Every finding on record at Otterbein Cortland

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored appropriately and not left at the bed side. This affected two residents (Residents #8 and Resident #44) out of two residents reviewed for medication storage. The facility census was 39. Finding include:1.Review of Resident #8's medical record revealed an admission date of 11/22/24. Diagnosis include unspecified dementia, need for assistance with personal care, cerebral infarction, hypo-osmolality, hyponatremia and cognitive communication deficit.Review of Resident #8's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed at the time of the assessment the resident had intact cognition. They required assistance with Activities of Daily Living (ADLs) including dressing, bed mobility, and medication administration. Review of Resident #8's physician orders dated January 2026 revealed she was not ordered Tylenol Arthritis, or artificial tears. Further review of Resident #8's physician orders revealed she was ordered Tylenol 650 milligrams (mg) every six hours as needed for pain.Observation on 01/21/26 at 8:33 A.M. of Resident #8's over bed table revealed there was four Tylenol with Arthritis pills left in a medication cup and there were three bottles of artificial tears left on the night stand.Interview on 01/21/26 at 8:52 A.M. with Registered Nurse (RN) #410 confirmed the medications were left on the over bed table and on the nightstand, however RN #410 denied putting those medications on Resident #8's over bed table or on her night stand. RN #410 confirmed Resident #8 was not on Tylenol with Arthritis or artificial tears. RN #410 stated there were no residents in the facility who were responsible for giving their own medications. RN #410 stated all medications were administered by nursing staff.Interview on 01/21/26 at 11:46 A.M. with Resident #8 revealed she takes the Tylenol in her room when ever she wants to and does not inform the nurse, and she stated she will use the artificial tears when ever she wants to and does not notify the nurse.2. Review of Resident #44's medical record revealed an admission date of 01/16/26. Diagnosis include malignant neoplasm of rectum, muscle weakness, need for assistance with personal care, hyperlipidemia, hypertension, and benign prostatic hyperplasia without lower urinary tract symptoms.Review of Resident #44's physician orders dated January 2026 revealed there were no orders present allowing Resident #44 to leave medication at bedside.Review of Resident #44's progress notes dated 01/21/26 at 12:27 A.M. authored by RN #458 revealed resident was alert and oriented to person, place and time. He was able to make needs known, denied any pain or discomfort. Resident #44 his used wheeled walker with limited assist by one staff member. He required assistance with dressing, and activities of daily living.Observation on 01/20/26 at 12:17 P.M. revealed Resident #44 had two pills in a cup on bedside table. Resident #44 revealed they bring a medication for his bladder and a medication for cholesterol between 4:00 and 5:00 A.M. and that was too early. The nurses leave them in the cup on table, and when he feels more awake he will take them.Interview on 01/20/26 at 12:19 P.M. with RN #458 confirmed the medications were left at bed side and should not of been.Review of facility policy titled Medication Storage, last revised 09/14/25 revealed, the nursing home shall assure safe storage of medications. Staff shall ensure all prescription medications and drugs, except those that are authorized to be kept at the bedside for self-administration in accordance with Resident Rights, shall be kept in locked storage areas and separate from materials that may contaminate the medicines.

Based on observation, interview, and facility policy review, the facility failed to maintain proper infection control practices during medication administration. This affected one Resident (Resident #17) out of four residents observed for medication administration. The facility census was 39. Finding include: Review of Resident #17's medical record revealed an admission date of 12/02/25. Diagnosis included congestive heart failure, cystitis, anemia, anxiety disorder, unspecified pain, vitamin deficiency, and chronic respiratory issues. Review of Resident #17's admission Minimum Data Set (MDS) 3.0 dated 12/02/25 revealed he was cognitively intact, required assistance by at least one staff member for all Activities of Daily Living (ADLs) including bed mobility, medication administration, dressing, showering, toileting and ambulation. Observation made during medication administration on 01/21/26 at 8:53 A.M. while preparing medications for Resident #17, Registered Nurse (RN) #410 sanitized her hands with liquid hand sanitizer, she then proceeded to touch the keys to the medication cart, the medication cards, computer screen and the medication cup. RN #410 then while checking the medications to the orders she popped each the pills one by one directly into her bare hand without re-sanitizing them, she then proceeded to place all the medications in the a medication cup, then dumped the cup into a pouch in order to crush the medications and placed them into apple sauce and administered them to Resident #17. Interview on 01/21/26 at 9:00 A.M. with RN #410 confirmed she did not perform proper hand hygiene when administering medications to Resident #17. Review of facility policy titled Medication Administration General Guidelines, last revised January 2025 revealed proper hand hygiene is to be used including washing your hands with soap and water, or use hand sanitizer and allow for dry time as well as when handling all medications gloves are to be worn.

Based on medical record review, review of facility policy and interviews, the facility failed to ensure resident medical records were documented accurately. This affected one Resident (#39) out of two residents reviewed for closed record review. The facility census was 39.Findings include:Review of the closed medical record for Resident #39 revealed an admission date of 12/21/25. Admitting diagnosis included cardiomegaly, urinary tract infection, acute vaginitis, bradycardia, edema, hypokalemia, and chronic obstructive pulmonary disease (COPD).Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition.Review of the progress note dated 01/03/26 timed 2:15 P. M. by Registered Nurse (RN) #503 revealed Resident #39 was having weakness, lethargy, and confusion along with having a hard time holding object and staying awake. Resident #39's husband was at bedside and requested resident to be seen at emergency room. Nurse practitioner (NP) on call was contacted and provided authorization to send the resident to the emergency room for evaluation and treatment.Further review of the medical record revealed a discharge date of 01/03/26. There was no evidence Resident #39 had returned to the facility or was available for medication/treatment administration on 01/05/26.Review of the Medication Administration Record (MAR) for Resident #39 revealed on 01/05/26 medications were signed off as administered for Alvesco HFA Aerosol Inhaler 80 mcg/Actuation, Calcium with Vitamin D 600 mg-10 mcg tablet, Cholecalciferol 25 mcg capsule, Eliquis 5 mg tablet, Flecainide 100 mg tablet, Miconazorb AF 2% powder, multivitamin tablet, Prevacid 24hr 15 mg capsule and, saline mist aerosol spray 0.65% on day shift (7:00 A.M.-7:00 P.M,) by RN# 410.Review of the Treatment Administration Record (TAR) for Resident #39 revealed on 01/05/26 the following treatments were signed off as completed applied ted hose to bilateral lower leg (BLE) in A.M., bilateral assist bars available, pressure reduction cushion to wheelchair was in place, head of bed (HOB) elevated, obtained full set of vital signs, monitored for signs and symptoms of dehydration, change in electrolytes, acute kidney injury, monitored for signs and symptoms of bleeding related to anticoagulation therapy, completion of oral care, and ensured protective barrier after each incontinence episode on day shift (7:00 A.M.-7:00 P.M.) by RN #410.Interview with Interim Director of Nursing (DON) #494 on 01/22/26 at 11:05 A.M. confirmed Resident #39 was discharged on 01/03/25 without readmission to facility, DON #494 also confirmed RN #410 as the initials listed on MAR and TAR dated 01/05/26 as administering medications and treatments for Resident #39 listed above.Review of facility policy titled Electronic Clinical Documentation revised date 05/20/22 revealed when a medication was not administered to a resident, the administering individual would indicate not administered and document the reason the medication was not administered in MAR.Review of facility policy titled Medication Administration General Guidelines dated 2007 revealed the individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. The policy also revealed if a dose of regularly scheduled medication was withheld the nurse shall document in the electronic medication administration record that the dose was withheld and enter and explanatory note.Review of MAR and TAR information key revealed correct documentation for a missed medication and missed treatment administering individual's initials were to be in parentheses with explanation directly below each missed individual medication and treatment missed.

