Every finding on record at Pataskala Oaks Care Center

Based on observation, interview, and record review, the facility failed to maintain the kitchen environment and store food in a sanitary manner. This deficient practice has the potential to affect all residents who receive meals prepared in the facility kitchen. The facility identified four residents (#32, #73, #81, and #90) who received nothing by mouth. The census was 58.Findings include:1. Observation of the facility kitchen occurred between 10:29 A.M. and 11:58 A.M. on 06/23/26. The facility had both a walk-in freezer and walk-in refrigerator in the kitchen. A number of food items were observed in these areas opened and undated.Observation of the walk-in freezer found a bag of sausage links, bag of meat patties, Ziploc bag of waffles, bag of chicken wings, and a plastic tray of cupcakes all opened and undated. During an interview at 11:16 A.M. on 06/23/26, Dietary Aide (DA) #34 confirmed that the items listed in the walk-in freezer were opened and undated.Observation of the walk-in refrigerator found a bag of lettuce, bag of parmesan cheese, and crates of pasteurized eggs that were opened and undated.During an interview at 11:19 A.M. on 06/23/26, DA #33 confirmed that the items listed in the walk-in refrigerator were opened and undated.Review of the facility's Sanitation Inspection policy (reviewed 08/25) indicated the facility will conduct inspections to ensure food service areas are clean, sanitary, and compliant with regulations. The policy directs staff to inspect refrigerators and coolers daily.2. Observation of the facility kitchen occurred between 10:29 A.M. and 11:58 A.M. on 06/23/26. The facility had a dishwasher in the kitchen that was observed during this time. The dishwasher was a low temperature dishwasher (American Dish Service model AFC-3D-S.) The dishwasher had requirements for sanitary function printed on the dishwasher. Those requirements stated a wash water temperature minimum of 120 degrees Fahrenheit (F), a rinse water temperature minimum of 120 degrees F, and a minimum 50 parts per million (ppm) chlorine sanitizer rinse,A wash cycle observed from 10:57 A.M. to 11:00 A.M. on 06/23/26 showed wash water at 128 degrees F and rinse water at 136 degrees F. Activities Manager (AM) #24 performed a chlorine test at 11:00 A.M. using a Hydrion test strip, which should turn purple if chlorine is above 50 ppm. The strip did not change color.During an in interview at 11:00 A.M. on 06/23/26, AM #24 confirmed the test strip did not change color. AM #24 confirmed that the test strip should have changed color to indicate adequate chlorine content, but it did not.Review of the Sanitation Inspection policy (reviewed 08/25) further stated that the dietary manager will conduct weekly inspections to ensure food service areas meet sanitation regulations.3. A second observation was conducted of the facility kitchen between 2:52 P.M. and 2:54 P.M. on 06/23/26. The top of the Baker's Pride oven had a noticeable layer of dust that adhered to the finger when touched. A stainless steel shelf above the stove burners was coated with grease, appeared yellowish, and felt sticky.During an interview between 2:52 P.M. and 2:54 P.M. on 06/23/26, after observing and touching the top of the oven and shelf above the stove, DA #48 confirmed the presence of dust on the oven and grease on the shelf.Review of the Food Preparation and Sanitation Audit dated 04/29/26, completed by Dietitian #95, documented that the tops of the oven and range required cleaning.Review of the facility's Sanitation Inspection policy (reviewed 08/25) reiterated the requirement for weekly inspections to ensure food service areas remain clean and compliant with sanitation and food service regulations.This deficiency represents non-compliance investigated under Complaint Number 3036428.

Based on record review, interview, review of self reported incident, and facility policy review, the facility failed to ensure a complete and timely abuse investigation was conducted for one resident, Resident #4, of two residents reviewed for abuse. The facility census was 58.Findings include:Review of Self-Reported Incident (SRI) #272660, submitted on 03/29/26, revealed Resident #2 reported to a nurse that CNA #283 pinched Resident #2's right arm during a transfer from bed to wheelchair. The SRI documented Resident #2 also alleged CNA #283 slapped Resident #2 and called Resident #2 an inappropriate name. The SRI documented Resident #2 had a small faint bruise on the right outer forearm, complained of discomfort to the arm, and reported pain at a level two on a pain scale of zero to 10. The SRI documented Resident #2 stated she felt safe at the facility and appeared to be at baseline.Review of SRI #272660 revealed CNA #283 and CNA #486 were interviewed separately. CNA #283 and CNA #486 both stated Resident #2 slapped CNA #283 and called staff an inappropriate name during the transfer. The SRI documented that, upon notification of the allegation to the Administrator on 03/29/26, the Administrator obtained a statement from CNA #283 and suspended CNA #283 pending the investigation. The Administrator interviewed Resident #2, CNA #486, and two nurses. The Administrator notified the Medical Director, Director of Nursing, and Resident #2's responsible party.Review of the facility-provided assignment information revealed CNA #283 provided care to Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. Of those 11 residents, Resident #2 and Resident #4 had BIMS scores below 8. The facility interviewed the other residents assigned to CNA #283; however, documentation provided did not show a skin assessment, injury assessment, or other assessment was completed for Resident #4 when the abuse allegation involving CNA #283 was brought to the facility's attention on 03/29/26.Review of Resident #2 medical record reveaeld the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, schizoaffective disorder, unspecified dementia, and major depressive disorder. Review of Resident #2's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of seven, indicating cognitive impairment. The resident had no hallucinations, delusions, or behaviors during the look back period. Resident #2 was coded to use antipsychotic, antianxiety and antidepressant meication in their care. The resident had limited mobility, required the use of a wheelchair, and was dependent on staff for toilet hygiene and showers. Review of Resident #4's Diagnosis Report, dated 05/13/26, revealed Resident #4 was admitted to the facility on [DATE], with a re-entry/admission date of 12/26/25. Diagnoses included Alzheimer's disease, post-traumatic stress disorder, unspecified dementia with behavioral disturbance, anxiety disorder, dysphagia, apraxia, peripheral vascular disease, severe protein-calorie malnutrition, and sleep apnea.Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment, dated 04/14/26, revealed Resident #4 was rarely or never understood. The MDS documented the BIMS was not completed because Resident #4 was rarely or never understood. The MDS documented Resident #4's decision-making for daily tasks was severely impaired.Review of Resident #4's Brief Interview of Mental Status (BIMS) Evaluation, effective 04/13/26 at 10:46 A.M., revealed the BIMS should not be conducted because Resident #4 was rarely or never understood. The staff assessment documented Resident #4's decision-making regarding tasks of daily life was severely impaired.Review of Resident #4's care plan revealed the resident had focus areas related to cognitive impairment, communication, psychosocial/behavioral needs, activities of daily living, skin risk, and safety needs. The care plan included interventions for staff to anticipate and meet Resident #4's needs, assist with communication, use simple and direct communication approaches, monitor for changes in behavior or condition, monitor skin condition, and report abnormalities.Review of Resident #4's Skin Check, effective 03/24/26 at 5:06 A.M., revealed Resident #4's skin was warm and dry, skin color was within normal limits, and skin turgor was normal. The assessment documented no external device was present. The foot evaluation was completed, and no new skin issues were found.Review of Resident #4's skin check log revealed skin assessments were completed on 03/13/26, 03/24/26, 03/31/26, 04/17/26, 04/30/26, 05/14/26, 05/18/26, 05/20/26, and 05/27/26. The skin check log did not include a skin assessment dated [DATE], the date Resident #2 reported the abuse allegation involving CNA #283.Review of Resident #4's Skin Check, effective 03/31/26 at 2:49 A.M., revealed Resident #4's skin was warm and dry, skin color was within normal limits, and skin turgor was normal. The assessment documented no external device was present. The foot evaluation was completed, and no new skin issues were found. This was the next documented skin check for Resident #4 after the abuse allegation was reported on 03/29/26.Interview on 05/13/26 at 2:34 P.M. with the Administrator confirmed SRI #272660 was filed on 03/29/26 after Resident #2 reported an allegation of abuse involving CNA #283. The Administrator confirmed Resident #4 was unable to communicate. The Administrator stated the facility did not complete a skin assessment for Resident #4 when the allegation was brought to the facility's attention. The Administrator stated the facility did not complete the skin assessment sooner because staff felt there was nothing to the allegation due to Resident #2's history and statements toward others. The Administrator confirmed the facility did not complete a timely skin assessment for Resident #4 as part of the abuse investigation, despite Resident #4 being unable to communicate.Review of the facility policy titled Abuse, Neglect, Misappropriation, and Exploitation, effective 06/2016 and updated on 11/29/16 and 08/12/25, revealed the facility was required to protect residents from abuse, neglect, and mistreatment. The policy documented allegations of abuse were to be reported, investigated, and addressed to ensure resident safety. The policy documented the facility was responsible for completing a thorough investigation when an allegation of abuse was reported. The policy included investigation steps such as identifying involved residents and staff, assessing residents for injury or change in condition, obtaining statements/interviews as appropriate, reviewing relevant documentation, notifying appropriate parties, and taking action to protect residents from further potential abuse or harm.

Based on interviews and record reviews, the facility failed to obtain an assessment and physician order for a wander guard for one resident (#5) out of one resident reviewed for restraints. In addition, based on observation, interview, record review and policy review, the facility failed to timely change PICC (peripherally inserted central catheter) line access dressings as ordered for three residents (#2, #21 and #33) of three residents reviewed. The facility census was 50.Findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including nontraumatic chronic subdural hemorrhage, cerebral infarction, hypertension, diabetes mellitus, major depressive disorder (MDD), anxiety disorder, post-traumatic stress disorder (PTSD), hemiplegia and hemiparesis, and congestive heart failure. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #5's Brief Interview for Mental Status (BIMS) score was 09 out of 15, which indicated moderately impaired cognition. Review of a nursing progress note, dated 08/12/25 at 3:49 P.M., revealed Resident #5 was outside this afternoon per his usual routine sitting on the patio and chose to go off of the patio and wheeled down the sidewalk. His wheelchair went off the path causing him to slide out of his wheelchair. The unit manager was first outside and contacted emergency medical services (EMS) after the fall. Emergency medical technicians assessed the resident, took vital signs, and transferred him to the stretcher. Resident was alert and oriented and able to answer questions with noted abrasions to left arm and head. Resident transported to emergency room (ER). Nurse practitioner (NP) and family notified.Review of the Care Plan, dated 08/13/25, revealed Resident #5 was an elopement risk due to personal choice and cognitive deficits with interventions including to apply a wander guard (security device that alerts staff when a resident has wandered from a protected zone) to wheelchair, to check wander guard bracelet at bedtime for proper function and placement, and to observe for and document any exit seeking behaviors. Interview with Resident #5 on 08/19/25 at 8:38 A.M. revealed he wants to be able to go outside whenever he chooses to do so. The resident stated that he had fallen out of his wheelchair last week and is no longer allowed to go outside unaccompanied. Review of nursing progress note, dated 08/19/25 at 5:43 P.M., revealed the interdepartmental team (IDT) met to discuss the placement of wander guard to wheelchair. The resident's behavior has improved with no delusions or hallucinations since his visit with the psychiatric certified nurse practitioner (CNP) with medication changes. IDT removed wander guard from wheelchair.Interview 08/21/2025 at 10:18 A.M. with Licensed Practical Nurse (LPN)/MDS #62 confirmed there was not a physician order for Resident #5's wander guard. LPN #62 stated nursing put the wander guard on the resident to keep an eye on him after his fall, but removed it from his wheelchair earlier this morning. Interview on 08/21/25 at 12:11 P.M. with Unit Manager/Registered Nurse (RN) #38 confirmed there was not a physician order for Resident #5's wander guard which was applied to his wheelchair.2. Review of the medical record for Resident #2, revealed an admission date of 12/30/24. Diagnoses included but were not limited to dependence on respirator, pressure ulcer of the sacral region, methicillin resistant staphylococcus aureus infection and type 2 diabetes mellitus. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 out of 15 suggested moderate cognitive impairment. Review of the physician order dated 06/15/25 for Resident #2 revealed to change PICC line dressing every week on Sunday nights.Observation on 08/21/25 at 8:58 A.M. of Resident #2 revealed a PICC line to the upper left arm with a dressing dated 08/10/25.Observation on 08/21/25 at 9:00 A.M. of Resident #2 ' s PICC dressing to the left upper arm with the Director of Nursing (DON) confirmed the dressing was dated for 08/10/25 indicating it was changed that day and not weekly on 08/17/25 (Sunday) per the order.3.Review of the medical record for Resident #21, revealed an admission date of 07/13/23. Diagnoses included but were not limited to multiple sclerosis, muscle weakness and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out o15 indicating intact cognition. Review of the physician order dated 08/10/25 for Resident #21 revealed to change PICC line dressing every week on Sunday nights. Observation on 08/20/25 at 8:22 A.M. of Resident #21 revealed a PICC line to the upper right arm with a dressing dated 08/09/25.Observation on 08/01/25 at 9:04 A.M. of Resident #21 ' s PICC dressing to right upper arm with the DON confirmed the dressing was dated 08/09/25 indicating it was changed that day and not weekly on 08/17/25(Sunday) per order.4.Review of the medical record for Resident #33, revealed an admission date of 02/22/25. Diagnoses included but were not limited to chronic kidney disease, pressure ulcer of sacral region, type 2 diabetes mellitus without complications and sepsis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out 15 indicating intact cognition. Review of the physician order dated 08/03/25 for Resident #33 revealed change PICC line dressing every week on Sunday nights.Observation on 08/18/25 at 9:41 A.M. of Resident #33 revealed a PICC line to the upper left arm with a dressing not dated.Observation on 08/01/25 at 9:04 A.M. of Resident #33 ' s PICC dressing to right upper arm with the DON confirmed the dressing was not dated indicating it is unknown as to when the dressing was changed and it is their practice to date dressings when changed. Review of the facility policy titled PICC/Midline/CVAD Dressing Change implemented on 03/31/25, revealed it is the policy of the facility to change PICC, midline or CVAD dressings weekly or if soiled.

