. revealed the push pad call light activation devise in the middle of Resident #3's chest. Resident #3 was asked if she could reach her push pad call activation signal. Resident #3 moved her right contracted arm in an attempt to activate push pad and was unable to do so. Respiratory Therapist (RT) #444 verified the aforementioned findings at the time of the observation. RT #444 also verified the sign above the bed of Resident #3 stating to keep the call light under the hand. Interview on 03/04/25 at 2:25 P.M. with the Director of Nursing verified Resident #3 was able to use the push pad call light activation device. A review of the undated facility document titled; Call Light Assessment revealed each resident, including ventilator or track patients will have proper access and ability to use a call light in their room. The clinical liaison in director of respiratory therapy will complete a bedside physical assessment as needed prior to patient arrival at the facility period the clinician will notify the admission team floor staff and maintenance to set up the proper equipment and ensure on arrival equipment is working and patient is able to properly and safely use the device. If patients cannot activate call light further steps will be needed in order to ensure patient has proper call light. A review of the facility policy titled: Call Light Policy dated 03/2025 revealed the call light is used by a resident to notify staff of the facility that the resident has a need that they would like addressed. The policy further stated staff will ensure that a resident is in a comfortable position and that the call light is within reach of the resident prior to leaving the room.

Based on record review, observation, interview and facility policy review, the facility failed to provide a sanitary environment for Resident #26. This affected one resident (#26) of three residents who were investigated for physical environment. The facility census was 92.Findings include:A review of Resident #26's medical record revealed an admission date of 08/05/25 and pertinent diagnoses included diabetes mellitus type II, chronic pain syndrome, hemiplegia and hemiparesis following cerebral infarction, Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed) of the left heel, Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining) of the right heel, Post-Traumatic Stress Disorder (PTSD), major depressive disorder, generalized anxiety disorder and insomnia.A review of Resident #26's Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Further review of the MDS revealed Resident #26 required set-up and clean up with oral hygiene and eating, substantial to maximum assistance with toileting, bathing, upper body dressing, and was dependent with lower body dressing and partial to moderate assistance with personal hygiene. Review of the MDS also revealed Resident #26 required substantial to maximum assistance with bed mobility and was dependent on a mechanical lift for safe transfers.An observation on 03/02/26 at 11:00 A.M. at Resident #26's bedside revealed small white flakes all over his floor. An interview with the resident during the observation revealed the flakes were dead skin particles from the daily dressing changes to the wounds on his bilateral heels. This was confirmed with Licensed Practical Nurse (LPN) #445 during the observation. LPN #445 and Resident #26 were unable to say when the floor in the resident's room was last cleaned or mopped.An additional observation and interview on 03/03/26 at 11:26 A.M. revealed Resident #26 stated that there were more flakes of dry skin from his feet after that morning's dressing changes. Resident #26 further stated his frustration that the excessive amount of dry skin ended up all over his clothes, bedding and his floor and he didn't want his personal space to be unsanitary. Resident #26 again stated he was unsure when his floor was last swept or mopped.Review of the housekeeping policy titled Daily Resident Room Cleaning Checklist and revised 11/22/24 revealed residents' floors are to be swept and mopped daily.

Based on review of beneficiary notification and interview, the facility failed to ensure Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was issued to residents discharged from a Medicare Part A stay. This affected three (Residents #118, #119, and #120) of the three discharged records reviewed for beneficiary notification. The facility census was 92.Findings include:Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #118 revealed the last covered day of a Medicare Part A covered service was 10/21/25. The facility was unable to provide documentation the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided to the resident/representative. Review of the NOMNC for Resident #119 revealed the last covered day of a Medicare Part A covered service was 09/06/25. The facility was unable to provide documentation the SNF ABN was provided to the resident/representative. Review of the NOMNC for Resident #120 revealed the last covered day of a Medicare Part A covered service was 11/26/25. The facility was unable to provide documentation the SNF ABN was provided to the resident/representative. Interview on 03/05/26 at 1:02 P.M. Administrative Personnel #357 confirmed no SNF ABN's for residents discharged from a Medicare part A stay from 09/04/25 to 03/04/26 had been completed.

Based on record review and interview, the facility failed to ensure accommodation was made for Resident #65 to participate in an activity of choice. This affected one resident (#65) of two residents reviewed for activities. The facility census was 92.Findings include:Record review revealed Resident #65 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, morbid (severe) obesity, borderline personality disorder, and legal blindness.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact and was dependent for toileting hygiene, showers, dressing, and personal hygiene.Interview on 03/02/26 at 12:15 P.M. with Resident #65 revealed she was banned from participating in activities which resulted in her no longer being able to play bingo telephonically due to Resident #65's impaired vision with the assistance of staff from her bedroom. Bingo was played by one staff member in the activity room having the phone on the speaker function and the other staff member was in Resident #65's room with another phone on the speaker function and would assist with marking the bingo card. Resident #65 reported it had been at least one month since she played bingo. Interview on 03/04/26 at 8:43 A.M. with Activity Director #396 confirmed Resident #65 participated regularly in bingo with the assistance of staff but no longer does due to Resident #65 contacting staff during their off time after obtaining their personal cell phone numbers. Activity Director #396 explained that staff were no longer permitted to use their personal cell phones for activities for that reason. Activity Director was unable to confirm when Resident #65 last played bingo and stated, I actually forgot about it and did not put any accommodations in place for Resident #65 to play bingo.Interview on 03/04/26 at 10:46 A.M. with Activity Staff #342 who confirmed she previously assisted Resident #65 with playing bingo using her personal phone but was informed she was no longer permitted to do so and was advised to block Resident #65 from contacting her.Review of the January 2026 activity calendar revealed bingo was scheduled 01/02/26, 01/06/26, 01/08/26, 01/13/26, 01/14/26, 01/20/26, 01/22/26, and 01/27/26. Review of Resident #65's January participation calendar revealed Resident #65 played bingo on 01/08/26 and 01/20/26. Further review of the activity participation calendars revealed Resident #65 did not participate in any activities in the month of February 2026 although bingo was scheduled 02/03/26, 02/05/26, 02/10/26, 02/12/26, 02/17/26, 02/25/26, 02/26/25.