Based on interview, record review, and review of facility policies the facility failed to ensure appropriate and consistent communication regarding dialysis treatment provided and the resident's response, complications, reactions, or recommendations. This affected Resident #15 who was identified as the only resident receiving dialysis in the facility. The facility census was 39. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included end stage renal disease, acute and chronic respiratory failure with hypoxia, and congestive heart failure. Review of the physician's order dated 02/16/21 revealed Resident #15 was to receive dialysis every Monday, Wednesday, and Friday from 10:00 A.M. to 1:15 P.M. at an outside dialysis center. Review of the care plan dated 06/28/22 revealed Resident #15 had end stage renal disease and received dialysis every Monday, Wednesday, and Friday at an outside dialysis center. Interventions included to have no trauma to the access site, Resident #15 would maintain her dry weight, and the facility was to communicate with dialysis facility as needed regarding resident dialysis care issues. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition and required assistance with all activities of daily living. Review of the nursing progress note dated 08/28/24 at 2:30 P.M. revealed Resident #15's son called the facility to notify them that Resident #15 had issues at dialysis and was returning to the facility. He reported the dialysis center scheduled a treatment for the next day and the family would provide the transportation. The nurse notified the physician. Interview on 09/04/24 at 10:00 A.M. with the Director of Nursing (DON) revealed the facility communicated with the dialysis center on an as needed basis. They did not communicate with every treatment and maybe only monthly if a problem arose. The DON confirmed on 08/28/24 the family notified the facility of Resident #15's trouble at dialysis and the added treatment not the dialysis center. Review of the facility's policies and procedures related to dialysis revealed the policies did not address a communication process with the dialysis providers to include how the communication would occur, who was responsible for communication, and where the communication and responses would be documented in the medical record.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of facility policy, review of the Ohio Board of Nursing Registered Nurse scope of practice, and review of facility investigation the facility failed to ensure staff provided care and services according to professional standards of practice/within their scope of practice. This affected one (#146) of five residents (#8, #15, #46, #142, #145) reviewed for medication errors. The facility census was 39. Findings include: Review of the medical record for Resident #146 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #146 was receiving hospice services and expired in the facility. Diagnoses included chronic obstructive pulmonary disease, bipolar disorder, and dysphagia (difficulty swallowing). Resident #146 had no known allergies. Review of the care plan dated [DATE] revealed Resident #146 was at risk for cardiovascular complications related to her disease process. Interventions included to administer medications as ordered and to monitor vital signs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 had severe cognitive impairment and required extensive assistance with all activities of daily living. Review of nursing progress notes dated [DATE] timed at 4:56 A.M. authored by Registered Nurse (RN) #500 revealed the following. On [DATE] at 7:45 P.M. Resident #146 took pills with whole thin liquids. Resident #146 was conversant. On [DATE] at 8:45 P.M. the aide informed the nurse Resident #146 could not breathe, and her lips were blue. On [DATE] at 8:46 P.M. the aide obtain equipment to obtain vital signs and the nurse stayed with Resident #146. On [DATE] at 8:50 P.M. vital signs were Blood pressure ,d+[DATE], Oxygen level 92% on six liters of oxygen, respirations 33, pulse 112. RN #500 attempted to contact Resident #146's family because Resident #146 had an advance directive of Do Not Resuscitate Comfort Care (DNRCC). On [DATE] at 8:55 P.M., RN #500 called Resident #146's son with no answer. On [DATE] at 9:00 P.M., RN #500 called emergency services (911). Resident #146 was struggling more to breath and had hemoptysis (spitting up blood or blood stained mucous). RN #500 made a clinical decision to administer 1 milligram of Morphine. RN #146 obtained the Morphine that was prescribed for another resident, Resident #145. On [DATE] at 9:05 P.M., RN #500 called the daughter who asked RN #500 to hold off sending Resident #146 to the hospital until speaking with her brother the power of attorney (POA). The daughter successfully called her brother on three way conference call. The son was notified of Resident #146's condition and that Morphine was given because RN #500 had no other options to keep Resident #146 comfortable. The ambulance squad spoke to the son, and he decided Resident #146 should be sent to the hospital. Resident #146 was sent to the emergency room via squad and admitted to the hospital intensive care unit with a diagnosis of hypoxia related to pneumonia. Review of Self-Reported Incident (SRI) dated [DATE] revealed Resident #145's Morphine was administered to another resident (Resident #146). Review of the controlled medication flowsheet confirmed that on [DATE], one milligram of Morphine was taken from Resident #145 and administered to another resident. Review of the witness statement dated [DATE] timed 9:00 P.M. from RN #500 confirmed RN #500 gave Resident #146 Morphine that belonged to Resident #145 without checking Resident #146's orders or calling the physician. RN #146 indicated she was called to Resident #146's room and found Resident #146 with blue lips struggling to breath. RN #500 assessed Resident #146's vital signs and placed her on six liters of oxygen via nasal cannula. Resident #146's vital signs were stable, but she was struggling to breath. They assessed her code status and learned she was a DNRCC. RN #500 assumed this meant the resident was receiving hospice services so she was unsure if she should call the medics. RN #500 attempted to reach Resident #146's son with no answer. RN #500 then decided to call 911 and made the independent clinical decision to administer Morphine 1 mg by mouth to Resident #146 to help with her breathing because she was a DNRCC, and she assumed the resident had an order for medication. Resident #146 began coughing up blood, so she administered the dose sublingually. The family did reach back out at the time the emergency squad arrived, and RN #500 informed the family of the situation and that she administered Morphine without an order. The family decided to send Resident #146 to the hospital. Later, that evening she received a call from the hospital informing her Resident #146 was pleasantly confused and being admitted to the hospital for hypoxia. Review of the hospital discharge summary dated [DATE] revealed Resident #146 was discharged with a diagnosis of hypoxia related to pneumonia and an order for a palliative care consult was placed. Review of the nursing progress note dated [DATE] revealed Resident #146's family decided to place Resident #146 under hospice care and an order for Morphine was obtained at that time. Interview on [DATE] at 3:30 P.M. with the Director of Nursing (DON) confirmed Resident #146 was administered Morphine without a physician's order. The DON said the incident was investigated and reported to the State Agency and RN #500, who was an agency nurse, was reported the Board of Nursing and placed on the do not return list. All staff were educated regarding misappropriation, following physician orders and not administering medications without a physician order. In addition follow up auditing was completed to ensure no medication was administered without a valid physician order. Review of the employee file for RN #500 confirmed she was employed by a staffing agency contracted by the facility. RN #500 had a current nursing license at the time of the incident and background screening had been completed. Documentation validated RN #500 received training on abuse and neglect and medication administration. Review of the Ohio Department of Health Scopes of Practice: Registered Nurses (RN) and Licensed Practical Nurses (LPN) dated [DATE] revealed the following. Registered Nurses Section 4723.01(B), ORC, defines the scope of RN practice as: Providing to individuals and groups nursing care requiring specialized knowledge, judgment, and skill derived from the principles of biological, physical, behavioral, social, and nursing sciences. Such nursing care includes: (1) Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen; (2) Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions; (3) Assessing health status for the purpose of providing nursing care; (4) Providing health counseling and health teaching; (5) Administering medications, treatments, and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice; (6) Teaching, administering, supervising, delegating, and evaluating nursing practice. RNs have independent licensed authority to engage in all aspects of practice specified in Section 4723.01(B), ORC, except that, when providing nursing care pursuant to Section 4723.01(B)(5), ORC, the RN must have an order from an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice for administration of medication or treatments or for the regimen that is to be executed. Rule [DATE](D), OAC. Review of the facility's undated Safe Medication Administration Practices, Long-Term Care policy revealed you must check the resident's medical record to make sure that all required documents, medication information, sensitivities, history and physical examination findings, diagnoses, and laboratory results are present and current. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] all medication carts were audited for any missing narcotic medications. On [DATE] the DON reported the incident to the contracted staffing agency and RN #500 was placed on the do not return list. On [DATE] the DON reported RN #500 to the Ohio Board of Nursing. On [DATE] all staff were educated on the abuse and misappropriation policies and procedures. On [DATE] Resident #145's Morphine was replaced. On [DATE] and [DATE] all staff were educated on medication administration and that there was on call physician coverage 24-hours a day and they were not to administer medications without an order. Audits were completed twice weekly regarding change of condition and calling the physician as appropriate for direction/orders and to ensure there was no misappropriation of resident medication for the weeks of [DATE] and [DATE], then monthly for three months on [DATE], [DATE], and [DATE]. No additional concerns were noted. Review of the quality assurance and performance improvement (QAPI) during the annual survey revealed the committee was involved in the development of the corrective action plan and ongoing compliance.

