Every finding on record at Orchard Villa

Based on observation, staff interview, and facility policy the facility failed to ensure residents protected health information was kept confidential. This affected 12 residents (#43, #52, #323, #421, #422, #423, #425, #427, #428, #429, #430, and #431) reviewed for protected health information. The facility census was 117. Findings include: 1. Observation on 03/19/25 at 8:35 A.M. revealed Registered Nurse (RN) #593 was at the medication cart in the hallway and she walked away from her medication cart with the computer screen open and visible. Concurrent observation revealed Resident #52's information for medication administration was displayed on the computer screen. During the observation Resident #101 was seated in her wheelchair next to the medication cart. Interview on 03/19/25 at 8:38 A.M. with RN #593 verified she left her medication cart computer open and visible. 51529 2. Observation on 03/17/25 at 2:02 P.M. of the medication cart located at C wing nurses station revealed a paper report sheet face up with residents' (#323, #425, #427, #428, #429, #430, and #431) full names corresponding room numbers, and a list of issues and needs. Subsequent interview with Registered Nurse (RN) #621 confirmed this observation and she stated she usually turns the paper over when she walks away from the medication cart. 3. Observation on 03/18/25 at 7:44 A.M. of the medication cart located outside room [ROOM NUMBER] revealed a paper report sheet face up with residents' (#43, #421, #422, and #423) full names corresponding room numbers, and a list of issues and needs. Subsequent interview with Licensed Practical Nurse (LPN) #624 confirmed this observation. Review of facility policy titled Documentation for Security and Privacy Compliance dated 01/06/25 stated documents would be maintained in accordance with the Health Insurance Portability and Accountability Act Privacy and Security Rule. This deficiency represents non-compliance investigated under Complaint Number OH00161938.

Based on review of the medical record, staff interview, and review of facility documentation of Ombudsman notification revealed the facility failed to ensure required notification to the Ombudsman's office. This affected one (#119) of one resident reviewed for hospitalization. The facility census was 117. Findings include: Review of the medical record revealed Former Resident #119 was admitted on [DATE] and was hospitalized on [DATE]. Diagnoses included osteomyelitis of vertebra, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, hypertensive chronic kidney disease, and type two diabetes mellitus with diabetic chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 12/17/24, revealed the resident was discharged . Review of the census documentation, revealed Resident #119 was hospitalized and discharged on 12/17/24. Interview on 03/19/25 at approximately 3:30 P.M. with Business Office Manager (BOM) #634 revealed the Ombudsman's office is only notified of transferred/discharged residents with the payee of Medicaid. BOM #634 verified Resident #119's hospitalization and discharge notice was not sent to the Ombudsman office as the residents payee was not Medicaid. Interview on 03/20/25 at 8:33 A.M. with BOM #634 verified in ten years the Ombudsman's office has only been notified of discharges of Medicaid residents. Review of the Ohio Department of Health/Ombudsman Discharge Tracker Submission Form, dated December 2024, verified Resident #119 was not listed on the transfer and discharge notice list.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents received adequate tube feeding (liquid nutrition through a feeding tube) to maintain weight. This affected one (#16) of two residents reviewed for enteral nutrition (tube feeding). The facility identified four additional residents (#51, #98, #116, and #322) received tube feedings (TF). The facility census was 117. Findings include: Review of the medical record for Resident #16 revealed an admission date of 08/11/24 with diagnoses of type II diabetes mellitus, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had impaired cognition and was dependent on staff for nutrition. Further review revealed she received nutrition and hydration via tube feeding. Additionally, Resident #16 had a significant weight loss and was not on a prescribed weight-loss regimen. Review of the weight history for Resident #16 revealed a current weight obtained 03/15/25 of 161.2 pounds with a basal metabolic index (BMI) of 32.6, indicating she was overweight. Further review revealed a weight obtained 02/13/25 of 172.8 pounds, reflecting a significant weight loss of 6.7% over 30 days. Additionally, Resident #16's weight on 12/19/24 was 176.5 pounds, reflecting a significant weight loss of 8.7% over 90 days. Further, Resident #16's weight on 09/13/24 was 182.9 pounds, reflecting a significant weight loss of 11.8% over 180 days. Review of the weight history for Resident #16 revealed her weight was in the 180-pound range from September 2024 through December 2024. Further review revealed Resident #16's weight declined from 184.8 pounds (12/02/24) to 176.5 pounds (12/19/24), and remained in the 170-pound range through 02/13/25 (172.8 pounds). Continued review revealed Resident #16's weight continued to decrease from 168.6 pounds (2/20/25) to 167.6 pounds (03/06/25), and finally to 161.2 pounds (03/15/25). Review of the Nutrition Assessment completed 12/20/24 revealed Resident #16 was readmitted from the hospital at 177.8 pounds. A recommendation was provided to provide tube feeding (TF) Glucerna 1.2 at 65 ml per hour to meet Resident #16's estimated nutrition needs. Review of the physician order initiated 12/20/24 revealed Resident #16 received Glucerna 1.2 at 65 ml per hour until the order discontinued on 01/13/25. Review of the Nutrition Assessment completed 01/13/25 revealed Resident #16 was receiving Glucerna 1.2 at 65 ml per hour and had two incidents of emesis (vomiting). A recommendation was provided to decrease the TF rate to 50 ml per hour to help decrease the potential for emesis. Review of the physician order initiated 01/13/25 revealed Resident #16 received Glucerna 1.2 at 50 ml per hour. Review of a nutrition progress note dated 02/03/25 revealed Resident #16 was having periods of nausea and vomiting and the symptoms were potentially caused by a recent antibiotic. Review of the Nutrition Assessment completed 02/14/25 revealed Resident #16 had a weight loss of 7.8% over 90 days and 17.5% over 180 days. Further review revealed Resident #16 received Glucerna 1.2 at 50 ml per hour at the time of the assessment and a recommendation was made to increase the TF rate to 65 ml per hour. Review of the current physician order initiated 02/12/25 revealed Resident #16 received Glucerna 1.2 at 50 ml per hour. Review of a nurses progress note dated 3/16/2025 and timed 10:50 P.M. revealed Resident #16 had no further emesis since 8:30 P.M. and the TF was restarted. Interview on 03/18/25 at 10:47 A.M. with Licensed Practical Nurse (LPN) #651 revealed she had just provided care to Resident #16 who vomited at the conclusion of the care. LPN #651 was not aware of previous incidents with Resident #16 vomiting. Interview on 03/18/25 at 11:56 A.M. with LPN #624 revealed she was familiar with Resident #16 and was aware she had emesis that morning and was also aware Resident #16 had emesis the previous Sunday (03/16/25). LPN #624 was not aware of additional incidents of Resident #16 vomiting. Interview on 03/19/25 at 9:20 A.M. with Dietetic Technician, Registered (DTR) #597 revealed she worked in the facility five days per week and monitored Resident #16's weights and TF in coordination with an offsite Registered Dietitian and an onsite Nurse Practitioner (NP). DTR #597 stated she was aware Resident #16 vomited and stated she and the NP determined the cause was likely due to infections and did not believe the vomiting was due to the TF formula. Further interview confirmed the staff decreased the TF rate in response to Resident #16's emesis. Additionally, DTR #597 stated she had not considered providing a more concentrated TF formula (to provide more nutrition in less volume) nor had she discussed the possibility of providing a medication to encourage digestion. Follow-up interview on 03/19/25 at 2:21 P.M. with DTR #597 confirmed Resident #16's TF rate was decreased in January because she was not tolerating it. Additionally, DTR #597 stated she spoke with the NP after the previous interview and learned there was a contraindication with providing a medication to Resident #16 to improve digestion. Interview on 03/19/25 at 2:25 P.M. with DTR #597 and NP #700 revealed they were aware of Resident #16's weight loss and emesis and continued to monitor Resident #16's tolerance to the TF. NP #700 stated there was no concern Resident #16 could not tolerate the TF, she felt Resident #16's intolerance was more likely attributed to infections and receiving antibiotics. Further interview revealed the interventions they implemented to offset the weight loss was administering Zofran (an anti-nausea medication) to offset the nausea and vomiting. NP #700 stated the Zofran was not scheduled routinely but was provided on an as-needed basis. Further interview confirmed Resident #16 lost 23 pounds in the last three months, and NP #700 confirmed the TF rate remained at 50 ml per hour (less than the desired rate of 65 ml per hour) to offset the nausea and vomiting. Continued interview with DTR #597 and NP #700 confirmed the facility did not attempt a more concentrated formula to provide more nutrition in less volume, and did not try a different way to administer the TF, such as bolus feedings (feeding a specific TF amount at one time, and letting the stomach digest it) rather than continuous TF. Further, DTR #597 confirmed Resident #16 was not receiving additional calories or protein from any supplements. Follow-up interview on 03/20/25 at approximately 10:00 A.M. with DTR #597 confirmed the TF rate was 50 ml per hour and there was no plan to increase the rate, to meet Resident #16's estimated nutrition needs, while they monitored Resident #16's tolerance to the lower rate. Telephone interview on 03/20/25 at 1:06 P.M. with Resident #16's family member revealed the family member had concerns regarding Resident #16's intolerance of the TF. Resident #16's family member stated Resident #16 could not tolerate the TF at the higher rate at the hospital or at the facility. Review of the policy Weight Monitoring, reviewed 01/06/25, revealed the purpose was to monitor weight changes and ensure adequate provision of nutrition for all residents. Additionally, the Dietitian/Dietetic Technician will evaluate weights and will initiate appropriate interventions as indicated.