Based on interview, record review, observation and facility policy review, the facility failed to implement preventive pressure ulcer skin interventions for 5 residents (#33, #2, #18, #4, and #63.) of 5 reviewed. The facility census was 50. Findings include:1. Review of the medical record for Resident #33, revealed an admission date of 02/22/25. Diagnoses included but were not limited to chronic kidney disease, pressure ulcer of sacral region, type 2 diabetes mellitus without complications and sepsis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also at risk for pressure ulcers and to have a stage 3 and stage 4 pressure ulcer. Review of the physician order dated 02/24/25 for Resident #33 revealed an air mattress to bed. Review of the plan of care revised on 04/25/25 for Resident #33 revealed at risk for pressure ulcer development with an intervention including but not limited to an air mattress to bed. Review of the most recent Braden Scale for Predicting Pressure Sore Risk dated 05/21/25 for Resident #33 revealed a score of 12 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at high risk for skin breakdown. Review of the most recent weight obtained on 08/20/25 for Resident #33 revealed him to be 151.2 pounds. Observation on 08/18/25 at 9:14 A.M. of Resident #33 revealed him to be in bed on an air mattress set to firm (highest setting for the air mattress). Per the Patient weight guide the bed was set to 400 pounds. Observation on 08/19/25 at 2:00 P.M. of Resident #33 revealed him to be in bed on an air mattress set to firm indicating the bed to be set for 400 pounds. Observation and Interview on 08/20/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) # 39 verified Resident #33's air mattress was set to firm indicating 400 pounds instead of his current weight of 151.2 pounds. 2. Review of the medical record for Resident #2, revealed an admission date of 12/30/24. Diagnoses included but were not limited to dependence on respirator, pressure ulcer of the sacral region, methicillin resistant staphylococcus aureus infection and type 2 diabetes mellitus. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 out of 15 suggested moderate cognitive impairment . The resident was assessed to require total dependence on bed mobility, toilet hygiene, shower/bathe self and transfers. This resident was also assessed to have a two pressure ulcer injuries present upon admission/reentry of a stage 3 and a stage 4. Review of the most recent Braden Scale for Predicting Pressure Sore Risk dated 06/23/25 for Resident #2 revealed a score of 13 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at moderate risk for skin breakdown. Review of the physician order dated 12/30/24 for Resident #2 revealed a pressure reducing mattress to bed. Review of the most recent weight obtained on 08/20/25 for Resident #2 revealed her to be 120.8 pounds. Observation on 08/18/25 at 9:47 A.M. of Resident #2 revealed her to be in bed on an air mattress set to firm indicating the bed to be set for 400 pounds. Observation on 08/19/25 at 8:12 A.M. of Resident #2 revealed her to be in bed on an air mattress set to firm, indicating the bed to be set for 400 pounds. Observation an interview on 08/20/25 at 2:30 P.M. with LPN #39 verified Resident #2's air mattress was set to firm indicating 400 pounds instead of his current weight of 120.8 pounds. 3. Review of the medical record for Resident #18, revealed an admission date of 08/12/25. Diagnoses included but were not limited to anoxic brain damage, not elsewhere classified, acute respiratory failure, encephalopathy, type 2 diabetes mellitus without complications, and personal history of sudden cardiac arrest. Review of the physician order dated 08/11/25 for Resident #18 revealed a pressure reducing air mattress to bed. Review of the clinical admission data dated 08/12/25 revealed Resident #18 to have a Brief Interview for Mental Status (BIMS) score of 0 out of 15 indicated severe cognitive intactness, to have a pressure ulcer to the right gluteus and to be totally dependent on all aspects of daily living. Review of the plan of care dated 08/12/25 for Resident #18 revealed to be at risk for pressure ulcer development with an intervention including but not limited to an air mattress bed. Review of the most recent weight obtained on 08/13/25 for Resident #18 revealed him to be 238.6 pounds. Review of the most recent Braden Scale for Predicting Pressure Sore Risk dated 08/19/25 for Resident #18 revealed a score of 9 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at very high risk for skin breakdown. Observation on 08/18/25 at 10:01 A.M. of Resident # 18 revealed him to be in bed on an air mattress set to medium indicating the bed to be set at 170 pounds. Observation on 08/19/25 at 8:15 A.M. of Resident #18 revealed him to be in bed on an air mattress set to firm indicating the bed to be set at 400 pounds. Observation and Interview on 08/20/25 at 2:36 P.M. with LPN #39 verified Resident #18's air mattress was set to firm indicating 400 pounds instead of his current weight of 238.6 pounds. 4. Review of the medical record for Resident # 4, revealed an admission date of 07/28/25 . Diagnoses included but were not limited to non pressure chronic ulcer of left heel and midfoot with unspecified severity, type 2 diabetes mellitus with foot ulcer, venous insufficiency, and osteomyelitis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. The resident was assessed to require partial/moderate assistance with bed mobility, substantial/maximal assistance with transfers and total dependence on toilet hygiene, shower/bathe self. This resident was also assessed to be at risk for pressure ulcer injuries. Review of the plan of care dated 07/29/25 for Resident #4 revealed at risk for pressure ulcer development with an intervention including but not limited to an air mattress to bed. Review of the physician order dated 07/29/25 for Resident #4 revealed an order for an air mattress to bed. Review of the most recent weight obtained on 08/13/25 for Resident #4 revealed him to be 322.2 pounds. Review of the most recent Braden Scale for Predicting Pressure Sore Risk dated 08/18/25 for Resident #4 revealed a score of 17 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at risk for skin breakdown. Observation on 08/18/25 at 9:56 A.M. of Resident #4 revealed him to be in bed on an air mattress set to medium indicating the bed to be set at 170 pounds. Observation on 08/19/25 8:14 A.M. of Resident #4 revealed him to be in bed on an air mattress set to medium indicating the bed to be set at 170 pounds. Observation and interview on 08/20/25 at 2:38 P.M. with LPN #39 verified Resident #4's air mattress was set to medium, indicating being set at 170 pounds and the resident's current weight to be 322.2 pounds. 5. Review of Resident #63's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia without behavioral disturbances, muscle weakness, need for assistance with personal care, and palliative care. Review of Resident #63's clinical admission assessment dated [DATE] revealed the resident was admitted to the facility with an unstageable pressure ulcer to his left heel. It was classified as an unstageable pressure ulcer, due to the wound having slough and/ or eschar present, limiting the wound bed to be fully visualized to determine the extent of the wounds depth. It measured 0.5 centimeters (cm) by 2 cm and had a small amount of light green drainage present on the old dressing. His admission weight was 148.2 pounds. Review of Resident #63's physician's orders revealed he had an order in place for the use of an air mattress to his bed. He was also to have his heels elevated as tolerated to promote skin integrity. The elevation of his heels had been in place since his admission and the use of the air mattress was implemented on 08/15/25. Review of Resident #63's care plans revealed he had a care plan in place for being at risk for pressure ulcer development related to weakness, limited mobility, and dementia with cognitive deficits. His care plan reflected he was admitted to the facility with a pressure ulcer to his left heel. The care plan originated on 08/14/25 and included the goal for his pressure ulcer to show signs of healing by/through the review date. The interventions included the use of an air pressure mattress to his bed for comfort. The setting for the air mattress was left blank on the care plan. They were also to follow the facility policies/protocols for the prevention/treatment of skin breakdown. On 08/18/2025 2:30 P.M., an observation of Resident #63 noted him to be lying in bed. He had an air mattress to his bed, but his heels were not elevated and were in direct contact with the air mattress. There were a pair of heel boots on the nightstand next to his bed that were not being used to off-load his heels. On 08/20/25 at 12:53 P.M., an ongoing observation of Resident #63 noted him to be lying in bed on his right side. He had his knees bent and his legs were drawn up putting him in a fetal position. His air mattress remained on his bed and set on static, normal pressure. There was a dial that was to be used to adjust the firmness of the mattress based on the resident's weight. The current setting was at 350 pounds, which was the firmest setting (too firm for the resident with his weight of 148.2 pounds). Again, the resident did not have his heels elevated off the bed and they were in direct contact with the mattress. Approximately six minutes later, Certified Nursing Assistant #10 was observed to enter the resident's room with two new pillows that were in plastic wraps. She was stopped for an interview as she entered the room. On 08/20/25 at 12:59 P.M., an interview with CNA #10 confirmed Resident #63 did not have his heels elevated off the mattress to off-load pressure, which was why she was bringing the pillows into his room. She was questioned about the settings on the resident's air mattress and confirmed based on the resident's weight, it was not set properly. She confirmed the resident was nowhere near 350 pounds, which was what the air mattress was set on. At that time, RN #23 entered the room. She had previously been asked by the surveyor to come to the resident's room to verify his heels were not elevated and his air mattress was not set properly resulting in the mattress being too firm for the resident based on his stated weight. She confirmed Resident #63 was known to have a pressure ulcer to his left heel. She acknowledged the resident's heels were not off-loaded and his air mattress was not properly set according to his weight, which could delay his wound healing or make his pressure ulcers worse. She stated they would check to see how much the resident weighed and set his air mattress to the proper firmness accordingly. Review of the Med-Aire 8 alternating pressure mattress replacement system with low air loss user instructions provided by the facility revealed the medical device must be installed and operated in the manner for which it was intended. The user was responsible for reading and understanding the product user manual. Under indications for use, it was described as an effective pressure redistribution therapy, but was only a component of a comprehensive pressure injury management program. Support surfaces were not substitutes for turning, repositioning, or functional weight shifts. The product features indicated it had an analog control unit that included an easy to use pressure dial that was adjustable to the resident's weight and comfort. Under operation, pressure range selection was achieved by the user adjusting the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting. Review of the facility policy titled Bed Maintenance and Inspections revealed evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present that included but was not limited to provide appropriate, pressure-redistributing, support surfaces.