Based on record review, interview, review of the facility self-reported incident (SRI), and facility policy and procedure review the facility failed to ensure Resident #22 was free from an incident of staff to resident verbal abuse. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 39. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included dementia, anxiety, and vitamin deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had moderately impaired cognition. She required extensive assistance from one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. She had no behaviors noted. Review of the facility SRI tracking number 230485 dated 12/26/22 and timed 1:52 P.M. revealed Resident #22 reported State tested Nurse's Aide (STNA) #204 told her to shut up. Review of the facility investigation completed on 12/27/23 revealed STNA #204 was suspended pending investigation. Staff working at the time of the incident were interviewed and confirmed hearing STNA #204 telling Resident #22 to shut up. STNA #20 was terminated from her employment. Interview on 05/02/23 at 12:21 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #205 confirmed the investigation led to finding of verbal abuse by STNA #204 and her subsequent termination. Review of the facility policy titled Abuse, Neglect, Misappropriation, and Crime Reporting, dated 01/18/21, revealed the facility would take measures to prevent abuse.

Based on record review and interview the facility failed to ensure the Ombudsman was notified of resident transfers and discharges to the hospital. This affected three (Residents #45, #46, and #10) of four residents reviewed for transfer and discharge to the hospital. The facility census was 54. Findings include: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45 was hospitalized from 03/13/22 through 03/22/22. Review of physicians orders dated April 2022 revealed orders for nursing staff to obtain a full set of vitals including pulse, respirations, blood pressure, temperature, and blood oxygen level twice a day and as needed, oxygen at three liters per min (LPM) via nasal cannula (NC) continuously, and the head of her bed was to be elevated to alleviate shortness of breath. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. Review of the care plan dated 03/23/22 revealed she was at cardiopulmonary risk related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff were to encourage the resident to cough and deep breath frequently, monitor respiratory rate, blood oxygen saturation, and lungs sounds every shift. The resident was to wear her oxygen at 3 LPM continuously. Review of nurses notes dated 03/13/22 at 8:59 P.M. revealed Resident #45 was in respiratory distress with a blood oxygen level of 79 percent (%) on 3 LPM, a non-rebreather oxygen mask was applied, and her oxygen was increased to 4 LPM, her blood oxygen level increased to 89%. Resident #45's daughter was at the bedside and kept informed of the resident's condition. Resident #45's physician was updated and gave an order to send the resident to the emergency room where she was admitted for [CONDITION(S)]. Review of nurses notes dated 03/14/22 revealed Social Worker (SW) #143 mailed out the resident's bed hold letter to the representative but did not notify or document notification to the Ombudsman. 2. Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE] revealed Resident #46 was cognitively intact and required extensive assist of one staff for bed mobility, transfers, toileting, and dressing. The MDS assessment dated [DATE] revealed Resident #46 was discharged , return not anticipated. Review of nurses notes revealed Resident #46 was sent to the hospital on 02/10/22 per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 was severely cognitively impaired and required extensive assist of one staff for bed mobility, transfers, toileting, and dressing. Review of nurses notes revealed Resident #10 was sent to the hospital on 03/04/22 per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses notes dated 03/07/22 revealed SW #143 mailed out the resident's bed hold letter to the representative but was absent documentation of any notification to the Ombudsman. Nurses notes dated 03/08/22 revealed Resident #10 returned to the facility. Interview on 05/04/22 at 2:00 P.M. with the Administrator confirmed the facility did not notify the Ombudsman of transfers or discharges of residents. The Administrator stated he was aware that the facility had to notify the Ombudsman of resident transfers/discharges to the hospital but could not say why it was not being done. He stated one years' worth of discharge notifications had been sent to the Ombudsman as of today 05/04/22. Interview on 05/04/22 at 2:01 P.M. with the Director of Nursing (DON) also confirmed they did not notify the Ombudsman of resident transfers or discharges. Interview on 05/05/22 at 9:43 A.M. with the Ombudsman confirmed the office had not received notifications of resident transfers or discharges from the facility. The Ombudsman confirmed she received emails last night (05/04/22) and this morning (05/05/22) of all the transfers and discharges for March, April and May 2022. Review of facility policy titled Discharge, Transfer of Resident dated 05/03 revealed the facility was to in situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility must send a notice of discharge to the resident and resident representative and must also send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice to the Office of the State Long Term Care (LTC) Ombudsman must occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the ombudsman only needed to occur as soon as practicable as described below. For any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative.