Based on medical record review, observation, staff interview, and review of facility policies the facility failed to ensure oxygen was administered as ordered. This affected two (Residents #50 and #29) of four residents reviewed for oxygen use. The facility identified 32 residents who were prescribed oxygen. The facility census was 117. Findings include: 1. Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia (low oxygen level) and hypercapnia (elevated carbon dioxide level), chronic obstructive pulmonary disease, emphysema, obstructive sleep apnea, and chronic heart failure. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 required moderate assistance with toileting, showering, footwear, personal hygiene, transferring and the resident required supplemental oxygen via continuous positive airway pressure (CPAP) machine. Review of the medical record for Resident #50 revealed a provider order dated 03/12/25 for the use of a CPAP machine with three liters of oxygen while sleeping. Additionally, there was a provider order dated 01/10/25 for continuous oxygen via nasal cannula at three liters. Observation on 03/17/25 at 2:38 P.M. of Resident #50's oxygen tank on her motorized wheelchair revealed the oxygen tank was empty. Subsequent interview with Registered Nurse #621 confirmed the oxygen tank was empty. 47057 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, and dependence on supplemental oxygen. Review of the current physician orders from 03/25 for Resident #29 revealed oxygen at two liters per minute per nasal cannula (nc). Review of the quarterly MDS assessment dated [DATE] for Resident #29 revealed he had mild cognitive impairment and required the use of oxygen. Observation on 03/17/25 at 9:29 A.M. of Resident #29 revealed he was wearing his oxygen and it was running at three and half liters per minute. Observation on 03/18/25 at 10:57 A.M. of Resident #29 revealed he was wearing his oxygen and it was running at three and half liters per minute. Interview on 03/18/25 at 11:00 A.M. with Licensed Practical Nurse (LPN) #686 verified the oxygen order for Resident #29 stated oxygen was to administered at two liters per minute and further verified the oxygen for Resident #29 was running at three and half liters per minute. Review of facility policy titled Medication Administration - General Guidelines dated November 2021 indicated medications would be administered as prescribed. Review of facility policy titled Oxygen Administration dated 06/08/22 indicated staff would check the physician's order for liter flow rate and method of delivery. The resident is also to checked at regular intervals to ensure the correct oxygen liter flow, contents of oxygen cylinder, level of fluid in humidifier, and the resident's respiration status to determine further oxygen needs.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure residents did not receive unnecessary medications. This affected one resident, (#69), out of 6 residents reviewed for unnecessary medications. The current census is 117. Findings include: Record review for Resident #69 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #69 include dementia, depression, myocardial infarction, pulmonary fibrosis, and syncope and collapse. Review of Resident #69's Minimum Data Set (MDS) dated [DATE] revealed the resident has impaired cognition and received antibiotics during the review period. Review of Resident #69's care plans dated 06/11/21 revealed a focus for Enhanced Barrier Precautions due to infections with colonization of multi-drug resistance organisms, (MDRO). Review of Resident #69's medication orders revealed on 08/08/24 the resident was ordered to receive an antibiotic, Cephalexin 250 milligrams (mg) daily prophylactic for urinary tract infections. Review of Resident #69's medication administration records (MAR) reviewed from 08/2024 to 03/2025 revealed the resident was receiving Cephalexin per physician order. Review of Resident #69's urinalysis testing and blood testing dating from 09/2024 to 02/2025 revealed no evidence of any infection in the results. No organisms were noted in the urine samples and the white blood cell counts were within normal ranges. No abnormal lab results were noted in the records. Review of the facility's infection report dated 09/24/24 revealed Resident #69 was diagnosed with cystitis, a common form of urinary tract infection. Per the infection report the resident was ordered to receive Levaquin 250 mg once a day for four days. Per the report the resident was to remain on prophylactic Cephalexin as previously ordered. No further infections were noted in Resident #69's medical records. Review of the facility policy titled Medication Administrarion - Preparation and General Guidelines, dated November 2021 stated if a medication seems to be unrelated to the resident's current diagnosis or condition the nurse calls the provider pharmacy for clarification or if necessary conducts the prescriber and the resulting order clarification is documented in the resident's medical record. Interview on 03/19/25 at 3:08 P.M. with Infection Control Preventionist (ICP) Registered Nurse (RN) #574 revealed Resident #69 had no signs or symptoms of an active infection requiring the administration of the antibiotics per the McGeer's protocols, which is the protocol the facility follows for antibiotics. ICP RN #574 stated Resident #69 had a history of infections, including cystitis in 09/2024, and the resident received Levaquin antibiotic for the infection. ICP RN #574 verified the primary physician ordered the Cephalexin antibiotic on 08/08/24 and ordered it to be continued prophylactically. ICP RN #574 verified there was no documentation for the rationale to continue the antibiotic when Resident #69 is not showing any signs or symptoms of urinary tract infections.

Based on observation, record review, resident interview, staff interview, and review of the facility policy the facility failed to ensure medications were stored securely and administration carts were locked when left unattended. This affected on resident (#57) reviewed for medications storage and had the potential to affect two residents (#14 and #18) that were cognitively impaired and independently mobile residing on the A hall. The facility census was 117. Findings include: 1. Medical record review for Resident #57 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, type two diabetes mellitus, bipolar disorder, and depressive state schizoaffective disorder. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 required extensive assistance with toileting, lower body dressing, personal hygiene, and was dependent for footwear, bathing and toileting. Interview on 03/17/25 at 9:02 A.M. with Resident #57 revealed she was given an incorrect number of pills on the previous day so she put the extra pills in her purse. Subsequent observation revealed Resident #57 opened her purse and removed one blue pill and one orange pill. Interview on 03/17/25 at 9:13 A.M. with Licensed Practical Nurse (LPN) #657 confirmed one blue pill and one orange pill were in Resident #57's purse. LPN #657 identified the pills as Zoloft (antidepressant) and Senna (bowel regulation). 47057 2. Observation on 03/19/25 at 8:35 A.M. revealed Registered Nurse (RN) #593 walked away from the A hall medication cart, leaving it unlocked and out of sight and walked into Resident #52's room to administer medication. Subsequently RN #593 exited Resident #52's room and returned to the unlocked medication cart, obtained a pair of gloves and then returned to Resident #52's room. Again the A hall medication cart was left unattended and unlocked. Concurrent observation revealed Resident #101 was sitting in her wheelchair next to the medication cart. Interview on 03/19/25 at 8:38 A.M. with RN #593 upon returning the A hall medication cart, verified the cart had been left unattended and unlocked. Interview on 03/19/25 at 8:52 A.M. with LPN #518 identified two residents (#14 and #18) residing on the A hall that are independently mobile and cognitively impaired. Review of the facility policy titled Medication Storage in the Facility, revised 01/18 revealed medications and biologicals are stored safely, securely, and properly. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Review of the facility policy titled Preparation and General Guidelines, revised 12/19 revealed during administration of medications, the medication cart is kept closed and locked when out of the sight of the medication nurse. This deficiency represents non-compliance investigated under Complaint Number OH00161938.

Based on medical record review, observation, staff interview, and facility policy the facility failed to ensure infection control procedures were followed. This affected one (#9) of one residents reviewed for indwelling urinary catheter and one (#322) of one residents reviewed for enhanced barrier precautions. The facility identified five residents with an indwelling urinary catheter who utilize a wheelchair and 66 residents that required enhanced barrier precautions. The facility census was 117. Findings include: 1. Based on medical record review Resident #9 was admitted on [DATE]. Diagnoses included multiple sclerosis, paraplegia, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 01/09/25, revealed Resdient #9 was cognitively intact and had limited range of motion on both sides of the upper and lower extremity and dependent for transfers. Resident #9 had an indwelling catheter. Review of the care plan, dated 10/30/23, verified Resident #9 was at risk for infection and/or trauma due to a suprapubic catheter and a diagnosis of neuromuscular dysfunction of bladder. Interventions include to check indwelling urinary catheter for patency, kinks in tubing every shift, monitor for signs and symptoms of urinary tract infection, and provide proper care if the urinary catheter leaked. Observation on 03/18/25 at 12:55 P.M. revealed Resident #9 was in her wheelchair, wheeling herself through the hallways of the common area and in the dining room with approximately five to seven inches of the urinary catheter tubing laying and dragging along the floor. Interview on 03/18/25 at 12:58 P.M. with Certified Nursing Assistant (CNA) #600 verified Resident #9's urinary catheter tubing was laying and dragging on the floor. 47057 2. Review of the medical record for Resident #322 revealed an admitted [DATE] with diagnoses of respiratory failure, percutaneous endoscopic gastrostomy tube (feeding tube into the stomach), anoxic encephalopathy (occurs when there is not enough oxygen to the brain leading to impairment), and tracheostomy. Review of the admission MDS for Resident #322 revealed the assessment was in progress. Review of the current physician orders date 03/25 for Resident #322 revealed an order for enhanced barrier precautions (EBP) (this required the use of gloves and gown during care for high contact interactions to prevent infection by way of artificial orifices for a resident, tracheostomy and feeding tube) for tracheostomy and feeding tube. Review of the care plan initiated 03/19/25 for Resident #322 revealed enhanced barrier precautions were care planned with interventions of gown and gloves required for high contact interactions. Observation on 03/17/25 at 8:57 A.M. of Resident #322's room revealed the resident had a tracheostomy and tube feeding running. Further observation revealed Resident #322's room did not have posted any signage for EBP to alert staff, and there was no personal protective equipment (PPE) immediately available prior to entering the room to don when providing high contact care. Interview on 03/17/25 at 8:58 A.M. with Registered Nurse (RN) #620 stated Resident #322 was admitted last week and verified no EBP signage on the door or PPE available for donning for high contact care for Resident #322. Review of the facility policy titled Enhanced Barrier Precautions dated 07/22 revealed enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multi drug resistant organisms. EBP are to be used with residents with indwelling medical devices such as feeding tube and tracheostomy. Gowns and gloves are to be used for high-contact resident care activities. Implementation of EBP will be to post signs that indicates the care activities that require the use of gown and gloves and make gowns and gloves available for resident room.