Based on record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were educated on the risks/ benefits associated with the use of psychotropic medications, and informed consent was obtained from the resident and/ or their representative prior to use. This affected five (Resident #1, #5, #27, #30, and #35) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: 1. Review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder, bipolar disorder, and anxiety disorder. Review of Resident #35's physician's orders revealed she was receiving the following psychotropic medications: Aripiprazole (an antipsychotic medications) 10 milligrams (mg) by mouth (po) once a day for bipolar disorder, Ativan (an anti-anxiety medication) 0.5 mg po twice a day for anxiety disorder, Trazadone (an anti-depressant medication) 100 mg po once daily for anxiety disorder, and Desvenlafaxine ER (an anti-depressant medication) 100 mg po once daily for depression. Review of Resident #35's electronic medical record (EMR) revealed it was absent for any signed consents being obtained for the use of psychotropic medications. There was no evidence of the resident having been provided education on the risks/ benefits associated with the use of the four psychotropic medications she was receiving as required. On 08/20/25 at 12:41 P.M., an interview with the Director of Nursing (DON) confirmed there was no documented evidence of Resident #35 having been informed of the risks/ benefits associated with the psychotropic medications she was receiving. She further confirmed they did not have a signed consent for the use of those psychotropic medications. She reported the facility's social service designee should have been the one to obtain the consents for the use of those medications. On 08/20/25 at 2:14 P.M., an interview with Social Service Designee (SSD) #1 revealed she did not have any signed consents from Resident #35 or her representative showing evidence they were provided education on the risks and benefits associated with the use of the resident's multiple psychotropic medications. A signed consent was later provided by the facility that had not been obtained from the resident until 08/20/25, after the facility's DON was asked about it. The signed consent provided only included the resident's signature and date signed but did not list out the psychotropic medications used, what it was being used for, or the risks/ benefits associated with it's use. 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including nontraumatic chronic subdural hemorrhage, fracture of third lumbar vertebra, cerebral infarction, hypertension, diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis, and congestive heart failure. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #5's Brief Interview for Mental Status (BIMS) score was 9 out of 15, which indicated moderately impaired cognition. Review of a physician order, dated 08/13/25, revealed the order for Aripiprazole 5 milligrams (mg) one tablet by mouth daily for moderate dementia with behaviors and moderate major depressive disorder; review of a physician order, dated 06/23/25, revealed the order for Sertraline HCL 75 mg one tablet by mouth daily for depression; review of a physician order, dated 04/14/25, revealed the order for Trazadone HCL 50 mg one tablet by mouth daily for insomnia. Review of Resident #5's consent form titled, Informed Consent for Psychoactive Medication Use, dated 06/06/24, revealed the section of the form which would indicate the resident had been informed of and understood the reason for/risk of using a psychoactive medication was blank. The medication and diagnosis sections were blank. Interview on 08/21/25 at 11:57 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence of Resident #5 having been informed of the risks/ benefits associated with the psychotropic medications he was receiving. She further confirmed that although the consent form for the use of those psychotropic medications was signed by the resident, the medication and diagnosis sections were blank and failed to indicate which psychotropic medications were used and for which diagnoses, and of the risks/ benefits associated with use. 3. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, diabetes mellitus, anxiety disorder, schizophrenia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/25, revealed Resident #30's Brief Interview for Mental Status (BIMS) score was 05 out of 15, which indicated severely impaired cognition. Review of Resident #30's Medication Administration Record (MAR), dated August 2025, revealed the physician orders for the following psychoactive medications: Escitalopram Oxalate 10 mg one tablet by mouth daily for major depressive disorder; Mirtazapine 7.5 mg one tablet by mouth daily for mood/appetite; and Buspirone 7.5 mg one tablet by mouth three times per day for anxiety. Review of Resident #20's electronic medical record (EMR) revealed no evidence of the facility's consent form, Informed Consent for Psychoactive Medication Use. Interview on 08/21/25 at 3:25 P.M. with the Director of Nursing (DON) confirmed there was no documented evidence of Resident #30 having been informed of the risks/ benefits associated with the psychotropic medications she was receiving. She further confirmed there was not a signed consent for the use of those psychotropic medications. 4. Review of the medical record for Resident #1, revealed an admission date of 04/17/25. Diagnoses included but were not limited to dependence on respirator (ventilator) status, acute and chronic respiratory failure with hypoxia and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15. The resident was assessed to require total dependence on all aspects of assisted daily living activities. Review of the physician order dated 04/18/25 for Resident #1 revealed paroxetine HCL (Hydrochloric acid) 30 mg one tablet once a day. Review of the consent form titled Informed Consent for Psychoactive Medication Use, dated 04/17/25, for Resident #1 revealed the section of the form which indicated the resident had been informed of and understood the reason for/risk of using psychoactive medication and diagnosis were blank. Interview on 08/21/25 at 11:20 A.M. with the DON confirmed the informed Consent for Psychoactive Medication use form for Resident #1 did not indicate the resident had been informed of and understood the reason for/risk of using a psychoactive medication and the diagnosis for which it is being used for due to the areas being blank. 5. Review of the medical record for Resident #27 revealed an admission date of 01/08/24. Diagnoses included but were not limited to: Unspecified Atrial Flutter; Pain; Rhabdomyolysis, unspecified fall; Essential Hypertension; Unspecified Heart Failure, Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection; Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms; Ventricular Flutter; Malignant Neoplasm of Bladder; Acute on Chronic Diastolic Congestive Heart Failure Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 13 out 15 indicating cognitive intactness. Review of Resident #27's medication orders revealed an order for Duloxetine 80 milligrams(mg), one tablet by mouth once daily for depression. The record also contained an order for Buspirone HCL 5 mg, one tablet by mouth two times daily for anxiety. Resident #27's record also revealed orders to monitor the effects of antidepressants. The orders were to observe closely for significant side effects of Anti-Anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift. Also, there was an order for Serotonin Syndrome Monitoring which included monitoring for increased agitation, restlessness, rapid HR, high BP, dilated pupils, loss of muscle coordination or twitching muscles, muscle rigidity, heavy sweating, diarrhea, headache. Notify medical provider if symptoms are noted. Review of Resident #27's medical record revealed a form titled Informed Consent for Psychoactive Medication Use. This consent form was signed by Resident #27 and dated 11/07/23. The remaining form, including the name of the medication, a supporting diagnosis, and witness to the form, was left incomplete. Interview on 08/21/25 at 11:57 A.M. with the Director of Nursing (DON) #40 confirmed there was no documented evidence of Resident #27 having been informed of the risks/ benefits associated with the psychotropic medications he was receiving. She further confirmed that although the consent form for the use of those psychotropic medications was signed by the resident, the medication and diagnosis sections were blank and failed to indicate which psychotropic medications were used and for which diagnoses, and of the risks/ benefits associated with use. Review of the facility's policy on Use of Psychotropic Medications dated 03/31/25 revealed it was the intent of the policy to ensure residents only received psychotropic medications when other non-pharmacological interventions were clinically contraindicated. Those medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience. Prior to initiating or increasing a psychotropic medication, the resident, family, and/ or resident representative must be informed of the benefits, risks, and alternatives for medications, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on record review, facility policy review, and staff interview the facility failed to accurately reflect the Resident code status in the electronic medical record and the paper copies in the facility binder used for emergencies. This affected two Residents (Resident #3 and #5) of the 22 residents reviewed for code status. The facility census was 50. Findings Include:1. Review of Resident #3 medial record revealed admission to facility 04/22/24 for diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type 1 with neuropathy (decreased sensation in nerve endings), high blood pressure, major depressive disorder, unspecified mood disorder, generalized anxiety disorder, unspecified disorders of adult personality and behavior, insomnia (inability to sleep), heart disease, chronic kidney disease. Review on 08/18/2025 at 11:53 A.M. of the code status binder at the nurse's station revealed an orange paper noting Resident #3 was a Full Code. Further review of the electronic medical record Point Click Care revealed Resident #3 was a Do Not Resuscitate-Comfort Care (DNR-CC) (do not provide heroic measures during end of life), order scanned in and signed by the medical provider on 08/14/24 and updated again on 05/03/25. Review of Resident #3 care plan revised on 02/13/25 revealed Resident #10 as a Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) (provide heroic measures during end of life until the heart stops beating). Review of Resident #3's most recent Order Summary active as of 08/19/25 revealed Resident #3 was ordered a DNR-CC code status. Interview on 08/19/2025 3:42 P.M with the Charge Nurse, Register Nurse (RN) #30 revealed code status binder at nurse's station listed Resident #3 as a DNR-CC with the current signed order dated 05/03/25. RN #30 reported that the unit manager is responsible for updating the code status binder. Interview on 08/19/2025 at 3:50 P.M. with Unit Manger and Licensed Practical Nurse (LPN) #39 revealed she had updated the code status binder at the nurse's station that morning for Resident #3 and one other resident. LPN #39 admitted that the book was not updated as frequently as it should be. 2. Review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obstructive sleep apnea (OSA), adult-onset diabetes mellitus, and chronic kidney disease. Review of Resident #35's active physician's orders revealed she had an order in place to be a Do Not Resuscitate Comfort Care (DNR-CC). The order was initiated on 07/14/25. Review of a code status binder the facility had at the nurse's station to be used in the event revealed Resident #35 was a DNRCC. Review of the electronic medical record (EMR) revealed the resident was a DNRCC- Arrest. The DNR order form was signed by the advanced level provider on 05/28/25. The form indicated for a DNRCC- Arrest the provider would treat the resident as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care protocol would be implemented. For a DNR-CC, the DNR protocol would be effective immediately. On 08/19/25 at 3:42 P.M., an interview with RN #30 revealed she determined what a resident's code status was by checking the physician's orders in the EMR. If the computer was down, they had a code status book at the nurses station that informed them what the resident's code status was. She verified Resident #35's code status in the code status book identified the resident as DNRCC-A. She then verified the resident's code status was identified as being a DNR-CC when she checked the physician's orders in the EMR. She reported the managers were responsible for updating the code status book. On 08/19/25 at 3:50 P.M., an interview with LPN #39 confirmed she was the one who updated the residents' code status in the code status book. They liked to update the code status book at the time the code status was added or changed, but it did not always get done as timely as they liked. She acknowledged Resident #35's code status as indicated in her physician's orders identified her as a DNRCC and the code status book had her as a DNRCC-A. She further acknowledged the physician's orders showed the code status changed to a DNRCC on 07/14/25 and had not been updated in their code status book. Review of the facility's policy on Residents' Rights Regarding Treatment and Advanced Directives (undated) revealed it was the policy of the facility to support and facilitate a resident's right to request, refuse, and/ or discontinue medical or surgical treatment and to formulate advance directives. Upon admission, the facility would determine if the resident had executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. During the care planning process, the facility would identify, clarify, and review with the resident whether they desired to make any changes related to any advanced directives. Any decision making regarding the resident's choices would be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on medical record review, interview, and policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) documents accurately reflected diagnoses. This affected three (Resident #5, #3 and #8) of three residents reviewed for PASRR documents. The census was 50. Findings Include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including nontraumatic chronic subdural hemorrhage, cerebral infarction, hypertension, diabetes mellitus, major depressive disorder (MDD), anxiety disorder, post-traumatic stress disorder (PTSD), hemiplegia and hemiparesis, and congestive heart failure. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #5's Brief Interview for Mental Status (BIMS) score was 09 out 15, which indicated moderately impaired cognition. Review of Resident #5's PASRR document, dated 06/06/24, under Section E: Indications of Serious Mental Illness, revealed the answer No was selected for the question: Does the individual have a diagnosis of any of the mental disorders listed below, check all that apply. There were no diagnoses selected. The PASRR document did not accurately reflect the diagnoses of anxiety, PTSD, or MDD. Interview on 08/21/25 at 1:40 P.M. with Social Services Designee (SSD) #1 confirmed Resident #5's PASRR document was not accurate and did not indicate the diagnoses of anxiety, PTSD, or MDD. SSD #1 stated that she would make this correction now and submit a new PASRR for the resident. 2. Record review on Resident #3 revealed admission to facility 04/22/24 for diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type 1 with neuropathy, high blood pressure, major depressive disorder, unspecified mood disorder, generalized anxiety disorder, unspecified disorders of adult personality and behavior, insomnia, heart disease, chronic kidney disease. Record review of Resident #3 most recent Pre-admission Screening and Resident Review (PASARR) completed on 03/20/24 revealed mental health diagnoses of mood disorders, panic disorder other severe anxiety disorders, and insomnia. Record review of Resident #3 diagnosis list revealed new diagnoses of Schizo- affective disorder, unspecified type on 08/14/24, delirium due to known physiological condition on 01/17/25, and unspecified dementia without behavioral disturbances on 02/05/25. Record review of Resident # 3 most recent quarterly Minimum Data Set (MDS 3.0) dated 07/24/25 revealed Section I with diagnosis Schizophrenia and Non-Alzheimer's Dementia selected. Interview 08/19/2025 2:47 P.M. with Social Worker Designee (SWD) #1 revealed process for facility reviewing and completing the PASRR of newly admitted Residents as follows: SWD reviewed all PASRRs completed prior to admission to facility for accuracy and updates accordingly if needed with in 30 days. If Residents have not had a PASRR completed, then the SWD would complete a new one within 30 days of admission. SWD #1 further explained if a Resident has a change in condition or new diagnosis related to mental health, she would update the PASRR. SWD #1 reported she was notified by nursing staff during daily huddle meetings and during inter-disciplinary meetings of change in condition or new and updated diagnosis. SWD #1 verified that there has not been and updated PASRR completed for Residents #3 related to diagnosis of Schizo-affective disorder and dementia. 3. Review of Resident #8's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, anxiety disorder, psychotic disorder with delusions, and schizophrenia. Those diagnoses were in place on or before 05/25/22. Her diagnoses list was updated to reflect she had a new diagnosis of dementia of an unspecified severity with mood disturbance on 01/11/23. Review of Resident #8's Pre-admission Screening and Resident Review (PASRR) Identification Screens revealed the last PASRR completed for the resident was completed on 08/18/22. Her mental illness diagnoses were properly identified under section (E.) and included schizophrenia and a mood disorder. At the time of the PASRR's completion, section (D.): Medical Diagnosis was properly marked to reflect the resident did not have a diagnosis of dementia at the time the PASRR was completed. Resident #8's EMR was absent of any evidence of a new PASRR being completed, after the resident was diagnosed with dementia on 01/11/23. The last PASRR on file remained the PASRR that was completed on 08/18/22. Review of Resident #8's prior Minimum Data Set (MDS) assessments reflected the resident did have a decline in her mental and physical condition around the time she was newly diagnosed with dementia. A quarterly MDS assessment completed on 10/19/22 revealed the resident's cognition was only moderately impaired and she was independent to needing only a limited assistance for all of her activities of daily living (ADL) assistance. Her quarterly MDS assessment completed on 01/10/23 revealed Resident #8 now had severely impaired cognition and required supervision to an extensive assist with all her ADL's reflecting a decline in both her mental and physical status. On 08/19/25 at 2:45 P.M., an interview with Social Service Designee (SSD) #1 revealed she had worked at the facility for about three years now. It was her responsibility to review PASRR's upon a resident's admission to ensure they had been completed and were accurate. She reported for the residents that already resided in the facility, she would complete a new PASRR for a change in condition. She was asked what would be considered a change in condition and replied a decline, or if the resident went hospice. She was then asked about residents that received a new diagnoses of a mental illness and indicated she would do a new PASRR only if she was told that it was needed. When asked to clarify who would be the one to tell her when a new PASRR was needed to be completed, she stated nursing. She would be told in morning meeting. She stated, according to the county's Area Agency on Aging, she was not required to do a new PASRR when a new diagnoses of dementia was added. She acknowledged a new diagnosis of dementia with a decline in the resident's physical and/ or mental status condition did require a new PASRR to be completed. She acknowledged the resident was given a new diagnosis of dementia on 01/11/23 and her quarterly MDS assessments completed on 10/19/22 and 01/10/23 did show she had a decline in both her mental and physical status. She reported she would go ahead and complete an updated PASRR Identification Screen due to the added diagnosis of dementia and a decline in her mental and physical status as a result. Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, undated revealed this facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in them most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States' Medicaid rules for screening.

Based on record review and staff interview, the facility failed to ensure a resident's comprehensive care plans included care plans to address all the resident's diagnoses that they received medications for. This affected one (Resident #35) of 22 residents reviewed for care plans. The facility census was 50. Findings include:Review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder, bipolar disorder, anxiety disorder, and chronic pain syndrome. Review of Resident #35's physician's orders revealed she had orders in place to receive Melatonin (a supplement used in the treatment of insomnia) 10 milligrams (mg) by mouth (po) every night at bedtime for insomnia. The resident also had orders in place for the use of Senna Plus (stool softener) 8.6 mg- 50 mg po every day and FiberCon (bulk forming laxative) 625 mg with the directions to take two tablets one time a day for constipation. Review of Resident #35's active care plans revealed she did not have a care plan in place to address insomnia or constipation, despite receiving medications on a scheduled basis to manage both. Findings were verified by the Director of Nursing (DON). On 08/20/25 at 12:41 P.M., an interview with the DON verified Resident #35 was receiving Melatonin every night at bedtime for the treatment of insomnia and was also receiving Senna Plus and FiberCon daily for management of constipation. She was not able to see where either diagnoses of insomnia or constipation had been addressed in the resident's comprehensive care plans. On 08/20/25 at 12:55 P.M., an interview with Licensed Practical Nurse (LPN) #62 revealed she was the one who developed the residents' care plans. She asked if there were any questions pertaining to Resident #35's care plans. She was informed the resident was receiving two different medications for constipation and Melatonin for the treatment of insomnia with no care plans in place for either. She indicated the resident was having regular bowel movements and did not have an official diagnosis of constipation, so she did not feel she needed one. She was further informed the resident was receiving medical intervention for constipation (two different medications on a scheduled basis for constipation), and with medical interventions in place to address the problem, she should have a care plan in place to reflect such. She was also informed the resident was being treated for insomnia (by being given the supplement Melatonin), so she should have a care plan for that as well.