Based on interview, record review, and review of facility Self-Reported Incidents and facility policy the facility failed to ensure an allegation of misappropriation of resident medications was reported to the state agency. This effected three residents (Resident #42, Resident #44 and Resident #45) of three residents reviewed for reporting of misappropriation. The facility census was 40. Finding include: 1. Review of closed medical records [REDACTED]. On [DATE], Resident #42 died at the facility under hospice care. Review of the quarterly minimum data set (MDS) revealed Resident #42 had severe cognitive impairment. Review of prescriber orders for February 2020 revealed orders for consulting with hospice and MEDICATION ORDERS FOR [REDACTED]. Review of care plans dated [DATE] revealed Resident #42 had frequent complaints of pain related to [MEDICAL CONDITIONS] and weakness and the resident was able to voice complaints of pain and request interventions with interventions to include administer medications as ordered, monitor and record non-verbal signs of pain, and use non-pharmacological measures for relief of pain. 2. Review of closed medical records [REDACTED]. Review of the comprehensive MDS 3.0 dated [DATE] revealed Resident #44 had intact cognition. Review of prescriber orders for February 2020 revealed Resident #44 had orders for consult hospice and MEDICATION ORDERS FOR [REDACTED]. Review of care plans dated [DATE] revealed Resident #44 was enrolled in hospice care related to severe malnutrition and failure to thrive with interventions to include manage pain and other uncomfortable symptoms of aggression and agitation and coordinate plan of care with hospice. 3. Review of the closed medical records [REDACTED]. On [DATE], Resident #45 died at the facility under hospice care. Review of the quarterly MDS revealed Resident #45 had severe cognitive impairment. Review of prescriber orders for February 2020 revealed Resident #45 had orders for admit to hospice and MEDICATION ORDERS FOR [REDACTED]. Review of care plans dated [DATE] revealed Resident #45 was enrolled in hospice for end stage [MEDICAL CONDITION] with interventions to include manage pain and other uncomfortable symptoms of aggression and agitation and coordinate plan of care with hospice. No evidence was found in the medical records for Residents #42 , #44, or #45 of any concerns regarding inadequate pain management. Interview on [DATE] at 8:00 A.M. with the Director of Nursing (DON) verified, on [DATE] or anytime after, she did not file a Self-Reported Incident (SRI) with the State Agency (SA) concerning the allegations of suspect misappropriation of controlled substances prescribed for three residents of the facility. The DON confirmed, until now, she did not know, nor did she receive any direction to report suspected misappropriation of resident medications to the SA. The DON stated, on [DATE], she received a report of suspect diversion or tampering of [MEDICATION NAME] solution bottles prescribed for Resident #42, Resident #44 and Resident #45 allegedly by one of her nurses. The DON stated the nurse reported the colors of the three bottles of liquid [MEDICATION NAME] were light pink and not the usual bright pink that the [MEDICATION NAME] medication solution usually has by the manufacturer. The DON stated the change in colors was a possible indicator of someone replacing the medication with another substance. The DON stated, on [DATE], they initiated an investigation into the [MEDICATION NAME] discrepancies and reported their concerns to the local police department, the pharmacy board, the nursing board and the drug enforcement agency. The DON stated, on [DATE], they suspended Licensed Practical Nurse (LPN) #304, attempted an interview and sent LPN #304 for drug screening, but the nurse failed to report for drug screening. The DON stated, on [DATE], they terminated the LPN #304's employment for refusing drug screening and participating in the investigation. The DON stated the local police confiscated the bottles of narcotics involved and are actively investigating the allegations. The DON stated no quantitative testing was performed on the narcotics to determine if they were tampered with. The DON stated they substantiated the allegation of diversion when LPN #304 failed to participate in the investigation and requested drug screening. The DON stated there was no evidence the residents involved suffered any harm related to the narcotic issue. Review of the facility investigation dated [DATE], revealed, on [DATE] at 6:00 P.M. a nurse on duty reported three bottles of [MEDICATION NAME] sulfate solution appeared to have been tampered with. The DON was contacted and initiated an investigation. Review of the medication administration records (MARs) and controlled drug records revealed the amounts of medications of the [MEDICATION NAME] sulfate solution bottles were correct and accounted for. On [DATE] at 7:00 P.M., local police officers arrived and confiscated the [MEDICATION NAME] bottles as evidence. On [DATE], the employment of the LPN #304 was terminated when the nurse failed to report for requested drug screening. Interview on [DATE] at 9:19 A.M. with Police Detective (PD) #600 revealed they were actively investigating the suspected diversion of narcotics from the facility, but have not been able to locate LPN #304 to question him. PD #600 stated they have not performed any quantitative testing on the narcotics to determine if any of the narcotics were diverted. Review of Self-Reported Incident (SRI) Reports filed by the facility from [DATE] to [DATE] revealed no SRIs involving misappropriation of medications prescribed for residents of the facility. Review of the facility Abuse, Neglect, Misappropriation and Crime Reporting Policy revised [DATE] revealed directions for External reporting of alleged abuse involving residents occurring in the Health Center, no later than 24 hours of notification of the alleged incident, the Administrator, Director of Nursing or designee must log on to the Department of Health EIDC (Enhanced Information Dissemination Collection) reporting website.