Based on medical record review, observation, staff and resident interviews, and review of the facility wheelchair cleaning schedule, the facility failed to ensure wheelchairs were clean. This affected two (Residents #9 and #58) of four residents reviewed for environment. The facility census was 117. Findings include: 1. Review of the medical record for Resident #58 revealed he was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis affecting his right side, chronic obstructive pulmonary disease, type two diabetes mellitus, chronic heart failure, hypertension, and dysphagia. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #58 had mild cognitive impairment. This resident had impairment to his upper and lower extremities on one side and required extensive assistance with dressing, toileting, upper body dressing, and personal hygiene. Resident #58 was dependent for lower body dressing, footwear, and transfers. Resident #58 utilized an electric wheelchair for mobility. Observation on 03/17/25 at 8:43 A.M. of Resident #58 sitting in his power wheelchair revealed there was a significant amount of accumulated debris, dirt, and dust on the frame and cushion of the chair. Concurrent interview with Resident #58 confirmed the chair was dirty and had been cleaned only once since he obtained the chair approximately one year ago. Observation on 03/19/25 at 3:57 P.M. of Resident #58 sitting in his power wheelchair revealed there was a significant amount of accumulated debris, dirt, and dust on the frame and cushion of the chair. Concurrent interview with Licensed Practical Nurse #503 revealed resident wheelchairs were supposed to be cleaned nightly. LPN #503 confirmed Resident#58's wheelchair was dirty and should have been cleaned. Observation on 03/20/25 at 8:56 A.M. of Resident #58 sitting in his power wheelchair revealed there was a significant amount of accumulated debris, dirt, and dust on the frame and cushion of the chair. Concurrent interview with Certified Nursing Assistant #600 confirmed Resident#58's wheelchair was dirty. 2. Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, paraplegia, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set 3.0 (MDS) assessment, dated 01/09/25, revealed the resident was cognitively intact, had limited range of motion on both sides of the upper and lower extremity, and utilized a wheelchair for mobility. Resident #9 was dependent for transfers and had a urinary catheter. Observation on 03/18/25 at 12:56 P.M. revealed Resident #9 in her wheelchair in the dining room. Resident #9's wheelchair was heavily coated with dirt and dust throughout the visible areas of the seat, frame and wheels. Subsequent interview with Resident #9 confirmed the wheelchair was dirty and she did not know the last time it was cleaned. Interview on 03/18/25 at 12:59 P.M. with CNA #600 verified Resident #9's wheelchair was dirty and in need of a deep cleaning. Review of the facility's wheelchair cleaning schedule revealed Resident #9 and Resident #58's wheelchairs were scheduled to be cleaned on Sundays. The cleaning schedule stated all wheelchairs would be taken into the shower room to be cleaned.

Based on observation, staff interview, resident interview and review of facility policy the facility failed to honor resident choice for medication to be administered with pudding. This affected one resident (#45) of three residents reviewed for choices. The facility census was 117. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, and pneumonia. Review of the medical record for Resident #45 revealed she was admitted to the rehabilitation unit and then had a room change on 03/13/25 to the long term care unit. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 revealed she was cognitively intact. Interview on 03/17/25 at 10:47 A.M. with Resident #45 stated she has difficulty swallowing medications and needs pudding to get her medication down. Resident #45 further stated she was originally on the rehabilitation unit and did not have any problems with getting pudding with her medication as requested. Resident #45 stated when she moved to the long-term care unit, she no longer gets pudding with her medications, even when she requests pudding. Resident #45 further stated the nurses on the long-term care unit only give applesauce with her medications and she has trouble swallowing the pills because the applesauce goes down before the pills. Interview on 03/19/25 at 7:46 A.M. with Licensed Practical Nurse (LPN) #537 stated pudding is readily available for medication administration, adding, pudding is available in the kitchen and the nurses just go and get it. Observation on 03/19/25 at 9:24 A.M. of the medication cart LPN #660 was administering medication from revealed no pudding on top of the medication cart and during observation of medication storage revealed no pudding inside the medication cart. Interview on 03/19/25 at 9:24 A.M. with LPN #660 stated she was asked by Resident #45 for pudding with her morning medications. LPN #660 stated she told Resident #45 she only had applesauce and if the resident wanted pudding LPN #660 would have to go to the kitchen to get the pudding therefore Resident #45 would have to wait for her medications. LPN #660 further stated she was aware Resident #45 preferred taking her medication with pudding and did not offer a reason for not having pudding readily available for Resident #45's morning medication administration. Interview on 03/19/25 at 11:18 A.M. with Registered Nurse (RN) #667 stated she cared for Resident #45 while she resided on the rehabilitation unit and recalled she preferred to take her medication whole in pudding. RN #667 stated we have a section on our report sheets that identify the preferred way a resident takes their medication. Interview on 03/19/25 at 11:22 A.M. with Resident #45 stated she requested her medication this morning be placed in pudding and was told by the nurse that she only had applesauce. Resident #45 stated applesauce does not work for her, but that she took the pills whole and hoped they would go down. Resident #45 further stated she is planning to buy her own pudding to keep in her room so she does not have to keep asking for pudding with her medication only to be told no. Interview on 03/19/25 at 5:17 P.M. with LPN #518 stated when a resident is admitted to her unit she inquires about the way the resident prefers to take their medication and the preferred method is put on the nursing report sheet to ensure the nurses will pass medications according to a resident's preferred method. Review of the facility policy titles Medication Administration - General Guidelines, dated November 2021 stated the facility should determine the most appropriate method for administering medications which considers each resident's safety, needs, medication schedule, preferences and functional ability. Review of the facility policy titled Federal and Ohio Residents Rights and Facility Responsibilities, dated 10/19 revealed residents have the right to a dignified existence. A facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents received adequate tube feeding (liquid nutrition through a feeding tube) to maintain weight. This affected one (#16) of two residents reviewed for enteral nutrition (tube feeding). The facility identified four additional residents (#51, #98, #116, and #322) received tube feedings (TF). The facility census was 117. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had impaired cognition and was dependent on staff for nutrition. Further review revealed she received nutrition and hydration via tube feeding. Additionally, Resident #16 had a significant weight loss and was not on a prescribed weight-loss regimen. Review of the weight history for Resident #16 revealed a current weight obtained 03/15/25 of 161.2 pounds with a basal metabolic index (BMI) of 32.6, indicating she was overweight. Further review revealed a weight obtained 02/13/25 of 172.8 pounds, reflecting a significant weight loss of 6.7% over 30 days. Additionally, Resident #16's weight on 12/19/24 was 176.5 pounds, reflecting a significant weight loss of 8.7% over 90 days. Further, Resident #16's weight on 09/13/24 was 182.9 pounds, reflecting a significant weight loss of 11.8% over 180 days. Review of the weight history for Resident #16 revealed her weight was in the 180-pound range from September 2024 through December 2024. Further review revealed Resident #16's weight declined from 184.8 pounds (12/02/24) to 176.5 pounds (12/19/24), and remained in the 170-pound range through 02/13/25 (172.8 pounds). Continued review revealed Resident #16's weight continued to decrease from 168.6 pounds (2/20/25) to 167.6 pounds (03/06/25), and finally to 161.2 pounds (03/15/25). Review of the Nutrition Assessment completed 12/20/24 revealed Resident #16 was readmitted from the hospital at 177.8 pounds. A recommendation was provided to provide tube feeding (TF) Glucerna 1.2 at 65 ml per hour to meet Resident #16's estimated nutrition needs. Review of the physician order initiated 12/20/24 revealed Resident #16 received Glucerna 1.2 at 65 ml per hour until the order discontinued on 01/13/25. Review of the Nutrition Assessment completed 01/13/25 revealed Resident #16 was receiving Glucerna 1.2 at 65 ml per hour and had two incidents of emesis (vomiting). A recommendation was provided to decrease the TF rate to 50 ml per hour to help decrease the potential for emesis. Review of the physician order initiated 01/13/25 revealed Resident #16 received Glucerna 1.2 at 50 ml per hour. Review of a nutrition progress note dated 02/03/25 revealed Resident #16 was having periods of nausea and vomiting and the symptoms were potentially caused by a recent antibiotic. Review of the Nutrition Assessment completed 02/14/25 revealed Resident #16 had a weight loss of 7.8% over 90 days and 17.5% over 180 days. Further review revealed Resident #16 received Glucerna 1.2 at 50 ml per hour at the time of the assessment and a recommendation was made to increase the TF rate to 65 ml per hour. Review of the current physician order initiated 02/12/25 revealed Resident #16 received Glucerna 1.2 at 50 ml per hour. Review of a nurses progress note dated 3/16/2025 and timed 10:50 P.M. revealed Resident #16 had no further emesis since 8:30 P.M. and the TF was restarted. Interview on 03/18/25 at 10:47 A.M. with Licensed Practical Nurse (LPN) #651 revealed she had just provided care to Resident #16 who vomited at the conclusion of the care. LPN #651 was not aware of previous incidents with Resident #16 vomiting. Interview on 03/18/25 at 11:56 A.M. with LPN #624 revealed she was familiar with Resident #16 and was aware she had emesis that morning and was also aware Resident #16 had emesis the previous Sunday (03/16/25). LPN #624 was not aware of additional incidents of Resident #16 vomiting. Interview on 03/19/25 at 9:20 A.M. with Dietetic Technician, Registered (DTR) #597 revealed she worked in the facility five days per week and monitored Resident #16's weights and TF in coordination with an offsite Registered Dietitian and an onsite Nurse Practitioner (NP). DTR #597 stated she was aware Resident #16 vomited and stated she and the NP determined the cause was likely due to infections and did not believe the vomiting was due to the TF formula. Further interview confirmed the staff decreased the TF rate in response to Resident #16's emesis. Additionally, DTR #597 stated she had not considered providing a more concentrated TF formula (to provide more nutrition in less volume) nor had she discussed the possibility of providing a medication to encourage digestion. Follow-up interview on 03/19/25 at 2:21 P.M. with DTR #597 confirmed Resident #16's TF rate was decreased in January because she was not tolerating it. Additionally, DTR #597 stated she spoke with the NP after the previous interview and learned there was a contraindication with providing a medication to Resident #16 to improve digestion. Interview on 03/19/25 at 2:25 P.M. with DTR #597 and NP #700 revealed they were aware of Resident #16's weight loss and emesis and continued to monitor Resident #16's tolerance to the TF. NP #700 stated there was no concern Resident #16 could not tolerate the TF, she felt Resident #16's intolerance was more likely attributed to infections and receiving antibiotics. Further interview revealed the interventions they implemented to offset the weight loss was administering Zofran (an anti-nausea medication) to offset the nausea and vomiting. NP #700 stated the Zofran was not scheduled routinely but was provided on an as-needed basis. Further interview confirmed Resident #16 lost 23 pounds in the last three months, and NP #700 confirmed the TF rate remained at 50 ml per hour (less than the desired rate of 65 ml per hour) to offset the nausea and vomiting. Continued interview with DTR #597 and NP #700 confirmed the facility did not attempt a more concentrated formula to provide more nutrition in less volume, and did not try a different way to administer the TF, such as bolus feedings (feeding a specific TF amount at one time, and letting the stomach digest it) rather than continuous TF. Further, DTR #597 confirmed Resident #16 was not receiving additional calories or protein from any supplements. Follow-up interview on 03/20/25 at approximately 10:00 A.M. with DTR #597 confirmed the TF rate was 50 ml per hour and there was no plan to increase the rate, to meet Resident #16's estimated nutrition needs, while they monitored Resident #16's tolerance to the lower rate. Telephone interview on 03/20/25 at 1:06 P.M. with Resident #16's family member revealed the family member had concerns regarding Resident #16's intolerance of the TF. Resident #16's family member stated Resident #16 could not tolerate the TF at the higher rate at the hospital or at the facility. Review of the policy Weight Monitoring, reviewed 01/06/25, revealed the purpose was to monitor weight changes and ensure adequate provision of nutrition for all residents. Additionally, the Dietitian/Dietetic Technician will evaluate weights and will initiate appropriate interventions as indicated.

Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure timely incontinence care for two (#84 and #102) of three residents reviewed for incontinence care. The facility census was 116. Findings include: 1. Review of the medical record for Resident #84 revealed an admitted [DATE]. Diagnoses included chronic obstructive sleep apnea, osteoarthritis, dementia, major depressive disorder, hypertension, ulcerative colitis and vitamin D deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was cognitively impaired. Resident #84 required moderate assistance for toilet hygiene, personal hygiene, mobility and transfers. Resident #84 was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 09/17/21 revealed Resident #84 had an activities of daily living (ADLs) self-care deficit. Interventions included: staff to provide extensive assistance with personal hygiene, bathing, toilet use and transfers. Further review revealed on 02/08/22, the care plan was revised to include frequent bladder incontinence. Interventions included: check resident for continence, offer assistance when incontinent, monitor for urinary tract infection, use verbal reminders for bathroom use and to place urinal/bedpan within reach of Resident #84. Observation on 07/02/24 at 10:51 A.M. of Resident #84 revealed the resident was sitting in a wheelchair in the middle of the hallway. Resident #84 appeared angry and in a loud voice stated, I cannot get anyone to help. Resident #84 went on to state he had a bowel movement and no one cared that he needed help or that he was sitting in feces. Observation on 07/02/24 at 10:58 A.M. revealed State tested Nurse Aide (STNA) #300 assisted Resident #84 to the bathroom. Continued observation of incontinence care provided to Resident #84 by STNA #300 revealed when the brief was removed, stool dropped onto the floor in front of the toilet and the resident had dark brown stool down the upper inner thigh and up the back. The stool had hardened and required STNA #300 to scrub the skin of Resident #84 with a soap and water to remove the dried stool. Concurrent interview with STNA #300 verified Resident #84 had not been provided incontinence care since the beginning of her shift, which began at 6:30 A.M. (nearly 4.5 hours earlier), and confirmed the resident had been sitting in the stool for some time based on the appearance of the dried stool on the resident's skin. 2. Review of the medical record for Resident #102 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, chronic obstruction pulmonary disease, bipolar disorder, type II diabetes mellitus, schizoaffective disorder, heart failure and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #102 was cognitively intact, required moderate assistance for oral care and maximal assistance for toilet hygiene, lower body dressing and personal hygiene. Resident #102 was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 07/12/22 revealed Resident #102 had an ADLs self-care deficit related to activity intolerance, limited mobility and decreased range of motion. Interventions included to monitor and report changes in physical functioning, staff to assist with ADLs, provide extensive assistance with toilet use and dressing, provide total care for bathing and refer to physical therapy and occupational therapy as needed. Interview on 07/02/24 at 8:41 A.M. with Resident #102 revealed the last time the resident was provided incontinence care was at approximately 2:00 A. M. Resident #102 stated at shift change, the night aide told the day aide she had just cleaned the resident up. Resident #102 stated that was incorrect and asked for assistance. Resident #102 stated she was told care would have to wait until after breakfast. Resident #102 stated she did not appreciated lying in a wet brief and a wet bed. Observation on 07/02/24 at 9:46 A.M. of incontinence care provided for Resident #102 by STNA #305 revealed a strong urine odor when the brief was removed. Resident #102 had reddened skin, with peeling skin on the left upper buttock. STNA #305 applied barrier cream and told Resident #102 the nurse would be notified of the skin condition. Interview on 07/02/24 at 9:55 A.M. with STNA #305 verified Resident #102 had not been checked or changed since the beginning of her shift at 6:30 A.M. (3.25 hours earlier). Review of the facility policy titled Incontinence Care, dated 11/30/23, revealed incontinence care is provided to keep residents skin dry and clean and to prevent irritation and odor. Soiled skin areas are to be cleansed with soap and water and dried thoroughly. This deficiency represents non-compliance investigated under Complaint Number OH00154772.

Based on medical record review, review of an authorization for the release of health information, review of electronic communications, and policy review, the facility failed to provide copies of the medical record to a resident representative in a timely manner. This affected one (Resident #125) of five reviewed for medical record requests. The facility census was 121. Findings include: Review of the medical record revealed Resident #125 had an admitted [DATE] and a discharge date of [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage five chronic kidney disease or end stage renal disease, type two diabetes mellitus with diabetic nephropathy and polyneuropathy, end stage renal disease, dependence on renal dialysis, anemia, noninfective gastroenteritis and colitis, abnormal weight loss, and acquired absence of the left foot. Review of the, Authorization for the Release of Health Information, form revealed one of Resident #125's family members requested a copy of the resident's medical record on 02/16/24. The family member who requested the medical information was not listed as a Power of Attorney (POA) for the resident. Review of facility the Self-Reported Incident (SRI) dated 02/19/24 revealed the family member submitted POA documentation for the resident after 8:00 P.M. on 02/19/24. The Administrator received the POA documentation on 02/20/24 at 8:00 A.M. Review of electronic communications between the Administrator and the facility's legal department revealed the POA was not provided with a copy of the resident's medical record until 02/27/24. Interview on 03/21/24 at 1:35 P.M., the Administrator verified the written request and POA documentation was submitted to the legal department on 02/20/24 and the resident was not provided with a copy of the resident's medical record until 02/27/24. Review of the policy, Medical Records Request, last revised 11/30/23, revealed the facility would handle the release and/or disclosure of all confidential resident medical records in a manner which strictly adheres to state and federal laws, rules and regulations. Records would be produced to the requesting party within two business days from receipt of the request. This deficiency represents non-compliance investigated under Complaint Number OH00151476.

Based on observations, staff interviews, and review of facility policy, the facility failed to date insulin pens after initial use and failed to date a vial of opened and used sterile water. This affected two out of four medication carts observed and had the potential to affect four (#54, #72, #75, and #119) residents with insulin pens that were opened and not dated. The facility census was 125. Findings include: Observation on 12/11/23 at 9:20 A.M. of medication storage for the medication cart on A hall on the skilled unit revealed one vial of sterile water that was opened and undated, one lantus insulin pen opened and undated, and one humalog insulin pen that was opened and undated for Resident #119. At the time of the observation Licensed Practical Nurse (LPN) #206 verified the opened and undated insulin pens for Resident #119 and sterile water. Observation on 12/11/23 at 11:30 A.M. of medication cart for A hall on the long term care unit revealed one opened and undated lantus insulin pen for Resident #54, one opened and undated lantus insulin pen for Resident #72, and one opened and undated humalog insulin pen for Resident #75. At the time of the observation LPN #203 verified the multiple opened and undated insulin pens. Review of an undated facility policy titled Storage of Medications, revealed when the original seal of a manufacturers container or vial is initially broken, the container or vial will be dated. This deficiency represents non-compliance investigated under Complaint Number OH00147531.