Based on record review, interview and review of facility policy, the facility did not ensure an allegation of verbal abuse was reported as required. This affected one resident (#68) of three residents reviewed for abuse. The facility census was 89.Findings included: Review of medical record for Resident # 68 revealed an admission date of 08/03/23 with diagnoses of schizoaffective disorder, malnutrition, epilepsy, and dementia.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had severely impaired cognition and required staff assistance for all activities of daily living (ADLs).Review of the care plan for Resident #68, dated 06/09/25, revealed Resident #68 had impaired cognition related to dementia, schizoaffective disorder, mood problems related to dementia and intellectual disability. Interventions included to reorient as needed, keep explanations simple and use yes or no questions and if resident resists care, assure safety, back off and reapproach later. Review of the 08/20/25 psychiatric evaluation revealed Resident #68 was alert but disoriented to person, place, time and situation. Memory was poor, impaired attention and concentration; insight, judgement and impulse control poor. Resident #68 reported no concerns during the evaluation. Review of the facility investigation, date initiated 09/06/25, revealed on 09/06/25 Licensed Practical Nurse (LPN) #282 and LPN #321 wrote a witness statement indicating Resident #68 told them an aide asked Resident #68 why am I still breathing. Review of an unsigned statement dated 09/08/25 revealed Resident #68 was interviewed and indicated an aide with curly brown hair and glasses asked her why is she still breathing. The aide was working in the facility at that time and when the writer pointed out the aide to Resident #68, Resident #68 said that it was her, however, that aide was not working in the facility at the time the incident was said to have occurred. When Resident #68 was asked about Certified Nursing Assistant (CNA) #240, Resident #68 stated she's good. Review of a statement written by Unit Manager (UM) #290 revealed an interview with CNA #240 who denied she had ever made any such statement to Resident #68. Other resident interviews included in the facility investigation revealed no findings related to abuse allegations. An interview on 09/11/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #321 revealed she was not a witness to the verbal abuse allegation and stated she saw Resident #68 in the morning following the alleged incident. LPN #321 stated Resident #68 wanted help to call her sister and let her know what had occurred during the night. LPN #321 assisted Resident #68 with the phone call and overheard Resident #68 stating the aide wanted her to stop breathing, and wanted her dead. LPN #321 stated no other residents came to her with any complaints of disrespect or verbal abuse. LPN #321 stated she reported the incident to the Unit Manager #290 in the morning.An interview on 09/11/25 at 11:02 AM with LPN #282 revealed during the morning following his shift on 09/06/25, CNA #201 reported to him that another CNA (CNA #240) had been verbally mean to Resident #68, however; CNA #201 did not witness it. LPN #282 stated he had worked at the time the incident allegedly occurred, and it was not brought to his attention at that time. LPN #282 stated he was unaware of any complaints of verbal abuse or complaints from residents aside from the allegation made by Resident #68. An interview on 09/11/25 at 11:48 A.M. with CNA #201 revealed that Resident #68 told her that CNA #240 said to Resident #68 to stop breathing. She stated she did not witness it, but CNA #240 could come across with a tone in her voice, aggressive and needed to have more patience with the residents. CNA #201 verified she reported the incident to the nurse. An interview on 09/11/25 at 3:00 P.M. with Unit Manager (UM) #290 revealed she spoke with LPN #282 and Resident #68 regarding the allegation. UM #290 stated Resident #68 could not identify the aide in question. UM #290 also interviewed the other residents on the floor which denied any inappropriate comments or verbal abuse. UM #290 verified Resident #68 had made an allegation of verbal abuse from an aide, identified by staff as CNA #240, and it had been investigated. An interview on 09/11/25 at 3:44 P.M. with the Director of Nursing (D.O.N.) revealed she spoke with Resident #68 about the incident but Resident #68 could not identify the aide. The DON stated she also spoke with the other residents and could not validate the alleged comments. The DON confirmed she did not report the allegation to Ohio Department of Health (ODH) and did not submit a Self- Reported Incident Form (SRI). The DON verified all allegations of abuse are required to be reported to the state agency. The DON verified an investigation had been done to determine if abuse had occurred. Review of the ODH Certification and Licensure System (CALS) on 09/11/25 confirmed no SRI was completed regarding the allegation of verbal abuse from staff to Resident #68. Review of facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2022, revealed the policy was to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property. Staff should immediately report all such allegation to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. This deficiency represents non-compliance investigated under Complaint Number 2614720 and 2612128.

Based on personnel file review, narcotic destruction log review, facility policy review and interview, the facility failed to ensure a thorough investigation to prevent the possibility of drug diversion and ensure the safety of all residents after the Administrator received a text message alleging a staff member was using drugs. This had the potential to affect all residents residing in the facility. The census was 92. Findings include: Review of Registered Nurse (RN) #200's personnel file revealed RN #200 received a Notice of Disciplinary Suspension dated 12/21/23. The notice indicated RN #200 was suspended as a result of an investigation of the narcotic destruction process. Review of a termination letter dated 12/27/23 revealed RN #200 was terminated effective immediately due to violation of narcotic destruction process policy, asking a staff member to falsify documents, and exercising poor nursing judgement. Interview on 12/12/24 at 1:58 P.M. with the Administrator revealed in December of 2023, there was no diversion of narcotics. RN #200 had a back log of narcotics that needed to be destroyed and destroyed the narcotics without a witness then asked the supervisor to falsify documents stating she was present when the narcotics were destroyed. The Administrator stated it was a one-time incident but RN #200 was terminated for using poor nursing judgement. The Administrator re-hired RN #200 on 05/13/24 with conditions which included random drug screening and having three staff present when narcotics were destroyed. The condition did not indicate the frequency of the random drug screening. Follow up interview on 12/12/24 at 3:32 P.M. with the Administrator revealed he received a random text message on 11/06/24 indicating RN #200 was using drugs. The Administrator spoke to three staff members including the Clinical Manager, Staff Development Coordinator and the Assistant Director of Nursing who denied having any issues or concerns with RN #200 or the narcotic counts. No further actions were taken. The Administrator did not interview direct care staff, residents, or review narcotic count sheets or narcotic destruction logs. The Administrator did not try to contact the person who sent the text message. Review of facility drug screening documentation revealed RN #200 had drug screens completed on 05/09/24 and 07/10/24. The Administrator verified no further drug screening was completed for RN #200. Review of the narcotic destruction sheets for the past three months with the Administrator revealed two staff signed and dated the destruction logs. Two additional staff signed at the bottom of the logs although the signatures did not include a date or time. The Administrator verified two staff signed the destruction of narcotics and the signatures on the bottom did not include a date and time. Review of the facility policy titled Controlled Medications-Disposal, dated 2019 noted narcotics must be destroyed in the presence of two licensed nurses. Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation, dated 2016 revealed staff who were suspected would be removed from the facility and schedule pending the investigation. The Administrator was to complete an investigation of the alleged violation which was to be completed within five days unless there were special circumstances. The Administrator was to interview residents, staff members, possible witnesses, and review personnel files if a staff member was suspected. This deficiency represents non-compliance investigated under Complaint Number OH00159787.