Based on record review, interview, and observation, the facility failed to maintain safe equipment for residents, which affected Resident #27. The facility also failed to maintain safety for Resident #10 identified as being a high fall risk. This affected two residents ( #10 and #27) out of 3 residents reviewed for accidents. The facility census was 50.1.Review of the medical record for Resident #27 revealed an admission date of 01/08/24. Diagnoses included but were not limited to: Unspecified Atrial Flutter; Pain; Rhabdomyolysis, unspecified fall; Essential Hypertension; Unspecified Heart Failure, Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection; Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms; Ventricular Flutter; Malignant Neoplasm of Bladder; Acute on Chronic Diastolic Congestive Heart Failure Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 13 of 15 which indicated cognitive intactness. The MDS also revealed the resident required assistance of one person for bed mobility, transfers and toileting. He required setup help only for meals. Review of a care plan dated 08/06/25, revealed Resident #27 was a fall risk due to a history of falls, weakness, impaired mobility, pain and difficulty ambulating. Interventions for wheelchair, footwear, and safety were implemented. For ADL interventions, bed mobility requires staff assistance of one with minimal to moderate assistance. Review of a care plan dated 08/06/25, revealed Resident #27 had altered respiratory status related to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with hypoxia. Interventions were put in place for oxygen via nasal cannula as ordered. The care plan failed to reveal an intervention for mobility bars. Review of Resident #27's progress note, dated 07/25/25 revealed Licensed Practical Nurse #400 was called into Resident #27's room by a (unknown) therapists who reported the resident had obtained a skin tear from a sharp area of his bedrail. A Band-Aid was placed over the sharp area and maintenance was notified. Review of incident report, dated 07/25/25 at 8:18 A.M., the resident obtained a skin tear on his left arm. The incident was unwitnessed. Resident #27 indicated there was a sharp place on his bed and a maintenance report was filed. On 08/20/25 at 2:23 P.M., an interview with Resident #27 revealed he had obtained a skin tear somewhere on my left arm there. He could not indicate which arm. He reported the hand rail on the left side of his bed had a sharp area on it which had torn his skin. Review of form titled Pataskala Oaks Care Center-Maintenance Log revealed a report on 07/25/25 which indicated a bed rail in Resident #27's room has a sharp piece sticking [arrow pointing upward] Band-aid covering it. The priority level on this was reported a High. This was confirmed by Maintenance Director #48 on 08/21/25. On 08/21/2025 at 3:08 P.M., an interview with Maintenance Director #48 revealed he was responsible for maintenance of the hand rails at the facility. These were checked on a monthly basis. When someone would notify him of an issue he would fix it as soon as he could. He confirmed on 07/25/25, he received a maintenance request to repair the hand rail of Resident #27's bed, which had a sharp edge on it. 2. Record review of Resident #10 revealed admission to facility on 04/06/25 with diagnosis including cerebral palsy, quadriplegia (unable to use all four limbs), tracheostomy (whole in wind pipe to breath), suprapubic catheter (tube in bladder to urinate), neurogenic bladder (bladder that does not respond to being full), lung disease, congestive heart failure, two non-pressure ulcers of left thigh (chronic) and right thigh (chronic), cognitive communication deficit, low blood pressure, depression, anxiety, acid reflux, feeding tube, and non-insulin dependent diabetes mellitus. Record review of Resident #10 most recent quarterly Minimum Data Set (MDS 3.0) assessment dated [DATE] revealed resident was completely dependent on staff for all care areas. Record review of Resident #10 Order Summary dated 08/19/25 revealed Keep bed in low position when not providing care. Observation on 08/20/2025 at 12:13 P.M. revealed Resident #10 door was open with the privacy curtain pulled. Resident #10 was laying on his back with bed in high position. No staff were present in room. The Breath Call (a call light used for individuals who cannot use hands to push a button for a traditional call light system and requires the individual to blow into the apparatus to activate it) call light was out of reach of resident, pushed to right side of bed approximately 3 feet from bed. Interview on 08/20/2025 12:14 P.M. with Registered Nurse (RN) #23 verified Resident #10 Breath Call device not within reach of Resident and bed in high position. RN #23 reported the nursing aides were probably getting ready to get Resident #10 up and needed to go get something. RN #23 proceeded to lower bed and place the Breath Call device within reach of Resident #10.

Based on policy review, record review, observation and interview, the facility failed to properly administer oxygen per nasal cannula as ordered by a physician. This affected three (Resident #12, Resident #27, and Resident #61) of three residents reviewed for oxygen use. The facility census was 50.Findings include:1.Review of the medical record for Resident #12 , revealed an admission date of 08/07/25 . Diagnoses included but were not limited to: Acute Respiratory Failure with Hypercapnia; Dyspnea; Diarrhea; Gastroesophageal Reflux Disease without Esophagitis; Anemia in Chronic Kidney Disease; Long term use of Anticoagulants; Essential Hypertension; Chronic Diastolic Heart Failure; Unspecified Atrial Fibrillation; Chronic Kidney Disease Stage 3; and Pneumonia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 10 out of 15 indicating moderate cognitive deficit.Review of Resident #12's orders indicated he was ordered oxygen at 2 Liters (L) via nasal cannula continuous.On 08/18/2025 at 10:31 A.M., and observation of Resident #12 revealed he was on Oxygen via nasal cannula. His Oxygen concentrator was set at 4 L.On 08/19/2025 at 11:48 A.M., Observation of Resident #12 revealed oxygen on via nasal cannula. His concentrator flow rate was set to 4L. Tubing was not dated. This was confirmed by Registered Nurse (RN) #30. On 08/19/2025 at 12:05 P.M., RN #30 confirmed the oxygen flow rate for Resident #12 should be set to 2L. She further confirmed the tubing for Resident #12 was not labeled.2. Review of the medical record for Resident #27 revealed an admission date of 01/08/24. Diagnoses included but were not limited to: Unspecified Atrial Flutter; Pain; Rhabdomyolysis, unspecified fall; Essential Hypertension; Unspecified Heart Failure, Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection; Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms; Ventricular Flutter; Malignant Neoplasm of Bladder; Acute on Chronic Diastolic Congestive Heart Failure Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating intact cognition.The MDS also revealed the resident used oxygen. Review of Resident #27's orders indicated he was ordered oxygen at 3 L via nasal cannula continuous.On 08/19/2025 at 11:44 A.M., Observation of Resident #27 revealed he was on oxygen via nasal cannula. The oxygen flow rate was set to 3.5 Liters (L). Confirmed by RN #30.On 08/19/2025 at 12:05 P.M., RN #30 confirmed the concentrator flow rates for Resident #27 should be 3 L.3. Review of the medical record for Resident #61 revealed an admission date of 08/13/24. Diagnoses included but were not limited to Sepsis; Unspecified Escherichia Coli; Weakness; Chronic Kidney Disease Stage 3; Alzheimer's Disease; Hyperlipidemia; Myasthenia Gravis without exacerbation; Essential Hypertension; Anxiety; Anemia, and Urinary Tract Infection. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9 out of 15 indicating moderate impairment. Review of Resident #61's orders indicated she was ordered oxygen on 08/18/25. The oxygen was ordered at 2 L via nasal cannula prn (as needed) to keep O2 (oxygen) sats (saturation) greater than 92%.On 08/18/2025 at 2:32 P.M., Resident #61 was noted to be on Oxygen via nasal cannula. The Oxygen concentrator was set to 3 L.On 08/19/2025 at 11:46 A.M., Observation of Resident #61 revealed an Oxygen concentrator in her room, which was running at a rate of 3L. Confirmed by RN #30 and stated that Resident #61's oxygen should be at 2 L as needed.On 08/19/2025 at 11:58 A.M. an interview with RN #30 revealed the resident's oxygen was managed by the RN on duty. Oxygen tubing was to be changed every Sunday night and labeled with tape to include the date, time, and initials of the RN who changed the tubing. Oxygen flow rate was to be determined by and order from the physician. Review of policy titled Oxygen Administration, dated 03/31/25, revealed Oxygen was to be administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy further explained: Oxygen is administered under orders of a physician, except in the case of an emergency. The policy required the residents care plans to identify the interventions for oxygen therapy, based upon the resident's assessment, which should include the oxygen delivery system, when to administer, such as continuous or intermittent, and when to discontinue. Oxygen saturations were also to be monitored as ordered. Oxygen tubing was to be changed weekly and as needed if became soiled or contaminated.

Based on record review, resident observations, policy review, and interviews, the facility failed to assess and implement trauma informed care for two Residents (Residents #5 and #24) of the two residents reviewed for trauma informed care. The facility census was 50. Findings Include: 1. Record review of Resident #24 revealed admission to facility on 03/12/20 with diagnosis including chronic kidney disease, cerebral atherosclerosis (blockage of vessels in the brain), hearing loss of right ear, dysphagia (difficulty swallowing), chronic cough, attention deficit hyperactivity disorder (ADHD), dementia (forgetfulness), diabetes mellitus type II, major depressive disorder, anxiety, mild cognitive impairment of unknown etiology, insomnia (inability to sleep), heart disease, and lung disease. Record review of Resident #24 most recent quarterly Minimum Data Set (MDS 3.0) assessment dated [DATE] revealed no diagnosis of trauma. Record review of Resident #24 most recent psychiatric visit notes by on 02/26/25 revealed no documentation of diagnosis of trauma or trauma related care. Record review of Resident #24 counseling care plan from counseling services with effective date 06/13/25 revealed no history or diagnosis of trauma or trauma focused care. The counseling care plan further revealed diagnosis for treatment including anxiety, dementia with behavioral disturbances, insomnia, low income and depression. Record review of Resident #24 most recent care plan updated on 05/27/25 revealed no specific diagnosis or care plan interventions related to history of trauma or trauma informed care. Several care plans reflected interventions for behaviors related to diagnosis of dementia, ADHD, depression, anxiety, frontotemporal neurocognitive disorder, and impulse control disorder. Interview on 08/18/2025 at 9:10 A.M. with Resident #24 revealed she was raped and had tubal pregnancies as result when she was younger. Resident #24 attributed the rape as why she is having problems with getting urinary tract infections. Resident #24 reported she has been having pain with urination and wanted the nurse to call the doctor. Resident #24 stated I just want the pain to go away, I am up and down all night, and I can't take pain anymore. Resident #24 punched hands into legs and raised her voice to express her frustration. Resident #24 further stated, I drink so much water, and it doesn't help. Resident #24 was crying during interview. Interview on 08/20/2025 at 11:00 A.M. with Registered Nurse (RN) #23 revealed she works as a RN in an as needed capacity and has only been with facility for a couple of months. RN #23 reported Resident #24 sometimes can have behaviors and make sounds as if she is crying but is not actually crying. RN #23 further reported that Resident #24 responded well to praise about her appearance and positive reinforcement. RN #23 reported that Resident #24 has some intellectual impairment and even though elderly her brain was like that of a child at times. RN #23 denied any knowledge of Resident #24 having a history of traumatic events. RN #23 further reported if residents have a known history of depression or are on medications for mental health the facility staff assessed for signs and symptoms of depression daily and reported any behaviors or concerns to the nurse Practitioner. Interview on 08/20/25 at 2:15 P.M. with Social Worker Designee (SWD) #1 revealed she was aware of Resident #24 reporting trauma from being raped as a young girl. SWD #1 reported that Resident #24 is currently getting on site counseling through TBS counseling services and she can see psychiatry provider if needed. SWD #1 admitted there was no specific screening tool or assessment the facility utilized to assess for Residents with a trauma history. SWD #1 reported the MDS nurse was responsible for establishing care plans for Residents. Interview on 08/20/25 at 3:15 P.M. with the Unit Manager, RN #38 revealed she was aware that Resident #24 has reported being raped as a young girl. RN #38 reported the facility refers Residents to counseling services that are provided on site as need. RN #38 further reported the facility can also make a referral to the psychiatry services if needed for changes in behavior or worsening anxiety and depression symptoms. RN #38 reported that Resident #24 was currently getting counseling services and the MDS coordinator formulated and updated Resident care plans. Interview on 08/20/25 at 3:18 P.M. with the MDS Coordinator, Licensed Practical Nurse (LPN) #62 verified Resident #24's care plans did not include any diagnosis or interventions related to trauma informed care. LPN #62 further revealed she was unaware of Resident #24 having any history of trauma or reporting she was raped as a young girl. LPN #62 reported that she did not have a software template for trauma informed care interventions. Interview on 08/21/25 at 8:00 A.M. with Resident #24 for follow up regarding urinary issues revealed she was still having concerns about pain with urination and repeated that she was raped as a young girl resulting in a pregnancy. 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including nontraumatic chronic subdural hemorrhage, cerebral infarction, diabetes mellitus, major depressive disorder (MDD), anxiety disorder, post-traumatic stress disorder (PTSD), hemiplegia and hemiparesis, and congestive heart failure. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #5's Brief Interview for Mental Status (BIMS) score was 09 out of 15 , which indicated moderately impaired cognition. This resident was assessed to have a diagnosis of PTSD. Review of the Care Plan for Resident #5 revealed there was not a plan of care in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Further record review for Resident #5 revealed no assessment had been completed to identify the cause of PTSD and to identify potential triggers which may cause re-traumatization. Interview with the Social Services Designee #1 on 08/21/25 at 9:45 A.M. verified an assessment of the cause of PTSD and possible triggers for Resident #76 had not been completed and additionally verified there had not been a plan of care implemented for Resident #5 to minimize the risk of re-traumatization. Record review of the facility policy titled Trauma Informed Care with revised date 03/31/25 revealed trauma events including rape will be addressed by minimizing triggers and/or re-traumatization. The policy further reveals that trauma-specific care plan interventions will recognize the interrelations between trauma and symptoms of trauma.