Based on observation, review of the medical record, resident and staff interviews and review of facility policy, the facility failed to ensure carpet was in good repair. This affected one (Resident #45) and had the potential to affect 23 (Residents 3, #9, #17, #18, #27, #28, #38, #39, #45, #46, #47, #53, #55, #73, #79, #81, #83, #84, #86, #89, #107, #118, and #121) who were indecently mobile and residing on the Bayshore hall. Additionally, the facility failed to ensure a resident's bathroom was kept in a clean and sanitary manner. This affected one (Resident #64) of one resident observed for bathroom cleanliness. The facility census was 124. Findings include: 1. Interview on 08/22/23 at approximately 9:30 A.M. with Resident #45 revealed the hallway carpet on Bayshore has a large snag and the resident was concerned she could trip and fall. Observation on 08/23/23 at 11:47 A.M. revealed in the walkway of the Bayshore hallway carpet, there was an indent of missing carpet and an area approximately one inch to one and a half inches high and approximately six to ten inches long that had bubbled up. Interview on 08/23/23 at 11:48 A.M. with Registered Nurse (RN) #316 verified the walkway of the hall carpet had a large bubble-like appearance. 42489 2. Review of Resident #64's medical record revealed an admitted [DATE]. Diagnoses included encounter for orthopedic aftercare following surgical amputation, other complications of amputation stump, type II diabetes, end stage renal disease, dependence on renal dialysis, morbid obesity, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, acquired absence of right leg below knee, and acquired absence of left leg below knee. Further review of Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact and required total dependence for transfers and extensive assistance with bed mobility, toilet use, and personal hygiene. Observation on 08/21/23 at 10:36 A.M. revealed Resident #64 in the bathroom. Staff entered the room, proceeded into the bathroom, and assisted Resident #64 into the room. Staff pulled the privacy curtain and continued to assist the resident with care. Observation of the bathroom revealed a brown substance on the toilet seat, down the right side of the toilet, and three nickel size brown, wet spots on the floor next to the right of the toilet. Continued observations on 08/21/23 at 11:56 A.M. and 1:20 P.M. revealed the brown substance remained on the toilet seat, down the side of the toilet, and on the floor next to the toilet, with the spots on the floor now dry. Interview on 08/21/23 at 3:00 P.M. of State tested Nurse Aide (STNA) #343 confirmed the substance on the toilet seat, down the right side of the toilet, and on the floor to the right of the toilet. STNA #343 stated she believed it to be feces, verified Resident #343 needed assistance in the bathroom, and stated it should have been cleaned up. STNA #343 proceeded to get housekeeping to assist with cleaning Resident #64's bathroom. Review of facility policy titled Routine Cleaning, reviewed 06/08/22, revealed to clean hard surfaces as needed (when spills or soiling occur). This deficiency represents non-compliance investigated under Complaint Number OH00145696.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure an effective pest control program. This had the potential to affect 11 (#1, #9, #17, #40, #46, #53, #83, #86, #89, #107, and #121) residents residing on the Bayshore unit. The facility census was 124. Findings include: Observation on 08/21/23 at 4:36 P.M. of the Bayshore unit dining area revealed multiple gnats flying around the refrigerator. A gnat trap on top of the refrigerator had approximately 15 gnats sitting on the trap. Interview on 08/22/23 at 7:30 A.M. of Resident #86 revealed there were gnats everywhere, including in the halls, resident rooms, and in the dining area. Resident #86 stated she believed they were coming from the drains. Observation on 08/22/23 at 2:18 P.M. with Maintenance Supervisor (MS) #276 verified the gnats in the dining area on the Bayshore unit. MS #276 stated they tried to keep up with the gnats and housekeeping put out the gnat traps. MS #276 stated the gnat trap must be full and needed emptied. While the facility had an exterminator at the facility monthly, MS #276 stated she had not had them address the gnats. MS #276 placed the gnat concern on the log for the exterminator and stated they would be out sometime this month but she did not know exactly when. Review of facility policy titled, Pest Control, undated, revealed the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. In addition, maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on medical record review, observation, and staff interview, the facility failed to ensure dependent residents received nail care. This affected one (Resident #47) of four residents reviewed for activities of daily living. The census was 124. Findings included: Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia with agitation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 required extensive two person assistance for personal hygiene and was dependent upon staff for bathing. Review of the care plan revised on 04/03/23 revealed Resident #47 required extensive assistance with personal hygiene and for staff to provide nail care as needed. Further review of the medical record revealed no documentation showing the resident received nail care or the resident refused nail care. Observation on 08/21/23 at approximately 2:00 P.M. revealed Resident #47 had long fingernails with dark substance embedded under each nail. Observation on 08/23/23 at 8:45 A.M. revealed Resident #47 had long fingernails with dark substance embedded under each nail. Observation on 08/24/23 at approximately 10:00 A.M. revealed Resident #47 in the common area and her fingernails continued to remain untrimmed with dark substance embedded under each nail. Interview on 08/24/23 at approximately 10:05 A.M. with Registered Nurse (RN) #316 verified Resident #47 had dark substance embedded under the nails and agreed they needed trimmed. Interview on 08/24/23 at 12:03 P.M. with Licensed Practical Nurse (LPN) #255 revealed Resident #47 was not always compliant but she has previously been successful with providing nail care.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure an appropriate copy of a resident's advanced directive was maintained in the resident's medical record. This affected one (Resident #383) of one resident reviewed for advanced directives. The facility census was 124. Findings include: Review of the medical record revealed Resident #383 was admitted on [DATE]. Diagnoses included urinary tract infection, acute kidney failure, hypertensive heart and chronic kidney disease, chronic kidney disease, pressure ulcer sacral region stage II, hyperkalemia, hyperlipidemia, diverticulosis of large intestine without perforation or abscess without bleeding. Review of the physician order dated 08/10/23 revealed Resident #383's advanced directive was Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). Review of the care plan dated 08/13/23 revealed Resident #383 had chosen advanced directive of DNRCC-Arrest. The medical record did not include a signed copy of the advanced directive. Interview on 08/23/23 at approximately 3:00 P.M. with the Director of Nursing (DON) verified Resident #383's medical record did not contain a copy of the advanced directive and provided a previous and current DNRCC document. Review of DNRCC document signed 08/23/23 verified Resident #383 advanced directive was DNRCC-Arrest. Review of DNRCC document signed June 12th with an unknown year, revealed Resident #383 had previously chosen DNRCC. Review of Resident #383's medical record on 08/24/23 revealed Resident #383's prior DNRCC document had been upload to the electronic medical record instead of the most recent DNRCC document. Review of the policy, Do Not Resuscitate Order, reviewed 06/08/22, verified do not resuscitate orders must be obtained by the resident's attending physician and the physician order sheet maintained in the resident's medical record.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure TED hose were applied per physician order. This affected one (Resident #61) of one resident reviewed for edema. The facility census was 124. Findings include: Review of Resident #61's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, bipolar disorder, schizoaffective disorder, congestive heart failure (CHF), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and required extensive assistance with dressing. Review of a plan of care focus area, revised 12/08/22, revealed Resident #61 was at risk for decreased cardiac output and abnormal lab values related to CHF, hyperlipidemia, use of anticoagulant medication, and use of diuretics. Interventions included knee high TED hose (stockings designed to help prevent blood clots and swelling in legs) as ordered. Review of current physician orders revealed knee high TED hose, apply every morning and remove at bedtime. Observation and concurrent interview on 08/21/23 at 2:57 P.M. of Resident #61 revealed the resident in bed and had bilateral lower extremity edema. Resident #61 stated she was supposed to wear TED hose every day but staff never put them on her. Additional observations of Resident #61 on 08/22/23 at 9:47 A.M., 12:13 P.M., and 1:52 P.M. revealed the resident was not wearing TED hose. Interview on 08/22/23 at 1:52 P.M. of Licensed Practical Nurse (LPN) #351 confirmed Resident #61 was not wearing TED hose. LPN #351 was unaware of Resident #61 refusing to wear them, and State tested Nurse Aides (STNAs) typically assisted residents with putting on TED hose. Interview on 08/22/23 at 1:55 P.M. of State tested Nurse Aide (STNA) #207 verified she did not assist Resident #61 with applying her TED hose today. STNA #207 stated she typically put them on the resident if she got out of bed, but since she did not want up, she did not put them on her. Follow-up observation and concurrent interview on 08/22/23 at 1:58 P.M. of Resident #61 revealed the resident in bed. Resident #61 had bilateral lower extremity edema and no TED hose on. Resident #61 stated she had three new pairs of TED hose but she was unable to put them on herself and staff did not assist her with applying the stockings.

Based on record review, resident interview, and staff interview, the facility failed to follow audiology recommendations to better assist with hearing. This affected one (Resident #14) of one reviewed for hearing. The census was 124. Findings include: Review of Resident #14's medical record revealed an admitted [DATE]. Diagnoses included end stage renal failure, congestive heart failure, and diabetes mellitus. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #14's most recent care plan revealed she had a communication problem related to a hearing deficit and was required to wear hearing aids. Review of the Audiology Group progress note dated 07/12/23 revealed the staff and family had noticed a recent decrease in Resident #14's responsiveness and she complained of newly decreased hearing. Recommendations were for the attending physician or nursing staff to complete wax removal from both ears. The audiologist would re-evaluate after the removal. Further review of Resident #14's medical record revealed no mention of ear wax removal for the resident. Interview with Resident #14 on 08/21/23 at 2:45 P.M. revealed she had been examined by the audiologist in early July 2023 and she was informed she had a wax build up in her left ear and the facility was to irrigate her ears and then she was to return to the audiologist for a follow up appointment. Interview with the Director of Nursing on 08/22/23 at 3:33 P.M. revealed she was unaware if the audiologist recommendations had been followed for Resident #14.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a hand splint was used to prevent contractures per physician order. This affected one (Resident #68) of one reviewed for contractures. The facility census was 124. Findings include: Review of Resident #68's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, aphasia, type II diabetes, congestive heart failure (CHF), major depressive disorder, asthma, atherosclerosis, and dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 was cognitively intact and required extensive assistance with dressing, personal hygiene, toilet use, locomotion, and bed mobility. Review of the plan of care revised 04/13/23 revealed Resident #68 had potential for alteration in skin integrity related to immobility, incontinence, and splint usage. Interventions included wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Additionally, Resident #68 had an activities of daily living (ADLs) self-care performance deficit related to decreased mobility along with diagnoses of hemiplegia and hemiparesis, aphasia, cerebral infarction and atherosclerosis. Interventions included wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Review of current physician orders revealed Resident #68 was to wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Observation and concurrent interview on 08/21/23 at 3:10 P.M. of Resident #68 had a left hand contracture. A splint was observed on the resident's bedside table. Resident #68 stated she was supposed to wear the splint every day but staff had only put it on her once. Resident #68 stated her left hand sometimes hurt and she was concerned about her fingernails digging into the palm of her hand. Additional observations on 08/22/23 at 9:49 A.M., 12:19 P.M., and 1:32 P.M. revealed Resident #68 was not wearing the splint on her left hand and the splint was laying on her bedside table. Interview on 08/22/23 at 1:50 P.M. of Licensed Practical Nurse (LPN) #351 verified Resident #68 was not wearing the splint on her left hand for contractures. LPN #351 stated therapy usually applied the splint each day and she had not been informed the resident had refused to wear it, noting Resident #68 did not refuse care. Interview on 08/23/23 at 8:45 A.M. of Director of Rehabilitation (DOR) #364 revealed therapy only applied splints during trial periods to ensure proper fit, and during trial periods, splints were not left in resident rooms. DOR #364 stated Resident #68 had already been properly fitted for her left hand splint and nursing staff were responsible to apply it per physician orders. Review of facility policy titled, Contracture Prevention and Management, reviewed 03/23/21, revealed contracture prevention and management involves the moving of joints and/or application of orthotic devices according to an individualized plan to prevent or reduce contractures/deformity/atrophy. Additionally, contracture management programs included orthotics, which was identified as the application of a supportive device to maintain an affected limb in a functional position to prevent or reduce contractures.