Based on interview, observation, review of medical record and review of Policy for Central Line Dressing Changes revealed the facility failed to ensure Resident #27's central line dressing was changed as ordered. This affected one resident (Resident #27) out of one resident reviewed in a sample of two residents, (Resident #27 and #241) with intravenous access. The facility census was 88. Findings included: Review of medical record for Resident #27 revealed an admitted [DATE] and his diagnoses included infection and inflammatory reaction due to internal right hip prosthesis, acute and chronic respiratory failure with hypoxia, diabetes, and hypertension. Review of quarterly Minimum Data Set (Minimum Data Set (MDS)) dated 03/29/23 revealed Resident #27 was cognitively intact. He required extensive assistance of one person with bed mobility and extensive assistance of two people with transfers. He was unable to ambulate. He received intravenous medications. Review of undated care plan revealed Resident #27 was on intravenous medications for septic joint infection. Intervention included change dressing to [NAME] (a type of central line usually used to administer medications intravenously through the venous system) catheter twice a week on Tuesdays and Fridays, check dressing at site daily, and monitor for any side effects of intravenous antibiotic use. Review of April 2023 Treatment Administration Record (TAR) revealed Resident #27 had an order to change his midline (A vascular access device placed into a peripheral vein in the upper arm) dressing and caps every week (every Tuesday on night shift) per protocol. The TAR revealed Resident #27's midline dressing change was to be changed on 04/11/23 but that the documentation for this date on the TAR was blank. Review of physician order dated 04/11/23 revealed Resident #27 was to have his midline dressing and caps changed every week. Observation on 04/18/23 at 8:52 A.M. revealed Resident #27 had a midline intravenous catheter to his right arm. The central line dressing to the midline catheter was noted to be partially coming off as it was peeling from the bottom and the dressing was dated 04/05/23 (13 days since last changed). Interview on 04/18/23 at 8:52 A.M. with Resident #27 revealed he was unsure when the last time they had changed his central line dressing and/ or how often it was to be changed. Interview on 04/18/23 at 8:54 A.M. with Agency Licensed Practical Nurse (LPN) #706 verified Resident #27's central line dressing to his right midline was partially peeling up from the bottom of the dressing and was not completely intact. She also verified the central line dressing was dated 04/05/23. She verified Resident #27 had an order to have his central line dressing changed once a week. Interview on 04/18/23 at 9:02 A.M. with the Director of Nursing also verified Resident #27's central line dressing to his right arm was dated as last changed on 04/05/23. She verified his central line dressing was to be changed once a week and had been scheduled to be changed per the TAR on 04/11/23 but was not changed as ordered. Interview on 04/20/23 at 1:00 P.M. with MDS/ Registered Nurse (RN) #669 verified Resident #27's care plan was not updated as previously he had a [NAME] catheter and the dressing change at that time was to be completed twice a week but Resident #27 had a midline to his right arm and his central line dressing change to his midline was to be completed once a week. Review of policy Central Line Dressing and Cap Changes dated 07/22/23 revealed a central line dressing change was a sterile procedure and should be changed at a minimum every seven days. The policy revealed if at any time the dressing peels, becomes wet underneath, or becomes dirty it should be changed

Based on interview, record review and policy review, the facility failed to ensure pharmacy medication review recommendations were addressed and followed up on. This affected three residents (Residents #37, #53, and #70) of five residents reviewed for use of unnecessary medications. The facility census was 71. Findings included: 1. Review of medical record for Resident #53 with an admission date of [DATE] revealed [DIAGNOSES REDACTED]. Review of care plan dated 10/09/18 for Resident #53 revealed he received [MEDICAL CONDITION] medications related to anxiety, depression, and post- traumatic stress disorder. Interventions included administer medications as ordered and monitor for side effects and effectiveness, observe for possible side effects such as excess sedation, dizziness, unsteadiness, gastrointestinal upset, headache, and drowsiness, and the pharmacist was to review his drug regimen monthly. Review of pharmacy medication regimen review dated 02/22/19 for Resident #53 per Pharmacy Consultant #951 revealed the pharmacist recommended adding a duration of therapy for Resident #53's ongoing as needed [MEDICATION NAME] order for anxiety. The pharmacist stated if the as needed [MEDICATION NAME] remained necessary after the initial 14-day duration, then current guidelines require a new duration of therapy and clinical rationale. The form was blank and not addressed by the physician or facility. Review of form labeled Note To attending Physician/ Prescriber dated 7/26/19 per Consultant Pharmacist #951 revealed since Resident #53 was readmitted recently with an order for [REDACTED]. Review of pharmacy medication regimen review dated 10/22/19 from Pharmacy Consultant #951 for Resident #53 revealed Resident #53 was readmitted late (MONTH) and continued to have an as needed [MEDICATION NAME] physician order [REDACTED]. The Pharmacy Consultant #951 recommended to discontinue the [MEDICATION NAME] used for anxiety or obtain a stop date/ duration of therapy. The form was blank and not addressed per the physician or facility. Review of physician orders [REDACTED].#53 continued to have an order for [REDACTED]. Interview with the Director of Nursing on 12/12/19 at 10:37 [NAME]M. verified the pharmacy recommendations for Resident #53 dated 02/22/19, 07/26/19, and 10/22/19 regarding Resident #53's order for as needed [MEDICATION NAME] was not addressed per the physician. She revealed they leave the pharmacy recommendations in the physician's folder, but he does not address the pharmacy recommendations. She verified Resident #53 had a [MEDICATION NAME] as needed order without a stop date that was re-ordered on his readmission on 09/24/19 and continued to have a [MEDICATION NAME] as needed physician order [REDACTED]. 2. Review of medical record for Resident #37 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of care plan dated 04/30/19 for Resident #37 revealed he used anti-anxiety medications related to anxiety disorder. Interventions included follow up with psychiatrist, give anti-anxiety medications as ordered and monitor for side effects. Review of pharmacy medication regimen review dated 06/27/19 from Pharmacy Consultant #951 for Resident #37 revealed he recommended the facility comply with current guidelines as the facility needed to update the duration of therapy for Resident #37's as needed [MEDICATION NAME] (anti-anxiety medication). The form was blank and not addressed per the physician or facility. Review of pharmacy medication review recommendation dated 09/27/19 from Pharmacy Consultant #951 revealed Resident #37 had physician orders [REDACTED]. The pharmacist revealed each medication had similar mechanism of action and administration of both these medications could represent a therapeutic duplication. He revealed Resident #37 had renal dysfunction that could result in the accumulation of both the [MEDICATION NAME] and [MEDICATION NAME] increasing the risk of central nervous system effects such as sedation, confusion, falls and dizziness. He recommended to review for dose or regimen titration's that were indicated. The recommendations were blank and not addressed per the physician or the facility. Review of form labeled, Pharmacy Communication as Needed [MEDICAL CONDITION] Notice Form dated 11/08/19 revealed Resident #37 had an order for [REDACTED]. The Primary Care Physician #952 documented on the form on 11/14/19 that the medication was being managed by psychiatry. No rationale of the medication or duration was added to the order. Review of Psychiatry Consult dated 11/22/19 revealed Psychiatrist #708 evaluated Resident #37 and recommended to either discontinue the [MEDICATION NAME] or give the [MEDICATION NAME] a two-week limitation. Review of physician orders [REDACTED].#37 continued to have an order for [REDACTED].#708's recommendation on 11/22/19. Resident #37 had an order for [REDACTED]. Review of Medication Administration Record [REDACTED].M. and 12/10/19 12:54 [NAME]M. after the medication was to be discontinued. Interview with Director of Nursing on 12/11/19 at 12:27 P.M. verified Resident #37's [MEDICATION NAME] was not discontinued or given a duration of two weeks per Psychiatrist #708's recommendation on 11/22/19. She verified the order continued without a stop date or duration as of today, 12/11/19. She verified Resident #37 was given [MEDICATION NAME] 0.5 mg one tablet as needed for agitation on 12/06/19 and 12/10/19 after the medication was to be discontinued per Psychiatrist #708's recommendation on 11/22/19 to either stop the [MEDICATION NAME] or continue only for 14 days. She verified the [MEDICATION NAME] for Resident #37 was never stopped or given a 14-day duration per recommendation. She verified the pharmacy recommendation dated 09/27/19 regarding the [MEDICATION NAME] and [MEDICATION NAME] dose or regimen titration's was not addressed per the physician as she did not have documentation and verified the recommendation was blank. 3. Review of medical record for Resident #70 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of care plan dated 05/17/19 revealed Resident #70 received [MEDICAL CONDITION] medications related to behavioral management, and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results. Review of Resident #70's physician orders [REDACTED]. Review of pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for [REDACTED]. The pharmacy medication review was blank and the physician or the facility did not address the recommendation. Review of pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order [REDACTED].#70 assessed and provide rationale of the as needed [MEDICATION NAME] in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale. Review of pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order [REDACTED].#70 assessed and provide rationale of the as needed [MEDICATION NAME] in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed for 14 days but provided no rationale. Review of Resident #70's current physician orders [REDACTED]. Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many [MEDICAL CONDITION] medications especially the [MEDICATION NAME] (anti-psychotic) and [MEDICATION NAME] as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his [MEDICAL CONDITION] medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his [MEDICAL CONDITION] medications. Interview with the Director of Nursing on 12/11/19 at 12:37 P.M. verified Resident #70 had an order for [REDACTED]. She verified Resident #70's pharmacy medication review dated 06/27/19 was not addressed by the physician. She also verified Resident #70's pharmacy medication review dated 08/18/19 was not addressed until 10/18/19. She verified Resident #70's as needed [MEDICATION NAME] was an anti-psychotic medication and should have been limited to a 14- day duration and rationale should have been documented justifying the use of the as needed [MEDICATION NAME]. She also verified Resident #70 was recently ordered [MEDICATION NAME] one milligram by mouth every six hours as needed for agitation on 12/06/19 and there was not a stop/ duration of 14 days added to the order. Interview with the Director of Nursing on 12/12/19 at 10:37 [NAME]M. revealed the facility did not have a policy or procedures for the monthly drug regimen review that included, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident or how the physician addresses the drug regimen review recommendation. Review of facility policy labeled, Use of Psychoactive Medications dated (MONTH) 2019 revealed [MEDICAL CONDITION] medication therapy was to be only used when it was necessary to treat a specific condition. The facility policy did not address [MEDICAL CONDITION] medications limited to 14 days or indicated duration for the medications other than anti-psychotic medications that were limited to 14 days. The policy revealed all as needed anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of that medication. The physician was to respond appropriately by changing or stopping problematic doses of medications or clearly document why the benefits of the medication outweigh the risks. The facility consultant pharmacist would assist by identifying gradual dose reductions and prompting prescriber's for periodic re-evaluation of medication and to prompt the facility to update their documentation.