Based on observation, record review and policy review, the facility failed to provide proper cleaning/disinfection of equipment between resident use. This affected two (Resident #32 and #12) of eight residents (Resident #5, Resident #9, Resident #12, Resident #27, Resident #32, Resident #34, Resident #45, and Resident #61) identified on Middle Hall as requiring blood pressures prior to medication administration and one (Resident #19) of one reviewed for glucometer use. The facility census was 50. Findings Include: 1. On 08/20/2025 at 8:16 A.M., observation revealed Registered Nurse (RN) #33 took Resident #32's blood pressure using an electronic blood pressure monitor. She did not sanitize the blood pressure cuff at that time. RN #33 then completed the medication administration of this resident. On 08/20/2025 at 8:39 A.M., observation revealed RN #33 take Resident #12's blood pressure with an electronic wrist blood pressure monitor. This was the same cuff used on Resident #32 and was not cleaned between residents. On 08/20/25 at 8:45 A.M., an interview with RN #33 revealed she did not sanitize the digital blood pressure monitor between uses. This included not sanitizing the monitor prior to use on Resident #32, before use on Resident #12, or after use on Resident #12. Review of the user guide for Dynarex Digital Blood Pressure Monitor indicated the machine should be cleaned with a soft, dry cloth. Further instructions were do not use petrol, thinners or similar solvent. Spots on the cuff could be removed carefully with a damp cloth and soapsuds. 2. Review of medical record of Resident #19 revealed admission to facility on 05/23/23 for diagnosis including hemiplegia (loss of limbs use of one side) and hemiparesis (loss of feeling limbs of one side) following a stroke, diabetes mellitus type II, chronic kidney disease, heart disease, and chronic ulcer of right lower leg. Review of Order Summary dated 08/21/25 of Resident #19 revealed orders for blood glucose checks four times a day. The Order Summary further revealed Resident #19 was ordered a FreeStyle Libre 2 Plus Sensor on 08/20/25 and to start use on 08/21/25. Observation on 08/21/25 at 11:30 A.M. revealed Registered Nurse (RN) #33 was cleaning the Assure Prism Glucometer with an alcohol wipe for less than one minute and then immediately returned to drawer in the medication cart while the glucometer was still wet. Interview on 08/21/25 with RN #33 revealed the process for cleaning the glucometer included wiping the glucometer with either alcohol or with Sani-Cloth Bleach Wipes (EPA #9480-8). She reported this was what she was instructed to do. When RN #33 was asked about wet time for Sani-Cloth Bleach Wipes and she could not answer, but Licensed Practical Nurse (LPN) #34, who was also present stated 5 minutes. Verified with LPN #34 and RN #33 the wet time per manufacture specified on the Sani-Cloth Bleach Wipes box was 4 minutes. RN #33 reported that she believed the wet time for the alcohol wipe was 5 minutes. LPN #34 was in agreement with 5 minutes. RN #33 verified that she had cleansed the glucometer with only one alcohol wipe and placed it back in drawer immediately without allowing to dry or ensuring wet time of 5 minutes. Interview on 08/21/25 with RN #33 verified the glucometer being used was for the medication cart assigned to Residents in room numbers 17, 18, and 19. RN #33 verified currently Resident #19 in room [ROOM NUMBER] was the only Resident utilizing the specified glucometer and that a personal FreeStyle Libre 2 Plus Sensor had been ordered for Resident #19 to monitor blood glucose but has not yet arrived. RN #33 verified Resident #19 currently had no diagnosis of blood borne pathogen diseases such as Hepatitis B or C or HIV. Review of the Assure Prism Multi glucometer manufacture's guidelines for cleaning and disinfecting revealed when the glucometer was used for multiple residents the following cleaning procedure should be followed: Each time the cleaning and disinfecting procedure is performed, two wipes are needed; one wipe to clean the meter and a second wipe to disinfect the meter. Always wear the appropriate protective gear, including disposable gloves. Open disinfectant package and pull out one towelette. Squeeze any excess liquid out of the towelette. Wipe the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from meter. Dispose of the towelette. Repeat above steps with a new towelette to disinfect the meter. Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Once complete, wipe meter dry. Use caution so as to not allow moisture to enter the test strip port, data port or battery compartment, as it may damage the meter. Review of Assure Prism Multi glucometer manufacture's guidelines for cleaning and disinfecting further revealed, Only wipes with the Environmental Protection Agency (EPA) registration numbers listed below have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device. These EPA registration numbers can be found on the EPA website. Wipes with EPA registrations numbers not listed below should not be used to clean and disinfect the Assure Prism meter. The products listed are Clorox Germicidal Wipes (EPA #67619-12, Clorox Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA # 56392-8), Super Sani-Cloth Germicidal Disposable Wipe (EPA # 9480-4), and CaviWipes1 (EPA #46781-13). Review of a policy titled Cleaning and Disinfection of Resident-Care Equipment, dated 03/31/25, revealed Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations to break the chain of infection. The policy referred to a Reusable multiple-resident item as items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators. The policy explanation and Compliance Guidelines for cleaning and disinfection further revealed staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. These guidelines should include: Verifying whether the equipment was single-use or reusable and discarding single-use items after use; Each user was responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident; and multiple-resident use equipment should be cleaned and disinfected after each use. Gloves should be worn when cleaning/disinfecting equipment, and staff should follow the manufacturer recommendations for cleaning equipment.

Based on record review, staff interview, and policy review, the facility failed to maintain an effective antibiotic stewardship program by not ensuring a resident was not started on an antibiotic for a suspected urinary tract infection until a urinalysis culture result was received to identify best course of treatment. This affected one (Resident #8) of four residents reviewed for urinary tract infections. The facility census was 50. Findings include: Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizophrenia, psychotic disorder with delusions, dementia, and the need for assistance with personal care. Review of Resident #8's nurses' progress notes revealed a nurse's note dated 06/04/25 at 3:13 P.M. that indicated the resident was seen by the nurse practitioner that day for increased confusion and weakness. She was previously ordered to have laboratory test performed to included a complete blood count and a complete metabolic panel, but had refused to have the lab drawn. A new order was to dip the resident's urine and to send it for a urinalysis and culture and sensitivity (U/A C&S) if positive. Her urine was dipped on 06/04/25 at 4:41 P.M. and was positive for leukocytes (white blood cells), protein, and blood. Her urine was collected and placed in lab refrigerator awaiting pick up. The nurse practitioner was notified and a new order was received to start the resident on Macrobid 100 milligrams (mg) by mouth twice a day for seven days for a urinary tract infection (UTI). Further review of Resident #8's nurses' progress notes revealed a nurse's note dated 06/09/25 at 4:30 P.M. that indicated the U/A C&S results were received. The nurse practitioner was in the facility and reviewed the results. She gave a new order to discontinue the resident's Macrobid and start Cipro 500 mg twice a day for seven days to treat her UTI. Review of the U/A C&S results for the urinalysis that was collected on 06/06/25 revealed Resident #8 had greater than 100,000 colonies/ milliliter of Klebsiella Pneumoniae in her urine indicative of a UTI. The susceptibility report showed Klebsiella Pneumoniae was only intermediate susceptible to Macrobid (the first antibiotic ordered), which meant the antibiotic might be effective at a higher or more frequent dose, but not as reliable as one of the susceptible results like Cipro (the second antibiotic ordered for the resident). On 08/21/25 at 1:40 P.M., an interview with the Director of Nursing (DON) confirmed Resident #8 was started on Macrobid for the treatment of a UTI on 06/04/25, prior to them receiving the final culture results. She further confirmed Resident #8's antibiotic had to be changed from Macrobid to Cipro on 06/09/25, after the culture results showed the organism causing the infection was more susceptible to Cipro than it was to the previous antibiotic ordered. She acknowledged antibiotics should not be initiated, until after the culture report was available identifying the the organism causing the infection, so an appropriate antibiotic could be ordered to properly treat the infection. She further acknowledged the resident was only given a partial course of the first antibiotic ordered, which could contribute to the identified organism being more resistant to the antibiotic. She was not able to provide any evidence of the resident having a history of sepsis, which may have supported the advanced level providers decision to go ahead and start the resident on an antibiotic out of precaution before the culture and sensitivity results were available. Review of the facility's Antibiotic Stewardship policy (not dated) revealed it was the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The DON was responsible for establishing standards for nursing staff to assess, monitor, and communicate changes in a resident's condition that could impact the need for antibiotics, use their influence as nurse leaders to help ensure antibiotics were prescribed only when appropriate, and educate front line nursing staff about the importance of antibiotic stewardship and explain policies in place to improve antibiotic use. Antibiotic orders obtained from consulting providers should be reviewed for appropriateness.

Based on observation, interview, review of manufacturer guidelines, and facility policy review, the facility failed to date a multi-dose vial of Tubersol tuberculin solution when opened for use. This deficient practice had the potential to affect 12 residents who were newly admitted after the tuberculin solution was received from the pharmacy. The facility census was 50. Findings Include: An observation on 04/23/24 at 7:43 A.M. revealed an in use opened multi-dose vial of Tubersol tuberculin solution in the medication refrigerator located in the facility medication room. There was a yellow sticker on the bottom of the vial with the word date written on it. There was no opened date written on the sticker, on the vial or on the box were the vial was stored. The storage box had a label from the pharmacy with a delivery date to the facility of 03/07/24. Interview on 04/23/24 at 7:50 A.M. with Licensed Practical Nurse (LPN) Unit Manager #400 confirmed the opened multi-dose vial Tubersol tuberculin solution did not have an opened date on the yellow sticker, the vial or the box where the vial was stored. She stated, Once the vial is opened then there is 30 days in which we use the solution and then the vial is discarded. There is no open date on this vial to show when it as started being used. Review of the manufacture guidelines for Tubersol tuberculin solution dated 10/2021 revealed, A vial of Tubersol which has been entered and in use for 30 days should be discarded. Review of the facility's policy titled, Storage of Medications dated 04/2019 revealed, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and review of facility policy, the facility failed to use appropriate hand hygiene during meal service. This had the potential to affect 46 of 46 residents who consumed food from the kitchen. The facility identified four residents (#25, #42, #46, #51) who were unable to eat by mouth. The facility census is 50. Findings include: Observation on 04/24/24 from 10:45 A.M. to 12:19 P.M. of the kitchen revealed Dietary Staff #466 doing a variety of tasks including the following: preparing puree food, putting gloved and ungloved hands into oven mitts to pull food out of the oven, setting up the steamtable, obtaining food temperatures, going in and out of the walk-in refrigerator, and serving food. Meal service included a bacon,lettuce,tomato (BLT) sandwich, Dietary Staff #466 was observed touching the bread for the BLT and the bread for grilled cheese sandwiches. During the entire observation Dietary Staff #466 was observed changing her gloves multiple times, however, she was not observed washing her hands during the entire observation. Observation on 04/24/24 between 10:45 A.M. to 12:19 P.M. revealed Dietary Staff #460 enter the kitchen from the dining room, put on gloves, and began preparing grilled cheese. Dietary Staff #460 did not wash her hands. Interview on 04/24/24 at 12:19 P.M. with Dietary Staff #466 and Dietary Manager #459 verified the observation. Review of the policy 'Hand Washing' undated, revealed employees were to wash hands in the following instances: when entering the kitchen, after handling soiled equipment or utensils, during food preparation as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks, before donning disposable gloves for working with food and after gloves are removed, and after engaging in other activities that contaminate hands.

Based on observation, interview, and review of facility policy the facility failed to ensure five residents (#11, #27, #28, #37, and #49) on a mechanically altered diet were served food at an appropriate texture. This affected five residents (#11, #27, #28, #37, and #49) of 15 residents on a mechanically altered or soft diet. The facility census was 50. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dysphagia, hypertension, and cognitive communication deficit. Review of Resident #27's diet order dated 09/29/23 revealed an order for a soft texture diet. 2. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including cerebral infarction, respiratory disorders, depression, and diabetes mellitus. Review of Resident #37's diet order dated 09/09/23 revealed she was to receive a mechanically altered diet. 3. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including dysphagia, cerebral infarction, schizoaffective disorder, and diabetes mellitus. Review of Resident #11's diet order dated 04/21/23 revealed an order for a mechanically altered diet. 4. Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including vascular dementia, depression, spondylolysis, and hypertension. Review of Resident #49's diet order dated 09/20/23 revealed an order for a mechanical soft diet. 5. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including dysphagia, depression, diabetes mellitus, and chronic respiratory failure. Review of Resident #28's diet order dated 02/21/24 revealed an order for a mechanically altered diet. Observation on 04/24/24 from 10:45 A.M. to 12:19 P.M. of the lunch meal revealed residents on a mechanically altered diet were offered the meal alternate chicken lasagna or an always available item. During meal service five residents (#11, #27, #28, #37, and #49) on a mechanically altered diet were observed to receive the chicken lasagna. The lasagna was observed to have large chunks of chicken, one piece of chicken leftover in a pan was observed to be slightly larger than a quarter. Interview on 04/24/24 following the lunch meal with Dietary Manager #459 verified residents on a mechanically altered diet received the chicken lasagna. She reported the lasagna came frozen and she was told by the previous cook that it was appropriate for residents on a mechanically altered diet without alterations. Dietary Manager #459 asked Speech Language Pathologist (SLP) #500 about the size of meat and SLP #500 indicated that she expected meat for those on a mechanically altered diet to be the size of a quarter (0.955 inches) or less. Dietary Manager #459 indicated she had used the frozen lasagna many times and 'just knew' the chicken was the size of a quarter or less. Interview on 04/25/24 at 9:40 A.M. with Dietary Manager #459 verified the facility policy indicated meat should be 1/4 an inch or less. Review of the facility policy 'Mechanical Soft Diet' undated, revealed a mechanical soft diet included chopped, ground and pureed foods as well as foods that break apart without a knife. It indicated foods to avoid included casseroles with large chunks of meat. All foods must be in pieces that are no longer than 1/4 of an inch. This may mean using a blender, food processor, grinder, or potato masher.