AMENDED 02/27/23 Based on medical record review, review of in room video camera footage, policy review and staff interview, the facility failed to appropriately transfer a resident from the bed to wheel chair. This resulted in actual harm when Resident #81 was transferred without a mechanical by one staff member and suffered a fracture of the left tibia which required hospitalization and surgery. This affected one resident (#81) of 16 residents that required a mechanical lift transfer. The facility census was 129. Findings include: Review of Resident #81's medical record revealed an admitted [DATE]. Diagnoses included dementia, epilepsy, liver failure, hemiplegia and hemiparesis following a cerebral vascular accident, aphasia, dysphasia, alcohol dependence, urinary incontinence, and coronary artery disease. Review of Resident #81's quarterly Minimum Data Set (MDS) assessment, dated 01/18/23, revealed she had cognitive impairment. She was a dependent of two person assistance for bed mobility and transfers. Review of Resident #81's most recent care plan revealed the resident was at risk for falls characterized by a history of falls, related injury, and multiple risk factors which included: psychoactive drug use, incontinence, impaired balance, pain, and seizure disorder. Interventions included a hoyer lift and two staff assistance with all transfers. Review of Resident #81's nursing progress notes dated 01/01/23 at 5:24 P.M. revealed the resident was complaining of pain coming from her right heel. The resident was assessed and the heel was swollen with discoloration and painful to touch. Review of Resident #81's nursing progress notes dated 01/01/23 at 7:00 P.M. revealed the resident was transferred to the local hospital due to uncontrolled pain. Review of Resident #81's emergency room hospital notes, dated 01/01/23, revealed the resident was admitted to the hospital for the management of swelling and pain of the left lower leg around the calf area. A doppler scan was completed on 01/03/23 and found to be negative for a deep vein thrombosis (DVT). Review of Resident #81's hospital x-ray report, dated 01/04/23, revealed the x-ray was obtained due to acute pain. The findings revealed the resident suffered a mildly displaced fracture of the distal tibia and the proximal fibula. Review of Resident #81's Orthopedics postoperative instructions revealed she required surgery for a left tibia fracture stabilization. She was hospitalized from 01/01/23 through 01/09/23 and discharged on antibiotics, opioid pain medication, and blood thinners. Review of Resident #81's hospital documentation, dated 01/09/23, revealed xrays were taken on 01/04/23 and revealed the resident had osteopenia with mildly displaced fractures of the left distal tibia and the proximal fibula. The resident had a tibial intramedullary (IM) nail insertion completed on 01/06/23. The documentation further read that the resident presented with a closed left tibia/fibula fracture, was wheelchair bound, and it was unclear as to how she fell as there were no reported falls. Review of in room video footage provided by Resident #81's family revealed on 12/31/22 (untimed) revealed State tested Nurse Aide (STNA) #216 transferred the resident from a lying position in her bed to a wheelchair. STNA #216 was observed on the video to be standing at the side of the resident's bed. STNA #216 locked the brakes on the wheelchair which was sitting at the resident's bedside. The wheelchair contained a mechanical lift pad. STNA #216 was then observed to sit Resident #81 up and transfer her to the wheelchair. STNA #216's right hand was under Resident #81's left axilla area the STNA's left hand was grasping Resident #81's right upper arm. No leg or lower body support was provided. Resident #81 was lifted from the bed. STNA #216's left elbow was observed to be raised to the level of her shoulder which placed Resident #81 in a sideways position to her left during the transfer. Resident #81 was placed into the chair and observed falling to her left and hitting her upper left arm/shoulder on the armrest. Resident #81 can be heard yelling Ow. STNA #216 slightly adjusted Resident #81's position in the wheelchair by pulling on something covered with a bed linen. STNA #216 did not not move the chair away from the bed and was observed to walk behind it and attempt to adjust the back of the chair. The video then ended. Telephone interview with Resident #81's daughter on 02/09/23 at 11:02 A.M. revealed the resident required surgery on 01/06/23 to repair the tibia and fibula fractures. The daughter stated the orthopedic surgeon informed her the fracture presented as if something hit the resident's leg or she hit the leg on something. Interview on 02/09/23 at 12:19 P.M. with the Director of Nursing (DON) and the Administrator verified she and the Administrator had viewed the video footage dated 12/31/22 of Resident #81's transfer and agency STNA #216 failed to transfer Resident #81 safely per her care plan. They verified the resident was sent to the hospital on 01/01/23 due to her lower extremity presenting to be warm to the touch with redness which the nurses thought was a deep vein thrombosis. The resident was in the hospital for five days before an x-ray was performed. The x-ray revealed Resident #81 suffered a tibia and fibula fracture. Review of the facility policy titled Mechanical Lift, dated 11/13/19, revealed the purpose was to safely lift and transfer residents with the assist of two individuals. This is non-compliance discovered during the investigation for Complaint Number OH00139600