Based on interview, and record review the facility failed to ensure residents were free of unnecessary medications as their as needed [MEDICAL CONDITION] orders were not limited to 14 days and/ or a documented physician rationale was not in the resident's medical record to indicate the duration of the as needed [MEDICAL CONDITION] medication order. This affected three residents (Residents #37, #53, and #70) out of five residents reviewed for use of unnecessary medications. The facility census was 71. Findings included: 1. Review of the medical record for Resident #53 with an admission date of [DATE] revealed [DIAGNOSES REDACTED]. Review of the care plan dated 10/09/18 revealed he received [MEDICAL CONDITION] medications related to anxiety, depression and post- traumatic stress disorder. Interventions included: administer medications as ordered and monitor for side effects and effectiveness, observe for possible side effects such as excess sedation, dizziness, unsteadiness, gastrointestinal upset, headache, and drowsiness, and the pharmacist was to review his drug regimen monthly. Review of the pharmacy medication regimen review dated 02/22/19 completed by Pharmacy Consultant #951 revealed the pharmacist recommended adding a duration of therapy for Resident #53's ongoing as needed [MEDICATION NAME] order for anxiety. The pharmacist stated if the as needed [MEDICATION NAME] remained necessary after the initial 14-day duration, then current guidelines require a new duration of therapy and clinical rationale. The form was blank and not addressed by the physician or facility. Review of the form labeled, Note To attending Physician/ Prescriber dated 7/26/19 completed by Consultant Pharmacist #951 revealed since Resident #53 was readmitted recently with an order for [REDACTED]. Review of the pharmacy medication regimen review dated 10/22/19 completed by Pharmacy Consultant #951 for Resident #53 revealed Resident #53 was readmitted late (MONTH) and continued to have an as needed [MEDICATION NAME] physician order [REDACTED]. Pharmacy Consultant #951 recommended to discontinue the [MEDICATION NAME] used for anxiety or obtain a stop date/ duration of therapy. The form was blank and not addressed per the physician or facility. Review of the physician orders [REDACTED].#53 continued to have an order for [REDACTED]. Interview with the Director of Nursing on 12/12/19 at 10:37 [NAME]M. verified the pharmacy recommendations for Resident #53 dated 02/22/19, 07/26/19 and 10/22/19 regarding Resident #53's order for as needed [MEDICATION NAME] was not addressed by the physician. She revealed they leave the pharmacy recommendations in the physician's folder, but he does not address the pharmacy recommendations. She verified Resident #53 had a [MEDICATION NAME] as needed order without a stop date that was re-ordered on his readmission on 09/24/19, and he continued to have a [MEDICATION NAME] as needed physician order [REDACTED]. 2. Review of the medical record for Resident #37 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the care plan dated 04/30/19 for Resident #37 revealed he used anti-anxiety medications related to anxiety disorder. Interventions included: follow up with psychiatrist, give anti-anxiety medications as ordered and monitor for side effects. Review of the pharmacy medication regimen review dated 06/27/19 completed by Pharmacy Consultant #951 for Resident #37 revealed he recommended the facility comply with current guidelines as the facility needed to update the duration of therapy for Resident #37's as needed [MEDICATION NAME] (anti-anxiety medication). The form was blank and not addressed by the physician or facility. Review of the form labeled, Pharmacy Communication as Needed [MEDICAL CONDITION] Notice Form dated 11/08/19 revealed Resident #37 had an order for [REDACTED]. Primary Care Physician #952 documented on the form on 11/14/19 that the medication was being managed by psychiatry. No rationale of the medication or duration was added to the order. Review of the Psychiatry Consult dated 11/22/19 revealed Psychiatrist #708 evaluated Resident #37 and recommended to either discontinue the [MEDICATION NAME] or give the [MEDICATION NAME] a two-week limitation. Review of the orders for current month (MONTH) 2019 revealed Resident #37 continued to have an order for [REDACTED].#708's recommendation on 11/22/19. Review of the Medication Administration Record [REDACTED].M. and 12/10/19 12:54 [NAME]M. after the medication was to be discontinued. Interview with the Director of Nursing on 12/11/19 at 12:27 P.M. verified Resident #37's [MEDICATION NAME] was not discontinued or given a duration of two weeks per Psychiatrist #708's recommendation on 11/22/19. She verified the order continued without a stop date or duration as of today, 12/11/19. She verified Resident #37 was given [MEDICATION NAME] 0.5 mg one tablet as needed for agitation on 12/06/19 and 12/10/19 after the medication was to be discontinued per Psychiatrist #708's recommendation on 11/22/19 to either stop the [MEDICATION NAME] or continue only for 14 days. She verified the [MEDICATION NAME] for Resident #37 was never stopped or given a 14-day duration per recommendation. 3. Review of the medical record for Resident #70 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the care plan dated 05/17/19 revealed Resident #70 received [MEDICAL CONDITION] medications related to behavioral management and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results. Review of Resident #70's physician orders [REDACTED]. Review of the pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for [REDACTED]. The pharmacy medication review was blank and the physician or the facility did not address the recommendation. Review of the pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order [REDACTED].#70 assessed and provide rationale of the as needed [MEDICATION NAME] in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale. Review of the pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order [REDACTED].#70 assessed and provide rationale of the as needed [MEDICATION NAME] in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed the medication for 14 days but provided no rationale. Review of Resident #70's current physician orders [REDACTED]. Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many [MEDICAL CONDITION] medications especially the [MEDICATION NAME] (anti-psychotic) and [MEDICATION NAME] as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his [MEDICAL CONDITION] medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his [MEDICAL CONDITION] medications. Interview with the Director of Nursing on 12/11/19 at 12:37 P.M. verified Resident #70 had an order for [REDACTED]. She verified Resident #70's pharmacy medication review dated 06/27/19 was not addressed by the physician. She also verified Resident #70's pharmacy medication review dated 08/18/19 was not addressed until 10/18/19. She verified Resident #70's as needed [MEDICATION NAME] was an anti-psychotic medication and should have been limited to a 14-day duration and rationale should have been documented justifying the use of the as needed [MEDICATION NAME]. She also verified Resident #70 was recently ordered [MEDICATION NAME] one milligram by mouth every six hours as needed for agitation on 12/06/19 and there was not a stop/ duration of 14 days added to the order. Review of facility policy labeled, Use of Psychoactive Medications dated (MONTH) 2019 revealed [MEDICAL CONDITION] medication therapy was to be only used when it was necessary to treat a specific condition. The facility policy did not address [MEDICAL CONDITION] medications limited to 14 days or indicated duration for the medications other than anti-psychotic medications that were limited to 14 days. The policy revealed all as needed anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of that medication. The physician was to respond appropriately by changing or stopping problematic doses of medications or clearly document why the benefits of the medication outweigh the risks. The facility consultant pharmacist would assist by identifying gradual dose reductions and prompting prescribers for periodic re-evaluation of medication and to prompt the facility to update their documentation.