Based on observation, record review, interviews, and facility policy review the facility failed to apply and document the use of a left elbow brace to decrease the decline of contracture. This affected one resident (Resident #5) out of two residents reviewed for position and mobility. The facility census was 50. Findings Include: Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses including Cerebral Palsy, high blood pressure, and type two diabetes mellitus. Resident #5 required assistance from staff to complete personal care tasks, transfers, and bathing. Resident #5 had mild cognitive impairment and used a wheelchair for mobility. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section O - Special Treatments, Procedures, and Programs splint or brace assistance was not marked. Review of Resident #5's signed physician orders for 04/2024 revealed an order dated 02/02/24 for Resident #5 to wear a left elbow extension brace/splint up to 6 to 8 hours daily, staff to don and doff the brace/splint. Review of Resident #5's Treatment Administration Record (TAR) dated 02/01/24 to 02/29/24, 03/01/24 to 03/31/24 and 04/01/24 to 04/23/24 revealed no documentation entries for the placement of Resident #5's left elbow brace. Review of the occupational therapy summary of skilled service notes dated 02/01/24 at 3:27 P.M. authored by Occupational Therapist Assistant (OTA) #725 revealed therapist placed left elbow brace on Resident #5 without complication. Resident #5 able to doff the brace with assistant from the OTA. Care giver education was completed for correct placement on Resident #5's left elbow to decrease contracture development. Review of staff education for correct left elbow placement dated 02/01/24 revealed six staff members had completed the education by the OTA. Review of Resident #5's Activities of Daily Living (ADL) care plan revised date of 03/13/24 revealed Resident #5 has limited range of motion and hemiparesis to left extremities. Resident #5 has an ADL intervention of a left elbow brace to be worn daily. Review of Resident #5's Point of Care (POC) task documentation for the last 30 days dated 03/23/24 to 04/23/24 revealed no entries documented for the placement of Resident #5's left elbow brace. An observation on 04/22/24 at 9:18 A.M. revealed Resident #5 was sleeping in bed, there was a brace laying on the over the bed table. An observation on 04/22/24 at 1:53 P.M. revealed the brace was laying top of the three drawer dresser at the foot of Resident #5's bed. Resident #5 was out of the room participating in activities. An observation on 04/23/24 at 8:58 A.M. revealed Resident #5 was resting in bed watching television, the brace was laying on the top of the three drawer dresser at the foot of the bed. An observation on 04/23/24 at 1:30 P.M. revealed Resident #5 sitting in a wheelchair watching television in her room, the brace was still laying on top of the three drawer dresser at the foot of the bed. Interview on 04/23/24 at 1:55 P.M. with Resident #5 revealed the staff sometimes apply the brace to her left elbow. Resident #5 stated Yes, sometimes they put that on me. Interview on 04/23/24 at 2:01 P.M. with State tested Nursing Assistant (STNA) #413 confirmed Resident #5's left elbow brace was laying on top of the three drawer dresser at the foot of the bed instead of being applied to Resident #5's left elbow. STNA #413 applied the left elbow brace to Resident #5's left elbow. Interview on 04/24/24 at 10:25 A.M. with Licensed Practical Nurse (LPN) Unit Manager #400 revealed when the order was originally written the task option was not activated for the order to be viewed on the POC task screen for the STNAs to be able to document application and removal of the left elbow brace for Resident #5. LPN Unit Manager #400 confirmed there was not documentation in Resident #5's medical record to reflect the application or removal of the left elbow brace by the STNAs. Review of the facility's policy titled, Resident Mobility and Range of Motion dated 07/2017 revealed, Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion.

Based on interview, record review, and review of facilities investigative report, the facility failed to ensure Resident #39 received the appropriate assistance, resulting in a fall. This affected one resident (#39) of two residents reviewed for falls. The facility census was 50. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including traumatic hemorrhage of cerebrum, anxiety, depression, epilepsy, neuromuscular dysfunction of bladder, quadriplegia, anoxic brain damage, chronic obstructive pulmonary disease, and chronic respiratory failure. Review of Resident #39's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed he had moderately impaired cognition. Resident #39 was dependent on staff for all activities of daily living. Review of Resident #39's plan of care dated 10/16/23 revealed he was at risk for falls related to poor communication, impaired vision, impaired mobility, weakness, impaired cognition, anoxic brain injury, and quadriplegia. Interventions included using a blow call light, bolster mattress, anticipate and meet needs, therapy evaluation as needed, and added on 02/22/24 bariatric air mattress. Review of Resident #39's plan of care dated 10/16/23 revealed he had an activity of daily living self-care performance deficit related to diagnoses including anoxic brain injury, quadriplegia, and hydrocephalus. Interventions included two-person total assistance for bed mobility and transfers. Review of Resident #39's progress note dated 02/22/24 revealed the State tested Nursing Assistant (STNA) assisted the resident to the floor from his bed when he was getting changed and turned to the opposite side. The resident was assessed, and no injuries were noted. Review of Resident #39's investigation report dated 02/22/24 revealed the floor nurse was told by the STNA providing care for Resident #39 that he was assisted to the floor during routine care, when he was getting changed and attempted to be turned to the opposite side. No injuries were identified, and he denied pain. The interdisciplinary team reviewed the event and indicated Resident #39 had been receiving Botox injections and had changed muscle tone, additionally he had a significant weight gain over the previous six months. It was noted that a larger bed would decrease the risk of another fall due to the resident being so close to the edge of the bed when being turned and repositioned during care and create a safer environment for bed mobility, transfers, and positioning. The new intervention was a bariatric air mattress. Interview on 04/23/24 at 4:39 P.M. with the Director of Nursing (DON) revealed during care a STNA rolled the resident away from her and he started sliding. The DON verified one aide was providing care at the time of the fall when it 'probably should have been two.' The DON verified Resident #39's plan of care indicated he required two-person assistance for bed mobility.

Based on observation, record review, interview, and facility policy review, the facility failed to change oxygen and nebulizer tubing as ordered. This affected one resident (Resident #14) out of two residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including asthma, high blood pressure, dementia, and weakness. Resident #14 had severe cognition impairment, required staff assistance for personal hygiene cares, transfers, and bathing. Review of Resident #14's signed physician orders revealed an order dated 01/11/23 Oxygen at 2 liters (L) as needed to maintain blood oxygen levels (SP02) greater than 90%, an ordered dated 09/29/23 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3 milligrams (mg) per 3 milliliters (ml) via nebulizer every four hours as needed for congestion, and an order dated 02/04/24 for Oxygen (02) tubing to be change every week on Sunday night shift. Review of Resident #14's Asthma care plan dated 07/18/23 revealed interventions to use oxygen with setting at 2 liters (L) via nasal cannula (NC) and to administer nebulizer medications as ordered. An observation on 04/22/24 at 9:32 A.M. revealed Resident #14 sitting in a wheelchair receiving oxygen via nasal cannula with tubing attached to the oxygen concentrator. Oxygen concentrator setting at 2 liters with the tubing dated 04/14/24. A nebulizer (breathing treatment machine) was noted sitting on top of the three-drawer dresser at bedside with tubing dated 04/14/24. An observation on 04/23/24 at 9:27 A.M. revealed Resident #14 sitting in a wheelchair in the unit lounge area. Oxygen concentrator was noted in Resident #5's room, [NAME] running, with the oxygen tubing laying on the bed and still dated 04/14/24. The nebulizer was still sitting on top of the three-drawer dresser and the tubing still dated 04/14/24. An interview on 04/23/24 at 9:30 A.M. with Licensed Practical Nurse (LPN) #419 confirmed Resident #14's oxygen tubing and nebulizer tubing was dated 04/14/24. LPN #419 stated, The oxygen and nebulizer tubing and supplies are changed on Sunday nights during night shift and then the order is signed off on the Treatment Administration Record (TAR) when completed. The dates are from Sunday night a week ago. Review of the facility policy titled, Oxygen Administration dated 03/2023 revealed, Staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on record review, interview, and facility policy review, the facility failed to complete a bed hold notice within 24 hours of a resident's discharge to the hospital. This affected one resident (Resident #55) out of four residents reviewed for hospitalization . The facility census was 50. Findings Include: Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE] and was sent to the hospital on 02/03/24 for evaluation of altered mental status and was discharged from the facility on 02/05/24. Review of Resident #55's medical record revealed Resident #55 primary payer was Ohio Medicaid which requires notification to resident's representative the option to hold the resident's bed at the facility following a discharge to the hospital. There was no bed hold notice found in Resident #55's medical record. Interview on 04/23/24 at 10:02 A.M. with the Business Office Manager (BOM) # 472 confirmed Resident #55 did not have a bed hold notification sent to the resident's representative due to having been discharged to the hospital on a weekend day (Saturday). BOM #472 stated, I do send the bed hold notices out within 24 hours of a resident being sent to the hospital. In this case, the resident was sent to the hospital on a Saturday. I would have sent the bed hold notice on the Monday after her discharge to the hospital. On that Monday, the resident's family had come in and informed the facility the resident would not be returning to the facility, so I did not complete the bed hold notice for the resident. Review of the facility's policy titled, Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail the rights and limitations of the resident regarding bed-holds.