Based on closed medical record review, review of hospital records, review of a transportation service report, review of a death certificate, staff interviews, physician interviews, review of the United States National Library of Medicine, National Institute of Health website, and review of facility policy regarding change in a resident's condition, the facility failed timely notify the physician of a significant change of condition for one resident (#319). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #319 experienced abnormally low pulse oximetry levels (a measure of the oxygen saturation of the blood) over the course of five hours after admission to the facility, with no notification to the physician of the abnormal levels until Resident #319 was found unresponsive with an absence of vital signs, expiring after failed resuscitative efforts. This affected one (#319) of four residents (#228, #229, #230, and #319) reviewed for change in condition and death. The facility census was 124 residents. On [DATE] at 3:16 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 6:56 P.M. when Licensed Practical Nurse (LPN) #438 failed to notify a physician regarding a significantly low pulse oximetry (SpO2) level for Resident #319. Resident #319's SpO2 level on [DATE] at 6:56 P.M. was 80 percent (normal levels are 95 to 100 percent, with levels below 94 percent considered low). Documentation of the SpO2 levels at 8:29 P.M. and 9:25 P.M. revealed the SpO2 level remained low at 80 percent. No attempts were made to contact a physician regarding the three low SpO2 levels. On [DATE] at 11:00 P.M. Resident #319 was found unresponsive in bed with absence of vital signs. Cardiopulmonary Resuscitation (CPR) was initiated per facility staff until the Emergency Medical Service (EMS) arrived and took over the resuscitation efforts. The resident was pronounced dead at 11:48 P.M. per EMS squad and the body was sent to the county coroner's office. The Immediate Jeopardy was removed on [DATE] at 10:30 P.M. when the facility implemented the following corrective actions: · On [DATE], LPN #438's employment with the facility was terminated for failing to report to work and not contacting the facility. · On [DATE], the Administrator implemented a Quality Assurance Performance Improvement (QAPI) plan related to failure to notify the physician of a resident's change in condition and failure to re-assess a resident. · On [DATE] between 3:16 P.M. and 10:30 P.M., the DON in-serviced all staff on notification of change in condition and re-assessing residents with changes in condition. Staff not in-serviced on [DATE] will not be allowed to work until in-service is completed. A sign was posted for staff to see management team prior to working on the units. New hires will be in-serviced on change of condition and notification to the physician. · On [DATE] at 4:30 P.M., the Administrator and DON notified the Medical Director regarding the incident with Resident #319. · On [DATE] at 6:45 P.M., the Respiratory Therapist (RT) assessed all residents who required oxygen to ensure oxygen needs were being met and they had the proper equipment. · On [DATE] at 9:58 P.M., the Unit Managers, LPN #434, LPN #400, Registered Nurse (RN) #439, RN #402, and RN #423, completed physical assessments of all residents, including a respiratory assessment to identify any changes of condition and notification to physician of any noted changes of condition. · On [DATE] at 10:30 P.M., Corporate Nurse RN #437 provided in-service education to LPN #434, LPN #400, RN #439, RN #402, and RN #423, who then educated all unlicensed nursing staff on change in condition of a resident. · On [DATE], pursuant to the QAPI plan, the facility implemented a new procedure for the 24-Hour Report to be reviewed daily by the DON/Designee for any resident change of condition. The DON/Designee will complete a Health Document Assessment of three residents three times a week for four weeks, then two residents weekly for two weeks, then two residents a month for two months. The Regional Nurse will begin visiting the facility three to four days a week for oversight of the QAPI plan. · On [DATE], the medical records for three additional residents (#228, #229, and #230) were reviewed for death and changes in condition, with no concerns noted. · On [DATE], the medical records for two additional residents (#96 and #226) were reviewed for oxygen administration and monitoring, with no concerns noted. · On [DATE] at 8:30 A.M., interviews with Resident #96 and Resident #226, who were utilizing oxygen, revealed no concerns regarding the staff care and treatment pertaining to their oxygen and respiratory status. · Observations on [DATE] between 8:30 A.M. and 8:40 A.M. of Resident #96 and Resident #226, revealed no concerns related to oxygen use and respiratory status. · On [DATE] between 11:05 A.M. and 11:20 A.M., interviews with LPN #406, LPN #426, LPN #434, State tested Nurse Aide (STNA) #200, STNA #213, and STNA #241, stated they received education on notification of changes and re-assessing residents. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #319's medical record revealed an admission date of [DATE] at approximately 6:00 P.M. [DIAGNOSES REDACTED]. Review of the hospital history and physical, dated [DATE], completed by the internal medicine Physician Assistant-Certified (PA-C) revealed Resident #319 was alert and oriented to person, place, and time. The resident was answering questions appropriately. The resident had been using oxygen at two to three liters per minute (lpm) while at home. The resident's SpO2 was noted to be 96 percent. Review of the hospital pulmonology consult, dated [DATE], by the Certified Nurse Practitioner (CNP) revealed Resident #319 had a SpO2 of 92 percent. Review of the hospital cardiology progress note, dated [DATE], documented the resident had become severely hypoxemic with an oxygen saturation of 71 percent. With the use of a Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) the oxygenation levels had improved to 99 percent at the time of the cardiology evaluation. Review of the hospital discharge orders revealed Resident #319 was to receive oxygen at eight (8) lpm via nasal cannula and would require skilled nursing facility services for less than 30 days. Review of the transport company report, dated [DATE] at 5:34 P.M., revealed Resident #319 arrived at the facility from the hospital. The resident was on 8 liters of oxygen via high flow nasal cannula. The resident was alert and oriented with SpO2 levels during transport being 97 percent at 4:46 P.M. and 5:17 P.M. Review of the admission physician orders, dated [DATE], revealed Resident #319 was a Full Code resuscitation status. Oxygen at 8 lpm via nasal cannula every shift was ordered. The orders did not contain any specification to check the resident's SpO2 levels and no parameters were noted on when to notify the physician of any abnormal SpO2 levels. Review of Resident #319's nursing admission notes, dated [DATE] at 6:27 P.M., revealed the resident was alert with short and long term memory recall appearing intact after five minutes. The resident had shortness of breath when sitting at rest, when lying flat and with exertion. Oxygen was ordered at 8 lpm via nasal cannula. Review of nurse's progress notes and skilled unit assessment, dated [DATE] at 6:54 P.M., revealed LPN #438 documented Resident #319 was alert and oriented, comprehended verbal questions and commands and had accurate recall. The resident had a blood pressure of ,[DATE] millimeters of mercury (mmHg), pulse of 95 beats per minute (bpm), respirations of 20 bpm, and SpO2 of 80 percent. There was no indication of any physician notification or any interventions being attempted to elevate the SpO2 levels. Review of Resident #319's vital sign record, dated [DATE], revealed at 8:29 P.M. the resident had an SpO2 result of 80 percent, blood pressure of ,[DATE] mmHg, respirations were 20 bpm, and the resident's pulse was 115 bpm. There was no indication of any physician notification or any interventions being attempted. Review of the nurse's progress notes, dated [DATE], documented at 9:23 P.M. Resident #319 continued with a blood pressure of ,[DATE] mmHg and respirations of 20 bpm. The resident's pulse was noted to be 95 bpm and identified as irregular of new onset. The resident's SpO2 was 80 percent on 8 lpm of oxygen. Short and long term memory problems were apparent. The resident was slow to respond to questions and had slow comprehension. There was no indication of any physician notification or any interventions being attempted. Review of Resident #319's nurse's progress note, dated [DATE] at 12:04 A.M., revealed at 11:00 P.M. the resident was found by an STNA unresponsive in bed. Vital signs were absent, and CPR was initiated. EMS was called and CPR continued for 45 minutes until time of death was called by the EMS at 11:48 P.M. The son was notified of the resident's death. On [DATE] at 12:45 A.M., the coroner's office was notified and at 2:35 A.M. the coroner's office removed the resident's body. Review of Resident #319's Certificate of Death record dated [DATE] revealed the immediate cause of death to be complications of left [MEDICAL CONDITION]. Other significant conditions contributing to death included [MEDICAL CONDITION] and [MEDICAL CONDITION] fibrosis. Interview on [DATE] at 4:15 P.M. with Corporate Nurse RN #437 and LPN #434 revealed LPN #434 had been on call on [DATE] and received a telephone call from LPN #438 who stated Resident #319 had expired after resuscitation had been attempted. LPN #434 stated she had been informed the resident's SpO2 level was low on admission to the facility. LPN #434 stated she informed LPN #438 to call the coroner's office and complete all the necessary charting. RN #437 stated the resident's son had been at the facility earlier and possibly the whole time. Corporate Nurse RN #437 stated LPN #438 was no longer employed at the facility. Corporate Nurse RN #437 also stated she was unable to verify the physician was notified of the resident's condition. During a telephone interview on [DATE] at 9:20 A.M., Physician #102 of the coroner's office revealed due to Resident #319 expiring within 24 hours of admission, the coroner's office was contacted. Physician #102 stated the resident's cause of death was complications from [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION] fibrosis. During a telephone interview on [DATE] at 9:40 A.M. with Physician #101's on-call answering service revealed the only page they received for Physician #101 from the facility occurred on [DATE] at 12:12 A.M. Interview on [DATE] at 9:52 A.M., RT #500 stated she would not have been working when Resident #319 was admitted to the facility and had not been informed to set up the resident's oxygen needs. RT #500 stated if a resident had an SpO2 of 80 percent and had not improved, then they should have been sent back to the hospital and did not belong at the facility. A telephone interview on [DATE] at 10:35 A.M. with Physician #101, listed on Resident #319's chart as the attending physician, revealed he spoke with his office answering service regarding any in-coming calls he may have received on [DATE]. Physician #101 stated the only call he received from the facility was on [DATE] at 12:12 A.M. when he was notified the resident had expired. Physician #101 stated he would have expected the nursing staff to have notified him of a resident with an SpO2 level of 80 percent. During a telephone interview on [DATE] at 2:26 P.M. with the Medical Director (Physician #103), he stated he did not recall being contacted by the facility regarding Resident #319's low SpO2 level of 80 percent. Telephone interview on [DATE] at 4:25 P.M. with STNA #236 revealed he came on shift on [DATE] at 10:30 P.M. He found Resident #319 unresponsive around 10:45 P.M. and called LPN #438 for help. Interview on [DATE] at 8:50 A.M. with Admissions Coordinator #600 revealed Resident #319's admission to the facility was delayed at one point due to the resident going on and off the [MEDICAL CONDITION]. During a telephone interview on [DATE] at 11:25 A.M. with RN #413 revealed on [DATE] around 11:00 P.M. he had been called to Resident #319's room by STNA #236. The resident was unresponsive and LPN #422 assisted him with starting CPR while LPN #438 went to check on the resident's code status. Emergency services were contacted. The resident did not survive. Review of a written statement dated [DATE] from Physician #104 revealed Resident #319 had been hospitalized for [REDACTED]. The resident received oxygen. The statement documented Resident #319 had been stable at the time of the hospital discharge with [MEDICAL CONDITION] noted at admission to the facility with minor exertion and transfer to bed. Review of LPN #438's personnel record revealed a date of hire of [DATE] and a termination date of [DATE]. The file contained a discipline on [DATE] for not thoroughly documenting on new resident admissions and not removing dressings to assess wounds on admission. Review of the facility policy titled Change in a Resident's Condition, dated [DATE], revealed the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a change in resident condition. According to the United States National Library of Medicine, National Institute of Health website at www.ncbi.nlm.nih.gov/pub/med/ 240, titled Pulse Oximetry: What the Nurse Needs to Know, an SpO2 less than 94 percent is considered hypoxic. If the SpO2 is less than 90 percent it is considered a clinical emergency. This is continued non-compliance from the survey completed [DATE].