Based on interview, record review and policy review, the facility failed to monitor Resident #70's bowel movements and implement bowel medications per physician orders [REDACTED].#70) of one resident reviewed for constipation. The facility census was 71. Findings included: Review of medical record for Resident #70 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #70's care plan dated 06/05/19 revealed he had a potential for constipation related to altered mobility and medication usage. Interventions included administer [MEDICATION NAME] (stool softener), Milk of Magnesia (laxative), [MEDICATION NAME] (laxative) and Senna (laxative) per physician orders, assess abdomen at least daily for tenderness, distension, bowel sounds and firmness, follow facility bowel protocol for bowel management, record bowel movement pattern each day, and monitor, document, report to physician as needed sign and symptoms of complications related to constipation. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition and required extensive assist of two people for bed mobility, transfers and toileting. He was always incontinent of bowel and bladder. Review of physician orders [REDACTED].#70 had a physician order [REDACTED]. He also had an order for [REDACTED]. Review of Medication Administration Record [REDACTED]. He did not receive a [MEDICATION NAME] suppository. Review of form labeled, P[NAME] (Plan of Care) Response History dated from 11/11/19 to 12/10/19 revealed staff documented Resident #70's bowel movements. Resident #70 had no bowel movements recorded from 11/13/19 through 11/16/19 (four days), from 11/18/19 through 11/21/19 (four days), and from 11/25/19 through 11/29/19 (five days). Interview with the Director of Nursing on 12/10/19 at 2:21 P.M. verified Resident #70 was to receive Milk of Magnesia as needed if he did not have a bowel movement after two days per his physician order. She verified he should have received Milk of Magnesia on 11/15/19, 11/20/19 and 11/27/19 per physician order [REDACTED]. She verified Resident #70's physician order [REDACTED]. Review of undated facility policy labeled, BM (Bowel Movement) Protocol revealed the facility was to assist with maintaining a good bowel regimen and prevent constipation. Bowel movements would be marked everyday by the nurse's aides and then the nurse would review the bowel record on 6:00 P.M. to 6:00 [NAME]M. shift and note which residents needed Milk of Magnesia and pass on in report to the day shift. Review of facility policy labeled, Medication Administration dated 06/21/17 revealed the facility did not ensure medications were administered per acceptable standards of practice. The nurse was to open the Medication Administration Record [REDACTED].