Based on open and closed medical record reviews, interviews with staff, review of side effects for Paxlovid (an antiviral medication), review of interaction warning for Paxlovid medication, review of fact sheet on Paxlovid, review of hospital records, and facility policy review, the facility failed to adequately monitor residents for signs and symptoms of bleeding while taking an anticoagulant medication. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #56 was prescribed Paxlovid (an antiviral medication) twice daily for five days to treat COVID-19 infection while also taking Rivaroxaban (generic brand for Xarelto), an anticoagulant medication. The facility failed to monitor Resident #56 for signs of bleeding and the resident subsequently exhibited signs of internal bleeding on [DATE] without facility intervention including notification of the medical practitioner. The Immediate Jeopardy continued [DATE] when Resident #56 again had signs of internal bleeding and was noted to have a moderate amount of blood in her stool and complained of abdominal pain. Resident #56 became lethargic, pale, and difficult to arouse, was sent to the emergency room for evaluation and treatment where she passed away from a brain bleed and a gastrointestinal (GI) bleed. In addition, concerns that did not rise to the level of Immediate Jeopardy were identified when six additional residents (Resident #9, #15, #30, #42, #48, and #109) reviewed for anticoagulant medication administration were identified without a care plan and/or adequate monitoring for signs and symptoms of side effects (including bleeding) from the anticoagulant medications. This affected seven residents (Resident #9, #15, #30, #42, #48, #56, and #109) of eight residents reviewed for anticoagulant medications. The facility census was 59. On [DATE] at 3:41 P.M. the Director of Nursing (DON) and Unit Manager (UM) #101 were notified Immediate Jeopardy began on [DATE] when Resident #56 was prescribed Paxlovid (a medication to treat COVID-19) while concurrently being administered the anticoagulant medication, Xarelto without any increased monitoring for any signs and symptoms of bleeding or bruising despite the warning that the two medications could have a severe interaction causing increased bleeding. On [DATE], Resident #56 was noted to have reddish colored urine but staff failed to notify Certified Nurse Practitioner (CNP) #192 of the change in condition and failed to complete any additional monitoring for signs and symptoms of bleeding or bruising. On [DATE] at 2:19 P.M., Resident #56 was noted to have a moderate amount of blood in her stool and complained of abdominal pain. On [DATE] at 3:24 P.M., Resident #56 was lethargic, pale, and difficult to arouse. The resident was sent to the emergency room . On [DATE] at 9:43 P.M., the facility was notified by Resident #56's family the resident had passed away as a result of a brain bleed and a gastrointestinal (GI) bleed. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] by 3:00 P.M. care plans for each resident who was receiving anticoagulant therapy were reviewed and updated to address anticoagulant therapy by Minimum Data Set (MDS) Nurse #128 with documentation on the care plan. This includes all potentially affected residents, Resident #8, #15, #258, #109, #30, #3, #50, #42, #37, #12, #9, #29, #6, #48, #44, #5, #41, #13, and #20. On [DATE] by 3:00 P.M. each nurse (nine registered nurses and 12 licensed practical nurses) and 30 Nursing Assistantswere educated in person or telephonically regarding monitoring for adverse effects of anticoagulant therapy by DON, Unit Manager #149, Unit Manager #l01. On [DATE] at 4:30 P.M. a discussion with Pharmacy Manager #220, Facility Pharmacist #221, Pharmacist #190, and Pharmacist #195 regarding drug interactions, process for contacting facility based on the level of severity of the interaction (mild/moderate/severe) and agreement was made for the pharmacy to call the facility for all severe interactions was held. Drug interactions will be assessed by the pharmacy. Their dispensing system will flag drug interactions as they verify the order and physician will be notified of potential interaction by facility. Pharmacist will not dispense medication and contact facility by phone. If there is a potential interaction, the pharmacy will not dispense medication until receiving verification from physician. The consulting pharmacist also completes a monthly review, the consulting pharmacist reviews the patient's current active medications every month and provides recommendations for nursing and medical staff follow-up. On [DATE] by 5:00 P.M. all residents receiving anticoagulant therapy including Residents #15, #8, #258, #109, #30, #3, #50, #42, # 37, # 12, # 9, #29, #6, #48, #44, #5, #41, #13 and #20 had skin assessments completed by nurse weekly. The skin assessment monitors for any new areas on the skin including signs of adverse effects of anticoagulant. These residents were assessed by the nurse with no adverse effects found. On [DATE] at 6:00 P.M. information was provided to the facility Quality Assessment and Performance Improvement (QAPI) Committee for review and additional guidance. The Medical Director provided input and approved the facility's abatement plan on 03/l ,d+[DATE] at 6:00 P.M. On [DATE] by 7:00 P.M. each nurse was educated in person or telephonically regarding the process for handing potential drug interactions by the DON, Unit Manager #149, or Unit Manager #101. Drug interactions will be assessed by the pharmacy. Their dispensing system will flag drug interactions as they verify the order and physician will be notified of potential interaction by facility. If the drug is flagged for an interaction, the pharmacy will not dispense medication until receiving verification from physician. On [DATE] by 8:00 P.M. a whole house audit for residents receiving anticoagulants was completed by the Director of Nursing (DON) or designee. No residents were noted to have adverse side effects from anticoagulants. Orders were verified to be in place and updated to monitor for adverse effects of anticoagulant therapy and if noted to report to the physician as clinically indicated for all residents who have orders for it. This was completed on [DATE] at 2:36 P.M. by Nurse Unit Manager #101. On [DATE] by 8:00 P.M. all 30 State tested Nursing Assistants (STNAs) were educated to report any signs of bleeding or bruising to the nurse and to ensure that the nurse visualized the concern by the DON, Unit Manager #149, or Unit Manager #101. On [DATE] by 8:00 P.M. the DON, Unit Manager #149, or Unit Manager # 101 completed an audit on all residents receiving anticoagulation therapy to include physician orders and care plans for monitoring adverse effects i.e.: bruising and bleeding. Residents #8, #15, #42, #258, #109, #30, #3, #37, #12, #9, #44, #5, and# 41 had care plans with anticoagulant monitoring. These care plans were reviewed and updated as necessary with documentation of the additions. The audit showed that Residents #50, #29, # 6, #48, #13, and #20 did not have care plans that addressed monitoring for adverse effects of anticoagulants. Appropriate interventions were added by the MDS Nurse #128 by 6:00 P.M. on [DATE]. On [DATE] by 8:00 P.M. the DON developed a monitoring tool and implemented monitoring tool and process of adverse effects of anticoagulant medications. This was implemented on [DATE] by 12:00 P.M. Monitoring tool will include list of residents on anticoagulant therapy and verification that monitoring was completed as ordered. This monitoring will be completed by DON, Unit Manager #149, or Unit Manager #101 that was trained on [DATE] by 8:00 P.M. On [DATE] by 12:00 P.M. the facility implemented a plan for audits to be conducted twice a week for two weeks and then weekly for a month by the DON, Unit Manager #149, or Unit Manager #101 to check for orders and care plans for monitoring of adverse effects of anticoagulant medications for all resident who have received them. On [DATE] at 12:00 P.M. the facility implemented a plan for audits on drug interactions and ensuring appropriate follow-up were completed and will be reviewed weekly by the QAPI Committee for two weeks. QAPI team will provide further guidance and monitoring as needed. On [DATE] at 3:00 P.M. the DON implemented an audit tool to monitor for appropriate follow up on each drug interaction and MMR made by the pharmacy. Audits will be conducted twice a week for 2 weeks and then weekly for a month by DON or designee. On [DATE] at 5:00 P.M. each nurse (12 LPNs and 9 RNs) were educated in person or via telephone regarding the process for handling potential drug interactions by the DON, Unit Manager #149, or Unit Manager #101. On [DATE] at 9:18 A.M. interviews with RN #152, STNA #160 and STNA #167 revealed all staff interviewed had received facility education related to anticoagulant medication use, drug interactions and/or monitoring for signs/symptoms of bleeding/bruising. Although the Immediate Jeopardy was removed on [DATE], 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: 1.Review of the closed medical record for Resident #56 revealed an admitted on [DATE] and a discharge date due to death on [DATE]. Medical diagnoses included major depressive disorder, anxiety disorder, gastrostomy status, tracheostomy status, unspecified psychosis, hypertension (HTN), malignant neoplasm of unspecified female breast, unspecified open wound of unspecified part of head, unspecified fractures of lower left femur, neck, multiple ribs on left side, and shaft of left clavicle, and displaced fracture of sixth cervical vertebra. Review of a hospital discharge record dated [DATE] (prior to admission to the facility) revealed Resident #56 sustained multiple fractures from a motor vehicle accident. Resident #56 was prescribed the anticoagulant medication, Xarelto for a diagnosis of coagulopathy (a condition in which the blood's ability to form clots is impaired). Resident #56 received surgical intervention to repair injuries to her left leg. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #56 required extensive assistance to total dependence from one to two staff to complete activities of daily living (ADLs). The assessment did not indicate Resident #56 had received an anticoagulant medication daily. The assessment was incorrect as the resident had received an anticoagulant daily. Review of the physician's orders revealed Resident #56 had a medication order, dated [DATE] for Rivaroxaban (generic for Xarelto) 20 milligrams (mg) via peg tube one time daily for prevention. The medication was ordered by Physician #200. On [DATE] the resident had an order for Paxlovid (,d+[DATE]) oral tablet therapy pack twenty X 150 milligrams (mg) and ten X 100 mg with instructions to give 300 mg via peg-tube two times daily for COVID-19 for five days and give 100 mg via peg tube two times a day for COVID-19 for five days. The medication was ordered by Certified Nurse Practitioner (CNP) #192. There was not a physician order to monitor for side effects or signs and symptoms of bleeding in place. Review of the Paxlovid order, dated [DATE] at 3:59 P.M. revealed the medication had an ALERT! Drug Interaction. The alert was located on the right-hand side in the electronic medical record when the physician order was clicked on to be viewed. Review of the Drug-to-Drug Interaction Details, viewed when the medication alert was clicked on in the electronic medical record, revealed there was a severe interaction with Rivaroxaban (Xarelto) medication which stated, Coadministration of rivaroxaban with combined Paxlovid should be avoided according to official package labeling in the United States. Review of an electronic Medication Administration Record (eMAR) note, titled Orders-Administration Note in the progress notes section of the electronic medical record, dated [DATE] at 4:01 P.M. revealed the system had identified a possible drug interaction with a severity of severe with Rivaroxaban with plasma concentrations and pharmacologic effects of Rivaroxaban may be increased in combination with Paxlovid. Coadministration of Rivaroxaban with Paxlovid should be avoided according to official package labeling in the United States. Review of the resident's care plan revealed the plan of care did not address anticoagulant medication or monitoring for signs and symptoms of bleeding or bruising. Review of a progress note from Certified Nurse Practitioner (CNP) #192 dated [DATE] revealed Resident #56 was seen for follow up due to COVID-19 diagnosis. Resident #56's medications were reviewed and reconciled. Care included to start COVID-19 protocol, Paxlovid ,d+[DATE] therapy pack twice daily for five days due to Resident #56's COVID-19 positive diagnosis. There was no mention of a possible interaction with Xarelto medication. Review of a progress note from CNP #203 dated [DATE] revealed Resident #56 was seen for follow up related to COVID-19 diagnosis. The resident's medications were reviewed and reconciled, and the resident would continue medications, including Paxlovid 300 mg twice daily. There was no mention of a possible interaction with Xarelto medication. Review of the Medication Administration Record (MAR) dated [DATE] revealed Resident #56 received Rivaroxaban daily as ordered and Paxlovid twice a day for five days (a total of ten doses) from [DATE] to [DATE] as ordered. Review of progress notes dated from [DATE] through [DATE] revealed on [DATE] at 6:40 A.M., an unidentified State tested Nursing Assistant (STNA) reported to Licensed Practical Nurse (LPN) #107 that Resident #56's urine color appeared reddish. Resident #56's vital signs were within normal limits and the resident denied any pain. The morning shift nurse (unidentified) was notified. There was no evidence the CNP or physician were notified of the change in condition. On [DATE] at 2:19 P.M., a progress note entered by Registered Nurse (RN) #152 revealed an unidentified STNA called the nurse to Resident #56's room. The resident had a moderate amount of blood in stool and Resident #56 complained of pain to abdomen. The resident's blood pressure was ,d+[DATE]. CNP #205 was notified and new orders for an abdominal x-ray, complete blood count (CBC), and complete metabolic panel (CMP) were provided. On [DATE] at 3:24 P.M. (approximately one hour later), a progress note entered by RN #152 revealed Resident #56 was lethargic, pale, and difficult to arouse. Resident #56's temperature was 100.3 degrees Fahrenheit and blood pressure was ,d+[DATE]. CNP #205 was notified and a new order to send Resident #56 to the emergency room was given. On [DATE] at 9:43 P.M., a progress note entered by RN #156 revealed Resident #56's family called to notify the facility that Resident #56 had passed away as a result of a brain bleed and a gastrointestinal (GI) bleed. Review of hospital records, dated [DATE] at 4:02 P.M. revealed Resident #56 had a history of deep vein thrombosis and was on Xarelto medication. The resident presented to the hospital for an evaluation of unresponsiveness. The records noted staff checked on Resident #56 at 1:00 P.M. and she had complained of abdominal pain and when checked again at 3:30 P.M., the resident was unresponsive. At 5:20 P.M., the radiologist reported Resident #56 had a large intraparenchymal hemorrhage of the right frontal lobe with mass-effect and vasogenic edema (a brain bleed). KCentra (a medication to reverse effects of anticoagulant) and Vitamin K were ordered. The family reported Resident #56 had dark stools and there was concern for GI bleeding. A rectal exam was performed and was positive for bloody stool. Troponin levels were elevated likely due to blood loss and hemoglobin was 7.1. Resident #56 was admitted to the Intensive Care Unit (ICU) for further critical care treatment. Resident #56 was pronounced deceased on [DATE] at 9:30 P.M. at the hospital. Interview on [DATE] at 2:51 P.M. with the Director of Nursing (DON) revealed Resident #56 was fine and was not on the radar for any concerns except weight gain prior to [DATE]. The DON stated she was notified on [DATE] of Resident #56's bloody stool. The DON was not aware and had not been notified of reddish colored urine on [DATE]. The DON confirmed Resident #56 was on an anticoagulant medication, Xarelto, and reddish colored urine would be a potential sign of bleeding. The DON stated she would have expected the CNP to be notified by the staff, additional monitoring for any other possible signs or side effects, a urine sample to be obtained and sent out for testing, and possibly additional lab work to be ordered. Interview on [DATE] at 3:57 P.M. with CNP #192 revealed she had not been notified that Resident #56 had reddish colored urine on [DATE]. CNP #192 stated she was not aware of any signs or symptoms of bleeding prior to [DATE]. CNP #192 confirmed Resident #56 was on Xarelto, an anticoagulant. CNP #192 stated staff noted resident concerns in a binder that she reviewed when she was on-site at the facility. CNP #192 confirmed the binder did not note any reddish colored urine for Resident #56. CNP #192 stated had she been notified of the change, she would have requested a more detailed description of the urine, ordered labs, and would have wanted the staff to continue monitoring for any signs or symptoms of bleeding (including blood in urine, blood in stool, or any increased bruising). Interview on [DATE] at 4:36 P.M. with CNP #192 revealed drug interactions between medications occur constantly and she would only consider stopping an anticoagulant if the interaction was a severe interaction. CNP #192 stated she assessed the benefits versus the risks of continued administration of Paxlovid and Xarelto together and felt the benefits outweighed the risks at that time to treat COVID-19 infection. CNP #192 confirmed she was aware of the possible severe interaction between the two medications and confirmed administering Paxlovid with Xarelto may increase bleeding. CNP #192 confirmed she should have been notified of Resident #56's reddish colored urine on [DATE] and would have expected staff to be monitoring Resident #56 of any signs or symptoms of bleeding while on the anticoagulant medication. Interview via telephone on [DATE] at 9:53 A. M. with Pharmacist #190 revealed she was a new consulting pharmacist who conducted monthly medication reviews at the facility since [DATE]. Pharmacist #190 stated a national software was used to identify drug interactions. If a severe interaction was identified, Pharmacist #190 notified the physician/DON/nurse manager directly due to the need for immediate attention as well as write a pharmacy recommendation. The pharmacist revealed it was the prescriber of the medication who made the final decision whether to continue administering the medications. Pharmacist #190 stated Paxlovid was a new medication and interacted with several medications. Pharmacist #190 confirmed Paxlovid administered with Xarelto could increase bleeding. Interview via telephone on [DATE] at 11:06 A.M. with Pharmacist #195 revealed he was a pharmacist with Complete Pharmacy Solutions, the pharmacy used to fill the facility's medication prescriptions. Pharmacist #195 stated medication orders were received via fax, electronically, or verbally but the bulk of the facility's orders were received by fax. Pharmacist #195 confirmed he checked for medication interactions with new prescriptions to ensure it was clinically safe to administer the medications prior to filling the prescription. If a severe interaction was identified, Pharmacist #195 stated he contacted the floor nurse who cared for the resident of the possible interaction. Pharmacist #195 confirmed there was risk for increased bleeding when Paxlovid and Xarelto were administered together. Pharmacist #195 stated a risk assessment would be completed with the floor nurse to review the benefits versus the risks of continuing administration of the medications together. Pharmacist #195 confirmed Paxlovid and Xarelto administered together would be a more major drug interaction with an increased risk of increased bleeding. Pharmacist #195 stated the resident should be monitored for signs and symptoms of increased bleeding. Pharmacist #195 confirmed Paxlovid was dispensed to the facility on [DATE] and confirmed Resident #56 was also on Xarelto for a long time. Pharmacist #195 stated the order was called in to the pharmacy by Nurse #207 and the same nurse would have been notified of the possible severe drug interaction. Interview via telephone on [DATE] at 4:50 P.M. with Physician #200 revealed he was aware Resident #56 was taking Paxlovid and Xarelto together to treat COVID-19 infection. Physician #200 revealed he felt the benefits outweighed the risks of administering the medications together at the time. However, Physician #200 confirmed the facility staff absolutely should have notified himself and/or the CNP of any signs or symptoms of bleeding for Resident #56. Physician #200 confirmed he was not notified of Resident #56's reddish colored urine on [DATE]. Physician #200 stated had he been notified of the reddish colored urine on [DATE], increased monitoring would have been initiated in an attempt to identify the cause of the reddish colored urine. Review of Paxlovid: What Prescribers and Pharmacists Need to Know, dated [DATE], revealed, there is uncertainty about effect magnitude in target populations and high certainty for harm with Paxlovid if drug interactions are not mitigated. Additionally, the fact sheet showed the recommendation if a resident was on Rivaroxaban (Xarelto) was do not coadminister, hold and restart two days after completing Paxlovid, and significant questions in drug concentrations expected. Do not coadminister due to risk of serious toxicity. If possible, use alternative COVID-19 agent. If not possible, then: low risk of clot: hold rivaroxaban. 24 hours after the last dose of rivaroxaban, start Paxlovid AND aspirin 81 mg daily. Finish Aspirin one day after completing Paxlovid. Restart Rivaroxaban two days after completing Paxlovid. High Risk of clot: hold rivaroxaban. 24 hours after the last dose of rivaroxaban, start Paxlovid AND therapeutic dosing of a subcutaneous low molecular weight heparin (LMWH). Finish LMWH one day after completing Paxlovid. Restart Rivaroxaban two days after completing Paxlovid. Review of Paxlovid Side Effects Center, dated [DATE], revealed Paxlovid had an established significant drug interaction with Rivaroxaban. Clinical comments included, Increased bleeding risk with Rivaroxaban. Avoid concomitant use. Review of the facility policy titled, Anticoagulation-Clinical Protocol, revised ,d+[DATE], revealed the policy stated, as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medications should be assessed for bleeding.) The physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines. The physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants. The physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant. If an individual on anticoagulation therapy shows signs and symptoms or evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant as indicated. Review of the undated facility policy, Medications and Treatment Orders, revealed: If a medication triggers with a severe interaction when putting it in resident's orders, physician will be notified, and pharmacy will verify medication with the provider. This will also be documented in resident's chart. When there is a medication which triggers with severe interactions and physician or NP chooses to continue with this medication therapy rational will be documented in a resident's record. Medications which have the potential for adverse reactions or side effects including anticoagulants, antibiotics etc . will have increased monitoring to meet assessment heeds. If any adverse reactions or side effects are noted, physician or NP will be notified immediately. 2. Review of Resident #9's medical record revealed an initial admitted [DATE] and readmitted on [DATE]. Medical diagnoses included dementia with other behavioral disturbance, unspecified atrial fibrillation, presence of cardiac pacemaker, chronic kidney disease Stage 3, and metabolic encephalopathy. Review of the care plan dated [DATE] revealed Resident #9's care plan addressed the resident taking an anticoagulant medication with interventions to monitor for signs and symptoms of bleeding. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #9 required supervision from staff to complete Activities of Daily Living (ADLs). Resident #9 was administered anticoagulant medication daily. Review of the physician's orders for [DATE] revealed Resident #9 had an order for Eliquis (an anticoagulant medication) 5 milligrams (mg) with instructions to give one tablet by mouth twice daily for atrial fibrillation. The order had a start date of [DATE]. There were not any orders to monitor for side effects or signs and symptoms of bleeding until [DATE] when an order was added (after surveyor intervention). Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE], February 2023, and [DATE] revealed Resident #9 received Eliquis medication twice daily as ordered unless the resident refused the medication. There was no evidence of any monitoring for side effects or bleeding noted on the MAR or the TAR for any of the three months. Review of progress notes dated from [DATE] through [DATE] revealed there was no evidence Resident #9 was monitored for any signs or symptoms of bleeding or side effects of anticoagulant medication. Interview on [DATE] at 3:49 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #9 was being monitored for side effects or signs and symptoms of bleeding while being administered an anticoagulant medication. 3. Review of Resident #30's medical record revealed an original admitted on [DATE] and a readmitted on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease (COPD), orthostatic hypotension, end stage renal disease, paroxysmal atrial fibrillation, and Type II Diabetes Mellitus. Review of the plan of care dated [DATE] revealed Resident #30 had a history of deep vein thrombosis (blood clots). Interventions included to monitor/document/report as needed any signs or symptoms of blood clots including abnormal bleeding, bruising, or petechiae (related to anticoagulant use). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #30 received daily anticoagulant medication. Review of physician's orders dated [DATE] revealed Resident #30 had an order for Eliquis (an anticoagulant medication) 2.5 milligrams (mg) with instructions to give one tablet twice daily for deep vein thrombosis (blood clot) prophylaxis. This order was dated [DATE] and the medication started [DATE]. There were no additional orders to monitor for side effects or signs and symptoms of bleeding until [DATE] when an order was added (following surveyor intervention). Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE], February 2023, and [DATE] revealed Resident #30 received anticoagulant medication twice daily as ordered. There was no evidence in the MARs or TARs Resident #30 was monitored for any side effects or signs and symptoms of bleeding while taking the anticoagulant medication. Review of the progress notes dated from [DATE] to [DATE] revealed there was not any evidence Resident #30 was monitored for side effects or signs and symptoms of bleeding. Interview on [DATE] at 3:49 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #30 was being monitored for side effects or signs and symptoms of bleeding while being administered an anticoagulant medication. Review of the facility policy, Anticoagulation-Clinical Protocol, revised ,d+[DATE], revealed the policy stated, the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications: for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. The staff and the physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs and symptoms or evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant as indicated. 4. Review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pneumonia, acute myocardial infarction, hemiplegia, metabolic encephalopathy, diabetes, acute kidney failure and heart failure. Review of Resident #15's physician orders dated [DATE] revealed an order for Lovenox (blood thinning medication); inject 40 mg (milligram) one time a day for deep vein thrombosis (DVT) prevention. Review of the Admission MDS assessment dated [DATE] revealed his cognition was not intact. He required extensive assistance for bed mobility and required total dependence of two or more staff members physical assistance for toilet use. The resident required extensive assistance of one staff member physical assistance for dressing and personal hygiene. The resident received anticoagulant medication six (6) days in the assessment period. Review of Resident #15's plan of care revealed there was no documented evidence of a plan of care for Lovenox or monitoring for sign and symptoms of bleeding related to the blood thinning medication. On [DATE] at 3:49 P.M. interview with the Director of Nursing verified the lack of monitoring for signs and symptoms of side effects from the anticoagulant/blood thinning medication. 5. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe pr [TRUNCATED]