Based on closed medical record review, review of hospital records, review of a transportation service report, review of a death certificate, staff interviews, physician interviews, review of the United States National Library of Medicine, National Institute of Health website, and review of facility policy regarding change in a resident's condition, the facility failed to provide care and treatment to monitor a resident's condition and failed to timely notify the physician of a significant change of condition for one resident (#319). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #319 experienced abnormally low pulse oximetry levels (a measure of the oxygen saturation of the blood) over the course of five hours after admission to the facility, with no notification to the physician of the abnormal levels until Resident #319 was found unresponsive with an absence of vital signs, expiring after failed resuscitative efforts. This affected one (#319) of four residents (#228, #229, #230, and #319) reviewed for change in condition and death. The facility census was 124 residents. On [DATE] at 3:16 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 6:56 P.M. when Licensed Practical Nurse (LPN) #438 failed to notify a physician regarding a significantly low pulse oximetry (SpO2) level for Resident #319. Resident #319's SpO2 level on [DATE] at 6:56 P.M. was 80 percent (normal levels are 95 to 100 percent, with levels below 94 percent considered low). Documentation of the SpO2 levels at 8:29 P.M. and 9:25 P.M. revealed the SpO2 level remained low at 80 percent. No attempts were made to contact a physician regarding the three low SpO2 levels. On [DATE] at 11:00 P.M. Resident #319 was found unresponsive in bed with absence of vital signs. Cardiopulmonary Resuscitation (CPR) was initiated per facility staff until the Emergency Medical Service (EMS) arrived and took over the resuscitation efforts. The resident was pronounced dead at 11:48 P.M. per EMS squad and the body was sent to the county coroner's office. The Immediate Jeopardy was removed on [DATE] at 10:30 P.M. when the facility implemented the following corrective actions: · On [DATE], LPN #438's employment with the facility was terminated for failing to report to work and not contacting the facility. · On [DATE], the Administrator implemented a Quality Assurance Performance Improvement (QAPI) plan related to failure to notify the physician of a resident's change in condition and failure to re-assess a resident. · On [DATE] between 3:16 P.M. and 10:30 P.M., the DON in-serviced all staff on notification of change in condition and re-assessing residents with changes in condition. Staff not in-serviced on [DATE] will not be allowed to work until in-service is completed. A sign was posted for staff to see management team prior to working on the units. New hires will be in-serviced on change of condition and notification to the physician. · On [DATE] at 4:30 P.M., the Administrator and DON notified the Medical Director regarding the incident with Resident #319. · On [DATE] at 6:45 P.M., the Respiratory Therapist (RT) assessed all residents who required oxygen to ensure oxygen needs were being met and they had the proper equipment. · On [DATE] at 9:58 P.M., the Unit Managers, LPN #434, LPN #400, Registered Nurse (RN) #439, RN #402, and RN #423, completed physical assessments of all residents, including a respiratory assessment to identify any changes of condition and notification to physician of any noted changes of condition. · On [DATE] at 10:30 P.M., Corporate Nurse RN #437 provided in-service education to LPN #434, LPN #400, RN #439, RN #402, and RN #423, who then educated all unlicensed nursing staff on change in condition of a resident. · On [DATE], pursuant to the QAPI plan, the facility implemented a new procedure for the 24-Hour Report to be reviewed daily by the DON/Designee for any resident change of condition. The DON/Designee will complete a Health Document Assessment of three residents three times a week for four weeks, then two residents weekly for two weeks, then two residents a month for two months. The Regional Nurse will begin visiting the facility three to four days a week for oversight of the QAPI plan. · On [DATE], the medical records for three additional residents (#228, #229, and #230) were reviewed for death and changes in condition, with no concerns noted. · On [DATE], the medical records for two additional residents (#96 and #226) were reviewed for oxygen administration and monitoring, with no concerns noted. · On [DATE] at 8:30 A.M., interviews with Resident #96 and Resident #226, who were utilizing oxygen, revealed no concerns regarding the staff care and treatment pertaining to their oxygen and respiratory status. · Observations on [DATE] between 8:30 A.M. and 8:40 A.M. of Resident #96 and Resident #226, revealed no concerns related to oxygen use and respiratory status. · On [DATE] between 11:05 A.M. and 11:20 A.M., interviews with LPN #406, LPN #426, LPN #434, State tested Nurse Aide (STNA) #200, STNA #213, and STNA #241, stated they received education on notification of changes and re-assessing residents. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #319's medical record revealed an admission date of [DATE] at approximately 6:00 P.M. [DIAGNOSES REDACTED]. Review of the hospital history and physical, dated [DATE], completed by the internal medicine Physician Assistant-Certified (PA-C) revealed Resident #319 was alert and oriented to person, place, and time. The resident was answering questions appropriately. The resident had been using oxygen at two to three liters per minute (lpm) while at home. The resident's SpO2 was noted to be 96 percent. Review of the hospital pulmonology consult, dated [DATE], by the Certified Nurse Practitioner (CNP) revealed Resident #319 had a SpO2 of 92 percent. Review of the hospital cardiology progress note, dated [DATE], documented the resident had become severely hypoxemic with an oxygen saturation of 71 percent. With the use of a Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) the oxygenation levels had improved to 99 percent at the time of the cardiology evaluation. Review of the hospital discharge orders revealed Resident #319 was to receive oxygen at eight (8) lpm via nasal cannula and would require skilled nursing facility services for less than 30 days. Review of the transport company report, dated [DATE] at 5:34 P.M., revealed Resident #319 arrived at the facility from the hospital. The resident was on 8 liters of oxygen via high flow nasal cannula. The resident was alert and oriented with SpO2 levels during transport being 97 percent at 4:46 P.M. and 5:17 P.M. Review of the admission physician orders, dated [DATE], revealed Resident #319 was a Full Code resuscitation status. Oxygen at 8 lpm via nasal cannula every shift was ordered. The orders did not contain any specification to check the resident's SpO2 levels and no parameters were noted on when to notify the physician of any abnormal SpO2 levels. Review of Resident #319's nursing admission notes, dated [DATE] at 6:27 P.M., revealed the resident was alert with short and long term memory recall appearing intact after five minutes. The resident had shortness of breath when sitting at rest, when lying flat and with exertion. Oxygen was ordered at 8 lpm via nasal cannula. Review of nurse's progress notes and skilled unit assessment, dated [DATE] at 6:54 P.M., revealed LPN #438 documented Resident #319 was alert and oriented, comprehended verbal questions and commands and had accurate recall. The resident had a blood pressure of ,[DATE] millimeters of mercury (mmHg), pulse of 95 beats per minute (bpm), respirations of 20 bpm, and SpO2 of 80 percent. There was no indication of any physician notification or any interventions being attempted to elevate the SpO2 levels. Review of Resident #319's vital sign record, dated [DATE], revealed at 8:29 P.M. the resident had an SpO2 result of 80 percent, blood pressure of ,[DATE] mmHg, respirations were 20 bpm, and the resident's pulse was 115 bpm. There was no indication of any physician notification or any interventions being attempted. Review of the nurse's progress notes, dated [DATE], documented at 9:23 P.M. Resident #319 continued with a blood pressure of ,[DATE] mmHg and respirations of 20 bpm. The resident's pulse was noted to be 95 bpm and identified as irregular of new onset. The resident's SpO2 was 80 percent on 8 lpm of oxygen. Short and long term memory problems were apparent. The resident was slow to respond to questions and had slow comprehension. There was no indication of any physician notification or any interventions being attempted. Review of Resident #319's nurse's progress note, dated [DATE] at 12:04 A.M., revealed at 11:00 P.M. the resident was found by an STNA unresponsive in bed. Vital signs were absent, and CPR was initiated. EMS was called and CPR continued for 45 minutes until time of death was called by the EMS at 11:48 P.M. The son was notified of the resident's death. On [DATE] at 12:45 A.M., the coroner's office was notified and at 2:35 A.M. the coroner's office removed the resident's body. Review of Resident #319's Certificate of Death record dated [DATE] revealed the immediate cause of death to be complications of left [MEDICAL CONDITION]. Other significant conditions contributing to death included [MEDICAL CONDITION] and [MEDICAL CONDITION] fibrosis. Interview on [DATE] at 4:15 P.M. with Corporate Nurse RN #437 and LPN #434 revealed LPN #434 had been on call on [DATE] and received a telephone call from LPN #438 who stated Resident #319 had expired after resuscitation had been attempted. LPN #434 stated she had been informed the resident's SpO2 level was low on admission to the facility. LPN #434 stated she informed LPN #438 to call the coroner's office and complete all the necessary charting. RN #437 stated the resident's son had been at the facility earlier and possibly the whole time. Corporate Nurse RN #437 stated LPN #438 was no longer employed at the facility. Corporate Nurse RN #437 also stated she was unable to verify the physician was notified of the resident's condition. During a telephone interview on [DATE] at 9:20 A.M., Physician #102 of the coroner's office revealed due to Resident #319 expiring within 24 hours of admission, the coroner's office was contacted. Physician #102 stated the resident's cause of death was complications from [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION] fibrosis. During a telephone interview on [DATE] at 9:40 A.M. with Physician #101's on-call answering service revealed the only page they received for Physician #101 from the facility occurred on [DATE] at 12:12 A.M. Interview on [DATE] at 9:52 A.M., RT #500 stated she would not have been working when Resident #319 was admitted to the facility and had not been informed to set up the resident's oxygen needs. RT #500 stated if a resident had an SpO2 of 80 percent and had not improved, then they should have been sent back to the hospital and did not belong at the facility. A telephone interview on [DATE] at 10:35 A.M. with Physician #101, listed on Resident #319's chart as the attending physician, revealed he spoke with his office answering service regarding any in-coming calls he may have received on [DATE]. Physician #101 stated the only call he received from the facility was on [DATE] at 12:12 A.M. when he was notified the resident had expired. Physician #101 stated he would have expected the nursing staff to have notified him of a resident with an SpO2 level of 80 percent. During a telephone interview on [DATE] at 2:26 P.M. with the Medical Director (Physician #103), he stated he did not recall being contacted by the facility regarding Resident #319's low SpO2 level of 80 percent. Telephone interview on [DATE] at 4:25 P.M. with STNA #236 revealed he came on shift on [DATE] at 10:30 P.M. He found Resident #319 unresponsive around 10:45 P.M. and called LPN #438 for help. Interview on [DATE] at 8:50 A.M. with Admissions Coordinator #600 revealed Resident #319's admission to the facility was delayed at one point due to the resident going on and off the [MEDICAL CONDITION]. During a telephone interview on [DATE] at 11:25 A.M. with RN #413 revealed on [DATE] around 11:00 P.M. he had been called to Resident #319's room by STNA #236. The resident was unresponsive and LPN #422 assisted him with starting CPR while LPN #438 went to check on the resident's code status. Emergency services were contacted. The resident did not survive. Review of a written statement dated [DATE] from Physician #104 revealed Resident #319 had been hospitalized for [REDACTED]. The resident received oxygen. The statement documented Resident #319 had been stable at the time of the hospital discharge with [MEDICAL CONDITION] noted at admission to the facility with minor exertion and transfer to bed. Review of LPN #438's personnel record revealed a date of hire of [DATE] and a termination date of [DATE]. The file contained a discipline on [DATE] for not thoroughly documenting on new resident admissions and not removing dressings to assess wounds on admission. Review of the facility policy titled Change in a Resident's Condition, dated [DATE], revealed the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a change in resident condition. According to the United States National Library of Medicine, National Institute of Health website at www.ncbi.nlm.nih.gov/pub/med/ 240, titled Pulse Oximetry: What the Nurse Needs to Know, an SpO2 less than 94 percent is considered hypoxic. If the SpO2 is less than 90 percent it is considered a clinical emergency.