Based on record review, interview and policy review, the facility failed to routinely assess and monitor one resident, Resident #17, at risk for elopement. This affected one of two residents identified by the facility as having an alarming bracelet due to elopement risk. The facility census was 71 residents. Findings include: Review of Resident #17's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had a memory problem, had continuous inattention and wandered daily in the look back period. Review of elopement risk assessments for Resident #17 revealed entries on 05/27/17 and 07/21/17. Review of the assessment dated [DATE] revealed Resident #17 was physically capable of leaving the facility; was confused to time and place; wanders, roams and paces; a listed intervention in place included a Roam Alert watchlet (keeps wander-prone residents safe by triggering an alert when a protected resident approaches a monitored exit). No further assessments were available for review. Review of physician's orders revealed an order dated 01/15/19 to check the Roam Alert placement every shift. Review of a care plan dated 07/20/17 revealed Resident #17 was an elopement risk due to wandering behavior. A goal indicated Resident #17 would not elope from the facility over the next 90 days. Interventions included: keep a [MEDICAL CONDITION] eye on resident's whereabouts (07/20/17), notify physician of any attempts from resident to leave facility (07/20/17) and Roam Alert to wrist, check placement daily (10/12/17). Review of nurses' note written by Licensed Practical Nurse (LPN) #406 and dated 08/25/19 at 1:00 P.M. revealed another resident's family made staff aware Resident #17 exited the building into the parking lot. LPN #406 and another nurse ran down the hallway and brought Resident #17 back in to the facility. The note stated the alarm light was flashing but there was no sound. Further review of Resident #17's medical record revealed the order for checking roam alert placement was completed as ordered from (MONTH) 2019 through (MONTH) 2019, however, no orders or indication the device was checked for functioning at any point was noted in the record. An interview was conducted on 12/11/19 at 2:25 P.M. with the Director of Nursing (DON). The DON stated Resident #17 had made it out to the porch of the facility on 08/25/19. The DON indicated Resident #17's Roam Alert had needed to be replaced, and Resident #17 was moved to the second floor of the facility as a result of the incident. The DON stated the MDS staff were responsible for completing elopement assessments. An interview was conducted on 12/11/19 at 3:25 P.M. with the Director of Maintenance (DOM) #401. DOM #401 stated eight doors were checked with a Roam Alert pendant each month to ensure the system would chirp then alarm. DOM #401 explained the system was passive, and the individual Roam Alert watchlet's did not have a battery. An interview was conducted on 12/11/19 at 3:46 P.M. with LPN #402. LPN #402 explained nursing staff were to sign off in the treatment administration record (TAR) the Roam Alert was physically on a resident daily, and the individual Roam Alert device was checked for functioning weekly. Interviews were conducted on 12/11/19 at 4:07 P.M. with MDS Nurse #403 and MDS Nurse #404. Both nurses shared elopement risk assessments were completed upon admission and various staff completed these assessments thereafter. A follow-up interview with the DON on 12/11/19 at 4:31 P.M. verified no further assessment of Resident #17's elopement risk was available for surveyor review. The DON verified nursing staff were to check a resident's individual Roam Alert device weekly to ensure proper function and sign off in the TAR. The DON confirmed Resident #17 did not have an order in her medical record for staff to check her Roam Alert device weekly to ensure proper function and shared no further information regarding Resident #17 being found in the parking lot was available for review. An interview was conducted on 12/12/19 at 10:31 [NAME]M. with LPN #406. LPN #406 verified her nurses' note from 08/25/19 and shared Resident #17 had been on the steps outside the front door of the facility that led to the parking lot. LPN #406 recalled the light had been blinking on the Roam Alert keypad, but it did not emit any sound. LPN #406 thought night shift was to check the Roam Alerts for functioning. She stated she was told to write a nurses' note and had not completed any further documentation regarding this incident. Review of the facility policy, Roam Alert Resident Bracelet revised 08/16/17 revealed a Roam Alert bracelet would be initiated when a resident experienced a decrease in the ability to guard self from accident or injury due to elopement. A resident would be evaluated upon admission and quarterly thereafter. Elopement was defined as when a patient or resident who was cognitively impaired left the facility unnoticed and/or prior to their scheduled discharge. A listed procedure included monthly testing of Roam Alert bracelets/system completed monthly by maintenance and once initiated, the Roam Alert function was to be checked weekly. Review of maintenance records revealed once a month, maintenance staff checked the operation of door monitors of the patient wandering system. Review of facility policy and procedure on elopement, revised 06/01/16 defined elopement as unauthorized leave from the facility premises without prior communication by the resident or responsible party to facility staff. Charge nurse was to document pertinent medical information in the clinical records; if found off-premises and/or any injuries sustained, an incident report would be completed. Post-elopement, the elopement risk assessment form would be reviewed and updated; the plan of care would be reviewed and updated; the watchlet policy would be reviewed and initiated; the resident could be moved to the second floor of the facility if not already residing there; a post-elopement investigation and documentation was to be completed by Administrator/designee. Review of the Roam Alert instruction manual dated (MONTH) 1999 revealed the function of the Roam Alert system was to monitor areas within a building for the presence of Roam Alert transponders. A transponder was sensed when it entered a radio frequency (RF) exciter field that was set up using the Roam Alert controller. Roam Alert was designed to assist nursing staff in providing a higher degree of safety for wandering patients but was not intended as the sole means of protection in preventing a wandering patient leaving the premises. Review of the Roam Alert controller instruction manual dated (MONTH) 2012 revealed the manufacturer's systems were designed to assist staff in providing a high degree of safety for people and assets and therefore should be used as a component on a comprehensive security programs of policies, procedures and processes. As with any security system one must perform regular system operational checks to verify functional integrity.