Based on record review and interview, the facility failed to ensure Resident #51's fall care plan was updated to reflect the current fall prevention interventions. This finding affected one of three resident records reviewed for falls. Findings include: Review of the medical record for Resident #51 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #51's physician order [REDACTED]. Review of Resident #51's current care plan dated 02/06/19 revealed an intervention dated 02/06/19 for a geri chair for comfort and positioning and an intervention dated 11/02/19 for a dycem (an anti-slip device) to the resident's wheelchair seat. The care plan did not indicate when the resident was to use a regular wheelchair as opposed to the geri chair which had been ordered to be used for comfort and positioning. Review of Resident #51's fall investigation dated 11/02/19 confirmed the resident slid out of her wheelchair. The new intervention included a dycem to be placed in the resident's wheelchair seat. Interview on 11/20/19 at 3:21 P.M. with Registered Nurse (RN) #820 indicated the dycem was added to Resident #51's fall interventions and was to be used when the resident was in a regular wheelchair. RN #820 indicated the only time the resident was placed in a regular wheelchair was when she was getting her hair was done. RN #820 confirmed Resident #51's care plan was not updated to reflect the use of the dycem in the regular wheelchair and the care plan did not direct staff to provide the appropriate fall prevention interventions when she was getting her hair done. This is an incidental finding discovered during the course of the complaint investigation.

Based on observation, interview and record review the facility failed to ensure Resident #43 drank from a two handled cup with lid without a straw per physician order. This affected one resident (Resident #43) out of three residents reviewed for nutritional needs and use of assistive devices. The facility census was 45 residents. Finding include: Record review for Resident #43 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Review of Resident #43's Speech Therapy Discharge Summary dated 01/03/19 completed by Speech Therapist #600 revealed she had dysphagia with risk of aspiration on liquids. She recommended a spouted cup with no straw with encouragement of small sips. Review of Resident #43's annual Minimum Data Set (MDS) 3.0 assessment, dated 04/01/19, revealed she was cognitively impaired and required extensive assistance of one person with eating. Observation on 04/16/19 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #601 administered Resident #43's [MEDICATION NAME] (medication used to treat constipation) 17 grams mixed in approximately four ounces of water in a plastic disposable cup. LPN #601 held the plastic cup while Resident #43 drank the [MEDICATION NAME] from a straw. Interview on 04/16/19 at 9:13 A.M. with LPN #601 verified Resident #43 had a physician order [REDACTED]. She revealed she had always given Resident #43's [MEDICATION NAME] in water in a plastic disposable cup with a straw. Interview on 04/18/19 at 8:27 A.M. with Speech Therapist #600 revealed she had treated Resident #43 from 12/20/18 to 01/03/19 for dysphagia. She revealed a straw placed liquid farther back into the mouth and caused an increased risk of aspiration for Resident #43. She recommended a spouted sipper cup without a straw to decrease the risk of aspiration when drinking liquids.

Based on observation, record review and interview, the facility failed to appropriately complete dressing changes in a manner to promote wound healing. This affected one (Resident #58) of three residents reviewed for pressure ulcers. Findings include: Resident #58 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] indicated the resident had a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). The wound assessment dated [DATE] indicated the resident had a Stage III pressure ulcer to the coccyx measuring 3.5 centimeters (cm) x 0.2 cm x 0.1 cm. The resident had a physician's orders [REDACTED]. On 11/30/16 at 12:30 P.M. the dressing change to the coccyx wound for Resident #58 was observed with Licensed Practical Nurse (LPN) #10. Resident #58 was positioned on her left side in bed. LPN #10 washed her hands and applied gloves. She removed the dressing from the coccyx of Resident #58. LPN #10 changed her gloves and opened a plastic [MEDICATION NAME] of normal saline. She squirted the normal saline onto and around the wound. She washed her hands and applied new gloves. She patted the wound area with a dry gauze pad. She removed her gloves and washed her hands. LPN #10 applied new gloves and was preparing to apply a clean dressing to the coccyx wound. The surveyor observed some white matter at the edge of the wound and questioned LPN #10 about it. LPN #10 lifted the right buttock to observe the coccyx wound. She removed a piece of white matter from the coccyx wound. LPN #10 said it was the calcium alginate dressing. She said she did not see it when she cleansed the wound. LPN #10 said she would have to cleanse the wound with normal saline again. She obtained a new [MEDICATION NAME] of normal saline, squirted the saline into the wound bed and patted the wound dry with a gauze pad. She washed her hands and applied clean gloves. She cut a small piece of calcium alginate and placed it onto the wound bed. She applied an occlusive dressing to the wound.