Based on interview, record review and policy review, the facility failed to ensure Resident #70 were not medicated with as needed [MEDICATION NAME] (anti-psychotic medication) prior to non- pharmacological interventions being attempted. This affected one of five residents reviewed for use of unnecessary medications. The facility census was 71. Findings include: Review of the medical record for Resident #70 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the care plan dated 05/17/19 revealed Resident #70 received [MEDICAL CONDITION] medications related to behavioral management and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results. Review of the pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for [REDACTED]. The pharmacy medication review was blank and the physician and the facility did not address the recommendation. Review of the pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order [REDACTED].#70 assessed and provide rationale of the as needed [MEDICATION NAME] in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale. Review of the pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order [REDACTED].#70 assessed and provide rationale of the as needed [MEDICATION NAME] in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed for 14 days but provided no rationale. Review of the physician orders [REDACTED].#70 had an order for [REDACTED]. Review of the Medication Administration Record [REDACTED].M., 10/08/19 11:12 [NAME]M., 10/13/19 4:16 [NAME]M., and at 1:57 P.M., 10/14/19 at 9:54 [NAME]M., 10/17/19 at 7:39 [NAME]M. and 10/22/19 at 9:41 [NAME]M. Review of the nursing note by Licensed Practical Nurse (LPN) #600 dated 10/07/19 at 9:13 [NAME]M. revealed Resident #70 was raising his fist at another resident. The nurse medicated the resident with [MEDICATION NAME] for behaviors. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review of the nursing note by LPN #955 dated 10/08/19 at 12:16 P.M. revealed Resident #70 was medicated with as needed [MEDICATION NAME] for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review the of nursing note by LPN #964 dated 10/13/19 at 5:09 [NAME]M. revealed Resident #70 was medicated with as needed [MEDICATION NAME] for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review of the nursing note by LPN #955 dated 10/13/19 at 2:32 P.M. revealed Resident #70 was medicated with as needed [MEDICATION NAME] for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review of the nursing note by LPN #901 dated 10/17/19 at 9:33 P.M. revealed Resident #70 was medicated with as needed [MEDICATION NAME] for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review of the nursing note by LPN #955 dated 10/22/19 at 10:07 [NAME]M. revealed Resident #70 was medicated with as needed [MEDICATION NAME] for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. He had physical behaviors one to three days and he wandered one to three days. Review of the Abnormal Involuntary Movement Scale (AIMS) test dated 11/22/19 for Resident #70 revealed he scored a six and had lip smacking present and his tongue thrusted moderately as adverse effects of the [MEDICAL CONDITION] medications. Review of Resident #70's physician orders [REDACTED]. Review of Resident #70's Medication Administration Record [REDACTED].M. and on 12/10/19 at 6:04 [NAME]M. Review of the nursing note per LPN #600 dated 12/06/19 at 11:22 [NAME]M. revealed she medicated Resident #70 with as needed [MEDICATION NAME] at 10:38 [NAME]M. for agitation with positive effect noted. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Review of the nursing note per LPN #600 dated 12/10/19 at 6:54 [NAME]M. revealed she medicated Resident #70 with as needed [MEDICATION NAME] for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed [MEDICATION NAME]. Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many [MEDICAL CONDITION] medications especially the [MEDICATION NAME] (anti-psychotic) and [MEDICATION NAME] as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his [MEDICAL CONDITION] medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his [MEDICAL CONDITION] medications. Interview on 12/11/19 at 3:45 P.M. with LPN #955 revealed Resident #70 does have lip smacking daily as a side effect of his [MEDICAL CONDITION] medications. He revealed at times one on one or activities would help calm him down and decrease his behaviors. Interview with the Director of Nursing on 12/10/19 at 2:24 P.M. revealed prior to the nurse administering a as needed [MEDICAL CONDITION] medication they were to attempt non-pharmacological interventions prior to administration. The nurse was to document the non-pharmacological interventions in the nursing notes that had been attempted prior to administration of the as needed [MEDICAL CONDITION] medication. She verified non-pharmacological interventions for Resident #70 prior to him receiving his as needed [MEDICATION NAME] were not documented in the nursing notes for (MONTH) 10/07/19 at 7:07 [NAME]M., 10/08/19 11:12 [NAME]M., 10/13/19 4:16 [NAME]M., and at 1:57 P.M., 10/14/19 at 9:54 [NAME]M., 10/17/19 at 7:39 [NAME]M. and 10/22/19 at 9:41 [NAME]M. and on 12/06/19 at 10:38 [NAME]M. and on 12/10/19 at 6:04 [NAME]M. She verified she did not have documentation of non- pharmacological interventions attempted prior to the administration of the [MEDICATION NAME]. Review of facility policy labeled, Use of Psychoactive Medications dated (MONTH) 2019 revealed [MEDICAL CONDITION] medication therapy was to be only used when it was necessary to treat a specific condition. Nursing staff was to document in detail an individual's behavioral symptoms. Non-pharmacological interventions would be attempted and documented following the resolution of the acute psychiatric situation.

Based on interview, observation, record review and policy review, the facility failed to ensure insulin's were dated when opened for Resident #24 and Resident #46. This affected two medication carts with undated insulin for Residents #24 and Resident #46 of three medications carts reviewed for medications storage and labeling. This had the potential to affect 11 residents (Residents #11, #22, #24, #33, #36, #37, #46, #47, #65, #70 and #274) receiving insulin. The facility census was 71. Findings include: 1. Review of medical record for Resident #46 with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #46's current physician orders [REDACTED]. Observation of medication storage on 12/09/19 at 4:45 P.M. of North Floor One medication cart with Licensed Practical Nurse (LPN) #600 revealed Resident #46 had a opened Tresiba FlexTouch Solution Pen-injector 100 unit per milliliter (ml) (insulin) in the medication cart undated when it was opened. Interview on 12/09/19 at 4:47 P.M. with LPN #600 verified Resident #46's Tresiba FlexTouch Solution Pen-injector 100 unit per milliliter (ml) (insulin) was not dated when the insulin was opened and revealed when the insulin was opened the nurse should have dated the insulin. 2. Review of medical record for Resident #24 with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #24's current physician orders [REDACTED]. Observation of medication storage on 12/09/19 at 4:55 P.M. with LPN #601 of West Cart Two revealed Resident #24 had a opened [MEDICATION NAME] Solution Pen- injector 100 units per milliliter (ml) had a black smudge on the side of the pen but was unable to read a date when the pen was opened. Interview on 12/09/19 at 4:57 P.M. with LPN #601 verified Resident #24's [MEDICATION NAME] Solution Pen- injector 100 units per milliliter (ml) had a black smudge on the side of the pen but was unable to read a date when the pen was opened. Review of facility policy titled, Medication Administration dated 06/17/17 revealed insulin was a high risk drug and warranted additional precautions for the safe and effective administration. The nurse was to ensure that all opened insulin was dated when opened by documenting on the vial or pen. The policy revealed vials and pens without an open date recorded should be discarded.

Based on observation and interview, the facility failed to ensure staff washed or sanitized hands before donning gloves and administering subcutaneous injections. This affected one (Resident #4) of three residents observed for proper medication administration. The total facility census was 77. Findings include: Observation of a medication pass for Resident #4 by Licensed Practical Nurse #108 on 07/15/19 at 8:32 A.M. revealed the nurse first administered the resident's pill and inhaler medications. Then put on gloves without washing or sanitizing her hands and administered Resident #4's subcutaneous injection. Interview with Licensed Practical Nurse #108 on 07/15/19 at 9:00 A.M. confirmed the above observation. She confirmed she should have washed her hands in-between giving the other medications and donning gloves for the subcutaneous injection. This deficiency substantiates Complaint Number OH 426.