Based on clinical record review and staff interviews, the facility failed to prevent three residents from inappropriate discharges from the facility. This affected three (Residents #19, #142, and #35) of 27 residents reviewed for admission, transfer, and discharge rights. Findings include: 1. Resident #19 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 discharge assessment, dated 08/18/16, indicated Resident #19 was discharged to another nursing home or swing bed. A Social Service Progress Note dated 07/25/16 revealed Resident #19's daughter asked Social Worker (SW) #11 about her mother staying long term at the facility. The note indicated that SW #11 explained there were no long term beds available. The Social Service Progress Note dated 07/28/16 revealed that Resident #19 was undecided about returning home versus long term care. The SW met with the family and encouraged them to tour alternate facilities, should the decision be for long term care. A Social Service Progress Note, dated 08/12/16, revealed that Resident #19 plateaued in skilled therapy and the plan was for her to be discharged on [DATE]. The note indicated the family was to determine whether or not they would take Resident #19 home or transfer her to another long term care facility, since the facility had no beds in long term care. The Social Service Progress note dated 08/15/16 revealed the SW contacted the resident's daughter to finalize discharge plans. The daughter indicated that Resident #19 should be discharged to another long term care facility, as she did not feel that she was capable of caring for her mother at home. A Nurses Progress Note dated 08/18/16 at 2:06 P.M. indicated the resident was discharged from the facility at that time to another long term care facility. 2. Resident #142 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS 3.0 discharge assessment dated [DATE] indicated Resident #142 was discharged from the facility to another nursing home or swing bed. The Social Service Progress Note dated 08/10/16 indicated Resident #142 was admitted to the facility under her skilled benefit to receive therapy. The Social Service Progress Note dated 08/12/16 revealed the resident used her 100 days of skilled therapy at another facility. The note revealed the resident was to be transferred to a facility that had long term care, since the facility had no long term beds available at that time. The note indicated a discharge date of [DATE] was proposed. The Social Service Progress Note dated 08/16/16 indicated the resident was accepted for admission by another facility. A Nurses Progress Note dated 08/16/16 at 6:30 P.M. indicated Resident #142 was discharged to another facility at that time. 3. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 discharge assessment dated [DATE] indicated Resident #142 was discharged from the facility to another nursing home or swing bed. The Social Service Progress Note dated 10/06/16 indicated that SW #11, discussed discharge plans with Resident #35. The note explained that Resident #35 had 18 days left under skilled services and she would be non-weight bearing for an additional six weeks. The SW indicated that she discussed options for both 24 hour care or long term care placement with the resident. Social Service Progress Note dated 10/07/16 provided information to the resident's son, about home care assistance for the resident, should she choose to return there. The Social Service Progress Note dated 10/17/16 indicated Resident #35's 100 days would expire on 10/24/16. The SW spoke with the resident who decided to be discharged to a long term care facility. The Social Service Progress Note dated 10/18/16 (documentation indicated the note had been edited), indicated that the resident signed a cut letter on 10/23/16 since she had exhausted her 100 day skilled benefit. The Social Service Progress Note dated 10/19/16 indicated the resident was to be transferred to another long term care facility on 10/24/16. The Nurses Progress Note dated 10/24/16 at 3:04 P.M., indicated Resident #35 was discharged to another Skilled Nursing Facility at that time. During an interview on 12/01/16 at 11:35 A.M., SW #11, acknowledged that Resident #35 was discharged to another long term care facility on 10/24/16 when she had exhausted her 100 days of skilled therapy. SW #11 explained she was discharged because she had resided on the skilled rehab unit, and the facility does not allow any long term residents in those (skilled rehab) beds. SW #11 revealed there were no beds available in long term care at that time. SW #11 indicated that Resident #19 was also a resident in the facility's short term rehab unit. She confirmed that there were no beds available in the facility's long term unit, so she was discharged to another long term care facility. SW #11 revealed that Resident #142 was admitted to the facility's short term rehab unit for skilled therapy. After admission, the facility discovered Resident #142's skilled rehab days had been exhausted while at another facility. SW #11 revealed that Resident #142 had been discharged from the facility because she had no skilled days remaining and there were no beds available on the facility's long term care unit. SW #11 acknowledged the facility was dually certified, however, she explained that the facility's short term rehab unit was specialized and all of the residents on the short term rehab unit have a discharge plan of going home after rehab. During an interview on 12/01/16 at 1:15 P.M., the administrator acknowledged that all 57 facility beds were dually certified. However, he revealed, that per corporate policy, beds must be available for the Independent Living Residents in case they would need one of the rehab beds. He indicated that they pay $150,000.00 per year to live in the independent living section. He explained that the independent living residents are guaranteed that they will have a bed in the nursing facility, should they be hospitalized and need skilled care post hospital-stay. He explained that the goal upon admission for outside residents (who are admitted to the short-term rehab beds) is for them to go home from rehab, not to stay in the facility long term. This deficiency substantiates Complaint Number OH 610.

Based on observation, record review and interview the facility failed to monitor the fluid restriction as ordered for Resident #208 and failed to demonstrate evidence of coordination of care between the facility and Hospice services for Resident #62 . This affected one resident (Resident #208) of one resident reviewed for [MEDICAL TREATMENT] and one resident (Resident #62) of one resident reviewed for Hospice services. Findings include: 1. Record review revealed Resident #208 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. The resident had physician's orders [REDACTED]. There was a physician's orders [REDACTED]. The initial care plan dated 09/04/15 indicated the resident was at risk for fluid imbalance related to conditions and diagnoses, which included [MEDICAL CONDITION], history of [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Interventions included to monitor dietary intake and weights. There was no indication that the resident was on a fluid restriction in the care plan. The care plan dated 09/04/15 for [MEDICAL CONDITION] and [MEDICAL TREATMENT] had interventions including to adhere to ordered fluid restriction, if applicable. Review of the medical record revealed there was no information that designated how much fluid was allotted each shift for nursing or any evidence that the resident's actual fluid intake was monitored to ensure compliance with the physician's orders [REDACTED]. On 09/09/15 at 2:59 P.M. Resident #208 was observed in her room sitting on the edge of her bed. Interview with the resident revealed she went to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. She said the facility sent a half of a sandwich, some animal crackers and a bottle of water with her. She was aware that she was on a fluid restriction, but she said the staff did not ask her what she drank. She said she got a small can of diet gingerale with meals and had a pitcher of ice in her room. There was a partial bottle of water observed on her bedside table and a water pitcher on her over the bed table On 09/09/15 at 3:55 P.M. interview with licensed practical nurse (LPN) #13 verified Resident #208 was on a fluid restriction of 1500 milliliters per day with 1000 ml designated for dietary and 500 ml designated for nursing. He verified there was no information in the medical record to designate how much fluid was allotted each shift for nursing or any evidence that the resident's actual fluid intake was monitored by the nurses to ensure compliance with the physician's orders [REDACTED]. On 09/09/15 at 4:10 P.M. interview with State tested nurse aide (STNA) #10 revealed she only gave ice chips to Resident #208. She said the point of care system (computerized charting system for use by the STNAs) identified Resident #208 was on a fluid restriction and the nurses and dietary gave her the allotted amount of fluids. STNA #10 said the amount of fluid Resident #208 consumed during her meals was not documented. On 09/10/15 at 11:00 A.M. interview with assistant culinary director #11 revealed Resident #208 was permitted 1000 ml of fluid per dietary per day. She said Resident #208 ordered her menu items for the week and she reviewed them. If the fluids chosen by the resident exceed the fluid restriction limit, then one of the items was removed from the menu for that day. On 09/10/15 at 11:25 A.M. interview with STNA #12 revealed the staff document the meal intakes and fluids in the point of care system each shift under the vital sign tab. The fluid intake record in the point of care system for was reviewed for Resident #208 since admission on 09/04/15. The information revealed Resident #208 consumed 250 ml of fluid for dinner on 09/08/15 and 250 ml of fluid for dinner on 09/09/15. There was no other documentation of fluid consumption for any other day or meal. There was no evidence of consistent on-going monitoring of daily fluid intakes at meals for Resident #208. 2. Record review revealed Resident #62 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately independent in decision making, required extensive assistance to meet her daily needs and received Hospice services. Record review of the September, 2015 monthly physician's orders [REDACTED]. Review of the facility Hospice care plan updated on 08/21/15 revealed Resident #62 was admitted to Hospice on 02/17/14 with a [DIAGNOSES REDACTED]. Record review of the Hospice Interdisciplinary Group (IDG) Comprehensive assessment dated [DATE] revealed a current problem list that included the need for facility staff care coordination. An interview on 09/09/15 at 2:11 P.M. with the licensed practical nurse (LPN) #21 revealed she was aware Resident #62 received Hospice services. LPN #21 stated the hospice assessments were located in the computer system and she was not aware of the hospice nurse schedule. An interview with registered nurse (RN) #22 on 09/09/15 at 3:48 P.M. verified Hospice visits and records were not in the computer. She also stated she thought the Hospice records were kept on the unit. An interview with LPN #24 on 09/09/15 at 4:07 P.M. verified Hospice visit records were not on the unit. She also stated she is not aware of where they are kept. An interview with LPN #23 on 09/0915 at 4:24 P.M. resulted in her stating that Hospice visit records and information were kept in a binder at the nursing station. However, upon request LPN #23 was not able to produce the Hospice visit records. LPN #23 verified she had not actually seen a Hospice binder in the nursing station. LPN #23 also stated she did not know where Resident #62's Hospice plan of care was located or when the Hospice nurse visited the resident. An interview with licensed social worker (LSW) #25 on 09/10/15 at 10:35 A.M. verified there was no documentation from Hospice supporting coordination of Resident #62's care. An interview with the medical record clerk (MR) #26 verified the facility had not received documentation of Hospice visits for Resident #62 since the Hospice had computerized their charting. The MR was not sure how long ago the hospice had started using computerized charting. On 09/10/15 at 1:11 P.M. an interview with the Director of Nursing (DON) verified there was no documentation of communication between the hospice staff and the facility staff.