Based on observation, record review, policy review and interview, the facility failed to ensure Resident #58 had a dignified dining experience and failed to ensure Resident #30 was treated with respect while sitting in a common area. This affected one (Resident #58) of 29 residents who ate in the second-floor dining room and one (Resident #30) of three residents reviewed for dignity. The facility census was 78. Findings include: 1. Record review of Resident #58 indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 09/25/18 Minimum Data Set (MDS) 3.0 admission assessment indicated Resident #58 was severely cognitively-impaired, needed set-up help with her meal and supervision with eating. Review of the 09/27/18 care plan indicated Resident #58 was confused at times, may yell or call out related to dementia and can become annoyed or agitated at times with an intervention to assess and anticipate resident ' s needs such as food and thirst. Review of the undated dining room seating chart policy indicated all the residents who are seated together at one table may be served at one time, in order to promote a more home-like atmosphere. Observation on 10/15/18 at 12:25 P.M. in the second-floor dining room revealed Resident #15, Resident #62, Assisted Living (AL) Resident #5 and Resident #58 were sitting at a dining room table together. Resident #15 and Resident #62 were served lunch and State-tested Nurse Aide (STNA) #1 assisted them with their meals; AL Resident #5 and Resident #58 were not served their lunch. Observation on 10/15/18 at 12:34 P.M. revealed Resident #15 and Resident #62 were feeding themselves and AL Resident #5 and Resident #58 hadn ' t received their meals. Resident #58 said to STNA #1 and STNA #3, who were walking by her to serve other residents their meal, I ' m waiting for my lunch . STNA #1 and STNA #3 did not respond to Resident #58. Observation on 10/15/18 at 12:35 P.M. Resident #58 said again to STNA #1 and STNA #3, who were walking by her to serve other residents their meal, when do I get mine? I ' m waiting for my lunch . STNA #1 and STNA #3 did not respond to Resident #58. Observation on 10/15/18 at 12:36 P.M. revealed AL Resident #5 and Resident #58 were served their lunch. Resident #58 started feeding herself. Interview on 10/15/18 at 12:39 P.M. with STNA #3 verified Resident #58 was served her meal 11 minutes after Resident #15 and Resident #50 was served. 2. Resident #30 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #30's annual Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment. The MDS assessment indicated Resident #30 needed extensive assistance of one staff member for locomotion on and off the nursing unit and the extensive assistance of two staff members for transfers. An observation of Resident #30 on 10/17/18 at 9:20 A.M. indicated Resident #30 was seated in front of the television in a wheelchair. Resident #30 was calling out to the staff requesting assistance to go to her room. Several staff members were walking in the hallway and in the common room and ignored Resident #30. At the time of the observation Licensed Practical Nurse (LPN) #6 was administering medications to Resident #5. Resident #5 was seated directly behind Resident #30. Resident #30 continued to ask for help to go to bed. LPN #6 did not respond or acknowledge Resident #30 until Resident #30 pushed back her wheelchair and bumped in to LPN #6's leg. LPN #6 then responded she could not go to her room right now and stated Okay, Kiddo?. An interview with LPN #6 upon completion of the medication administration to Resident #5 verified she had addressed Resident #30 as Kiddo and verified the above observation. A review of the facility policy and procedure titled Resident Rights and Facility Responsibilities dated 11/28/16. The policy indicated the facility would abide by all resident rights and to communicate theses right to the residents and designated representative. Nursing facility residents are granted specific rights under Federal law and indicated a duplication of the Federal regulation for reference. The facility duplicated Federal regulations and indicated item (e) Respect and Dignity: The resident had the right to be treated with respect and dignity.

Based on closed record review and interview the facility failed to timely identify the presence of infection to an unstageable right heel pressure ulcer for Resident #83. The facility failed to ensure pressure ulcer treatments were completed as ordered to decrease the risk of infection and failed to ensure adequate interventions and monitoring were in place to prevent the development of maggots to Resident #83's right heel unstageable pressure ulcer. Actual harm occurred on 07/15/18 when Resident #83 was assessed to have increased pain and the presence of maggots in the pressure ulcer requiring hospitalization for debridement and care. This affected one resident (Resident #83) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #83's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] revealed the resident had a three centimeter (cm) in length by four cm width unstageable pressure ulcer to the right heel, a three cm in length by five cm in width unstageable pressure ulcer to the left heel and a three cm in length by one cm width blister to the front of the resident's right lower leg. A plan of care, dated 05/18/18 revealed the resident had pressure ulcers and the potential for further pressure ulcer development related to altered mobility, medication usage, diabetes and incontinence. Interventions included to elevate lower extremities, ACE wraps to bilateral legs for compression, complete treatments as ordered and monitor for effectiveness. A nursing progress note, dated 05/19/18 revealed the left heel ulcer was 2.2 cm in length by four cm width and unstageable and the right heel was 3.2 cm in length by four cm width and unstageable. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/25/18 revealed the resident was at risk for developing pressure ulcers and had two unstageable pressure ulcers that were present on admission. The resident was alert and oriented, required physical assistance of one staff for bathing, extensive assistance of two or more staff for bed mobility, hygiene, dressing and toileting and was dependent on two or more staff for transfers. Resident #83 had a physician's orders [REDACTED]. Record review revealed there were no changes in the treatment orders for the heel ulcers between 06/19/18 and 07/15/18. Review of the July, (YEAR) treatment administration record (TAR) revealed the daily treatment to the heels were not signed as completed on 07/10/18, 07/11/18, 07/12/18 or 07/13/18. However, there was a nursing progress note dated 07/10/18 that indicated the treatment was provided to the heels on 07/10/18. A skin wound note, dated 07/10/18 revealed the right heel measured 2.1 cm in length by four centimeters width with 0.3 cm depth and 75 percent slough (dead tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy at times) tissue. The right heel was assessed as having a moderate amount of clear and bloody drainage. The left heel measured 2.2 cm in length by 3.8 cm width with 0.1 cm depth, 75 percent slough and a moderate amount of clear and bloody drainage. The record also contained a skilled nursing note dated 07/13/18 that indicated the dressings to the lower extremities were changed early in the morning and were clean, dry and intact. There was no evidence in the record that the daily treatments were provided to the resident's heels on 07/11/8 or 07/12/18. On 08/07/18 at 12:50 P.M. interview with the director of nursing (DON) verified there was no evidence in the medical record that the dressings to the heels were changed daily as ordered on [DATE] or 07/12/18 and no evidence treatment completion was documented on the TAR from 07/10/18 through 07/13/18. Review of a nursing progress note, dated 07/15/18 at 11:07 P.M. revealed the nurse was called to room of Resident #83. Another nurse was about to change the dressing to the resident's right heel and noted the ulcer had several small insect-like creatures all over the wound bed, with many going into the sides of wound bed. The perimeter of the wound bed was red and discolored. The physician was notified and ordered to send the resident to the emergency room . The family was notified. The resident was transferred to the hospital at 11:00 P.M. by ambulance and admitted . Review of the hospital notes, dated 07/15/18 indicated the resident complained of severe pain to her legs, which was likely due to [MEDICAL CONDITION]/wounds. Hospital documentation revealed the wounds were irrigated and a lot of maggots were removed . The notes indicated the resident [MEDICAL CONDITION] (infection) due to [MEDICAL CONDITION] with infected wounds and maggots. The note indicated the resident would need debridement and rule out osteo[DIAGNOSES REDACTED] (bone infection). The hospital history and physical dated 07/15/18 indicated the resident had a chronic ulcer to the bottom of her right heel and she complained of pain. The note indicated staff reported maggots in the wound. The note indicated the resident had a foul smelling sore, the size of a half dollar, to the right heel with visible maggots falling out. On 08/07/18 at 12:50 P.M. interview with the director of nursing (DON) revealed the resident would sit outside in the hot sun during the days prior to the discovery of the maggots in the right heel wound on 07/15/18. She indicated the family would take her outside. Record review revealed there was a nurse's note,dated 07/08/18 that indicated the resident was sitting outside, however there was no further documentation of the resident sitting outside after this date. The DON verified the lack of evidence to support the resident had been outside between 07/08/18 and 07/15/18. This deficiency substantiates Complaint Number OH 279.