Based on observation and interview the facility failed to ensure the lunch meal on 06/09/14 in the east rehabilitation dining room was served in a sanitary manner. This had the potential to affect the 39 residents who receive their meals from the east rehabilitation kitchen. Findings include: Meal observations were made on the East rehabilitation dining room on 06/09/14 from 11:23 A.M. to 12:05 P.M. The meal was served out of a satellite kitchen from a steam table. The residents were seated at tables in the dining room. Staff were wearing gloves and served the cold side dishes and drinks first. The hot food meal service started at 11:30 A.M. Dietary Cook (DC) # 1 was observed standing in front of the steam table wearing latex gloves preparing to serve the meals. DC #1 was holding the residents' individual menus that had been filled out previously by each resident. DC # 1 went through each menu with her gloved hands as the meal was served. DC # 1 read the menus, then filled the orders according to the resident's stated preference wearing the latex gloves. DC # 1 was sweating and wiped her forehead with her gloved hand, and reached into a bag of rolls and put the roll on a resident plate. DC #1 then touched her face again and reached into the steam table with her contaminated gloved hand and put a grilled cheese sandwich on a plate. DC # 1 verified the above observation at the time of discovery.

Based on observation, interview and record review, the facility failed to ensure confidential medical information was secured. This affected ten residents; Residents #16, #37, #47, #63, #77, #78, #138, #187, #190 and #193. The facility census was 56. 1. An entrance tour was completed on 06/09/14 at 9:50 A.M. Observation of the South Unit common lounge area revealed lounge chairs and two tables for seating of four people, furnished the lounge. The same lounge served as a common hallway to the dining room, main entry/exit and two additional units. Staff, residents and visitors were observed passing through the area. On one of the two tables, a chart was observed. The front of the chart said "Resident Record". Review of the content revealed a Restorative Referral form for Resident #37. The form identified the resident's mobility and plan of care needs. The record also contained a list of residents on modified liquid and food textures and a resident who was not allowed oral foods or fluids. The residents identified were Residents #16, #47, #63, #77, #78, #138, #187, #190 and #193. A form labeled 'Inventory of Personal Effects' contained the name of Resident #193 and a list of personal items belonging to the resident. The observation was verified by Registered Nurse (RN) #22 and Licensed Practical Nurse (LPN) #23, at the time it occurred. LPN #23 said the chart belonged in the nurses station. Review of the facility undated Commitment To HIPAA (Health Insurance Portability and Accountability Act) revealed health care information must be secured to protect the integrity, availability and confidentiality of information. 2. A meal observation was completed in the East Rehabilitation dining room on 06/09/14 from 11:23 A.M. to 12:05 P.M. Numerous residents were seated at tables throughout the dining room. The meals were served from a pass-through kitchen window which opened to the dining room. There was a sign posted on the wall next to the pass through window. The sign listed residents, by name, who received thickened liquids, pureed diets and/or no oral nutrition. The residents listed were Residents #16, #47, #63, #77, #78, #138, #187, #190 and #193. The observation was verified by Licensed Practical Nurse (LPN) #10 at 11:41 A.M. This deficiency substantiates complaint OH 856

Based on observation and interview, the facility failed to ensure medications were secured in the medication carts, failed to discard an expired medication and failed to date a vial of insulin when opened for Resident #98. Findings include: The medication rooms and carts were observed with Licensed Practical Nurse (LPN) # 23 on [DATE] from 1:30 P.M. to 2:30 P.M. The long term care medication cart was observed to have five loose unidentified pills on the bottom of the drawers. The rehabilitation medication cart was observed to have 17 loose unidentified pills at the bottom of the medication cart drawers. The same cart had one bottle of stool softener that expired ,[DATE] and one vial of insulin for Resident # 98 that was opened and not dated. The above findings were verified at the time of discovery by LPN #23. )

Based on interview and record review, the facility failed to ensure Resident #104 and Resident #187 were notified of a room change. This affected two of two residents reviewed for room changes of twenty two residents interviewed. Findings include: 1. An interview was completed with Resident #104 on 06/10/14 at 9:09 A.M. Resident #104 said he was moved to his current room "about a month ago". Resident #104 revealed he did not know why he was moved and was not notified he was being moved. An interview was completed with Licensed Social Worker (LSW) #24 on 06/11/14 at 9:27 A.M. The LSW said any room change is discussed with the resident and family member to obtain permission, prior to the move. If they refuse, the facility would not move them out of their room. The LSW said she documents the move in the resident's progress note. LSW #24 verified Resident #104 was moved from the South Unit to the East Unit on 05/24/14. LSW #24 verified the Resident's record revealed no evidence Resident #104 was notified he was being moved to a new room. 2. An interview was completed with Resident #187 on 06/09/14 at 3:09 P.M. Resident #187 said she had been in a different room prior to the current room. Resident #187 said she was not notified she would be moved to a new room. She said, "There was a man in this room. They moved him out of this room and put me and my roommate here. They did not let me know until it happened". An interview was completed with LSW #30 on 06/11/14 at 10:30 A.M. LSW #30 verified Resident #187 was admitted [DATE] to a different room and on 05/24/14 Resident #187 was moved to the current room. LSW #30 verified the resident's record revealed no evidence Resident #187 was notified she was being moved to a new room. Review of the facility policy revised 05/09/13, revealed "Once a decision to change your room has been made, we will promptly notify you, and if known, your Representative or interested family member of the room changes. Reasonable notice of the room or roommate change, including an oral or written explanation of the reason for the change, will be given to you prior to the room or roommate change".

Based on record review, observation and interview the facility failed to ensure interventions were in place to prevent a fall for one resident (Resident #175). This affected one of three residents reviewed for accidents. Findings include: Review of Resident #175's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #175's fall risk assessment dated [DATE] revealed Resident #175 was at high risk for falls. Review of the nurses note dated 04/19/14 timed 10:10 P.M. revealed the nurse was notified by the state tested nurse aide (STNA) that Resident #175 was on floor in her room. The nurse observed Resident #175 face down on floor in her room. At that time Resident #175 denied pain. Upon assessment there was a small raised circular bump on the right side of Resident #175's forehead measuring one centimeter by one centimeter with no bruising noted. Resident #175 was transferred from the floor to the wheelchair by the nurse and the STNA. New nursing interventions implemented were 15 minute checks for three days. Review of the fall investigation dated 04/25/14 revealed Resident #175 experienced a fall from the wheelchair. The intervention after this fall revealed to institute a pin alarm to the wheelchair. Review of the plan of care dated 04/25/14 revealed Resident #175 was at risk for falls with an intervention to monitor and maintain alarms as ordered. Review of the current physician orders [REDACTED].#175 was in the wheelchair to help prevent against falls. Observation on 6/11/14 at 9:50 A.M. revealed Resident #175 in a geri-chair (a specialized wheelchair that cannot be self propelled) with her feet on the floor. A pin alarm was not observed to be in place on Resident #175. Resident #175 was positioned facing a night stand. On top of the night stand was a white box resembling a piece of the pin alarm system. Resident #175 was alone in her room at the time of the observation. Observation of Resident #175 on 06/11/14 at 2:31 P.M. revealed Resident #175 in her chair in the lounge area on the 200 hall. Resident #175 was seated in her geri-chair. Resident #175 was positioned at a large table with pictures in front of her. Resident #175 did not have a pin alarm placed on her person during this observation. There were no staff present in the area at the time of the observation. Interview on 06/11/14 at 2:51 P.M. with Licensed Practical Nurse (LPN) #11 confirmed Resident #175's pin alarm was not on her person. LPN #11 indicated that Resident #175 was to have the pin alarm on when in the chair.

Based on interview and record review the facility failed to assessments were routinely completed for one resident (Resident #122) following [MEDICAL TREATMENT] treatments. The facility failed to consistently assess bruising for one resident (Resident # 98). This affected one of one residents reviewed for [MEDICAL TREATMENT] of two [MEDICAL TREATMENT] residents identified by the facility and one of three residents reviewed for skin conditions. Findings include 1. Resident #122 was initially admitted [DATE] and readmitted after a hospital stay 05/22/14 with [DIAGNOSES REDACTED]. Resident #122's [MEDICAL TREATMENT] care plan initiated 05/07/14 indicated the resident had end stage [MEDICAL CONDITION] and received [MEDICAL TREATMENT]. The resident had a Tessio catheter (a catheter used for the blood exchange in [MEDICAL TREATMENT]) for [MEDICAL TREATMENT] in her right chest. The interventions included to monitor skin around vascular access; note redness, [MEDICAL CONDITION], local warmth, exudate, tenderness. Resident #122 received [MEDICAL TREATMENT] three times per week on Monday, Wednesday and Friday. Review of the medical record revealed no evidence assessments were completed when Resident #122 returned from [MEDICAL TREATMENT]. Interview with the director of nursing (DON) on 06/12/2014 at 11:05 A.M. verified there was no ongoing post [MEDICAL TREATMENT] assessment consistently completed when Resident #122 returned from [MEDICAL TREATMENT]. 2. Resident # 98 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident # 98 had a [MEDICAL TREATMENT] fistula in the left arm. Resident # 98 had a care plan initiated 06/03/14 for at risk for skin breakdown due to the effects of diabetes and [MEDICAL CONDITION] with [MEDICAL TREATMENT]. The interventions included skin inspection every week. Review of the weekly skin assessment dated [DATE] indicated Resident # 98's right upper extremity was ecchymotic from the upper arm to the hand and the right hand had a two centimeter (cm) x two cm scabbed area. The assessment also indicated Resident # 98's left upper extremity was ecchymotic with no other assessment of the area. Review of the weekly skin assessments dated 06/04/14 and 06/11/14 revealed no information concerning the resident's bruises/ecchymotic areas. Resident #98 was observed seated on the edge of the bed reading a magazine on 06/10/2014 at 6:16 P.M. Resident # 98 had extensive bruising over both arms. Resident # 98 stated [MEDICAL TREATMENT] started at approximately 9:30 A.M. and if her arm did not bleed she would be home around 4:30 P.M. Resident # 98 stated at times it takes the [MEDICAL TREATMENT] staff a while to stop the bleeding in her arm. Resident # 98 stated that was the reason for the bruises. The DON was interviewed on 06/12/14 at 8:43 A.M. The DON verified there was no ongoing tracking of Resident # 98's bruises after the initial assessment in the record on 05/28/14.

Based on record review, observation and interview the facility failed to ensure a medication error rate of less than 5%. There were two medication errors of 25 opportunities resulting in a medication error rate of 8%. This affected affected one (Resident #193) of five residents reviewed during medication pass. Findings include: Observation of medication administration on 06/11/14 from 8:29 A.M. to 8:52 A.M. revealed Licensed Practical Nurse (LPN)#10 prepare and administer Resident #193's medications via percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into a residents stomach used for feedings and/or medications when resident is unable to take in by mouth). LPN #10 prepared [MEDICATION NAME] 25 mg, [MEDICATION NAME] 50 mg, Vitamin D3 5000, Vitamin B12 1000 micrograms (mcg), [MEDICATION NAME] 15 milliliters(ml), Ferosul 325 mg/7.4 ml, potassium chloride 10 milequivalent (meq)/7.5 ml and Magnesium Oxide 400 mg (a supplement). LPN #10 administered the medications after flushing the PEG tube with water. Each of the crushed medications was diluted with water and given separately with water given in between the medications. During the medication administration there was medication noted left over in two of the medication cups. After completing the medication administration LPN #10 looked in the cups one by one and verified there was still medication in two of the cups. LPN #10 indicated the medications that were still in the cups were Vitamin B12 and Magnesium Oxide. LPN #10 verified the resident did not receive the entire dose of the two medications.