Based on medical record review, review of hospital records, review of a fall investigation, facility policy review, and staff interviews, the facility failed to provide effective pain management to Resident #23 following a fall on 05/21/22 that resulted in two fractured ribs. This affected one resident (#23) of one resident reviewed for pain management. The facility census was 59. Actual Harm occurred to Resident #23 on 05/21/22 when the resident was not provided effective pain relief until being transferred to the hospital on 05/22/22 at 11:21 P.M. (nearly two days after the fall occurred) where subsequent additional treatment was provided to the resident for effective pain management. During the time period between the fall and the hospitalization the resident complained of increased pain, ineffective pain medication (Tylenol) and feeling fatigued due to an inability to sleep. Findings Include: Review of the medical record for Resident #23 revealed an original admitted on 04/05/22 and a readmitted [DATE]. Medical diagnoses included cerebral infarction, pain, fracture of rib, and difficulty in walking. Review of care plan dated 04/06/22 revealed Resident #23 was at risk for falls and had actual falls related to balance issues and weakness, macular degeneration, impaired cognition, impaired safety awareness, and repeated falls. Interventions included review information from past falls and attempt to determine the cause of falls, record possible root causes, alter or remove any potential causes if possible, and monitor/document/report as needed for 72 hours to physician for signs and symptoms of pain or injury and change in mental status. Resident #23 has potential acute and chronic pain related to history of frequent falls. Interventions included administer analgesic medications as per orders, monitor and report to nurse any signs and symptoms of non-verbal pain, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #23 required limited to extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #23 had one fall with injury, except major injury, since admission or the prior assessment. Review of physician orders for May 2022 revealed Resident #23 had an order for Acetaminophen 650 milligrams (mg) with orders to give one tablet every six hours as needed for mild pain. The order was entered with a start date of 04/14/22 and was discontinued on 05/25/22 at 10:28 A.M. Assess for pain every shift with a start date on 04/06/22. Review of the Morse Fall Scale assessment dated [DATE] at 12:50 A.M. revealed Resident #23 was a high risk for falling with a score of 80. Resident #23 had a history of falling. Resident #23 used an ambulatory aid and had a weak gait. Resident #23 overestimated or forgot limits. Review of the Incident Report dated 05/21/22 at 12:50 A.M. revealed the aide alerted Former Nurse (FN) #210 (no longer employed at facility) to Resident #23's fall. Resident #23 stated she was trying to find a snack. FN #210 observed Resident #23 sitting on the floor beside the bed with back facing her night stand and leaning against the trash can. Resident #23 was wearing non-skid socks and walker was in front of her. Resident #23 was assisted off the floor with assistance from three staff and helped back into bed. Injury to the right rear iliac crest was noted with a pain level of five out of ten on the pain scale with ten being the worst pain level. Redness to Resident #23's right lower back was also noted. Resident #23 was noted to be ambulating without assistance. The fall was reviewed by the Interdisciplinary Team (IDT) and Resident #23 would be offered a snack and keep snacks at her bedside. Review of the Interdisciplinary Fall/Incident Investigation dated 05/28/22 revealed the date of the fall was 05/21/22 at 12:50 A.M. Resident #23 was found on the floor. The resident had a dry brief on. Resident #23 was alert to self, place, and situation. Resident #23 had complaint of pain to her iliac crest but was able to stand with assistance and transfer back to bed. The CNP was notified and x-rays were ordered that were returned with negative results. Resident #23 was administered Tylenol with mixed effectiveness 24 to 48 hours post fall. The CNP was notified of continued pain and was sent to the emergency room for pain medication. Review of progress notes dated from 05/21/22 through 05/31/22 revealed on 05/21/22 at 1:15 A.M., a progress note titled, Communication with Physician, that stated, alerted on call of resident fall and complaints of right lower back pain. Redness to area and rates pain five out of ten on the pain scale. Recommendations were a new order for a sacral and lower thoracic x-ray and to only call if fracture or abnormal findings were noted from x-ray. On 05/21/22 at 1:56 A.M., a progress note stated the aide alerted the nurse that Resident #23 was on the floor. The nurse entered the room and observed resident sitting on the floor on her bottom beside the bed with her back facing the night stand and leaned against trash can. Vital signs were within normal limits. Resident #23 complained of pain to her right lower back. Area was noted to be red on right lower back. The nurse asked Resident #23 if she would like to go to the hospital and the resident declined. Resident #23 stated she had pain when she moved. Tylenol was administered. The on-call physician/Certified Nurse Practitioner (CNP) was notified and a new order for an x-ray of sacral area and lower thoracic area was given. Assistant Director of Nursing (ADON) was notified. Resident #23 was educated to use call light for assistance. Will continue to monitor Resident #23. On 05/21/22 at 12:10 P.M., a progress note stated the nurse left a message for the CNP and requested a return call regarding Resident #23's as needed pain medication. Awaiting a return call. On 05/21/22 at 4:39 P.M., a progress note stated post fall day one, Resident #23 had pain to her right lower back and hip area. As needed (PRN) Tylenol was administered. No new skin issues were noted from fall. Awaiting results from the x-ray. On 05/21/22 at 5:18 P.M., a progress note stated xray results were received on this date and no acute fractures to the sacrum or spine were noted. On 05/21/22 at 11:36 P.M., a progress note stated post fall day one, no new skin issues were noted related to the fall. Resident #23 continued to complain of generalized pain. PRN Tylenol was administered with intermittent relief. On 05/22/22 at 11:21 P.M., a progress note stated Resident #23 complained of increased lower back pain. Resident #23 was administered PRN Tylenol with no relief. On-call provider was notified and an order was received to send Resident #23 to the emergency room for pain management. Resident #23 left the faciity on [DATE] at 11:20 P.M. (nearly two days following the fall). Review of the Order Administration Notes dated from 05/21/22 through 05/23/22 revealed on 05/21/22 at 12:56 A.M., an administration note stated Acetaminophen Tablet give 650 mg by mouth every six hours as needed (PRN) for mild pain. Complains of back pain. On 05/21/22 at 10:00 A.M., an administration note stated Acetaminophen 650 mg by mouth every six hours as need for mild pain. Follow-up pain scale was four out of ten on the pain scale with 10 being the worst pain level. PRN administration was ineffective. On 05/22/22 at 7:00 P.M., an administration note stated Acetaminophen 650 mg by mouth every six hours PRN for mild pain. Resident #23 complained of lower back pain. On 05/22/22 at 10:07 P.M., an administration note stated Acetaminophen 650 mg by mouth every six hours as needed for mild pain. PRN administration was ineffective. Resident #23 continued to have increased pain. Follow-up pain scale was eight out of ten on the pain scale with ten being the worst pain level. Review of the Pain Tool assessment dated [DATE] at 12:50 A.M. revealed Resident #23 had pain on right iliac crest (rear) (located on right side of lower back above buttock). The pain was described as redness, sharp stabbing pain at first. Resident #23 stated she had pain with movement. Current pain level was noted as five out of ten on the pain scale with ten being the worst pain level and was marked as hurts even more on the faces scale. Rest made the pain better. Pain level at its least was described as three out of ten on the pain scale with ten being the worst pain level. Movement made the pain worse. Methods for alleviating pain were rest and PRN Tylenol. The effectiveness was not noted in the assessment. There were no additional Pain Tool assessments completed following Resident #23's fall. Review of the Medication Administration Record (MAR) dated May 2022 revealed Resident #23's pain levels 05/21/22 were six out of ten on the pain scale with ten being the worst pain during day shift and three during night shift. Pain levels on 05/22/22 were five out of ten on the pain scale with ten being the worst pain level during the day and eight during night shift. Acetaminophen Tablet give 650 mg by mouth every six hours as needed for mild pain was administered on 05/21/22 at 12:56 A.M. for a pain level of five out of ten on the pain scale with ten being the worst pain level. The medication was documented to be effective. On 05/21/22 at 7:34 A.M., the medication was administered for a pain level of six and was documented as ineffective. On 05/22/22 at 7:00 P.M. (approximately 36 hours later), the medication was administered for a pain level of eight out of ten on the pain scale with ten being the worst pain level and it was documented as ineffective. There were not any additional medications for pain administered to Resident #23. Review of hospital records dated 05/22/22 for Resident #23 revealed the resident admitted to the hospital on 05/22/22 at 11:40 P.M. with an expected discharge date of [DATE] (two days later). Resident #23's pain level on 05/22/22 at 11:50 P.M. was eight out of ten on a pain scale from zero to ten with ten being the worst pain level. The Attending Physician (AP) Note showed Resident #23 was seen, examined, and discussed with a trauma team. Findings included rib fracture. The traumatic event was noted as a ground level fall with complaint of back and rib pain following a fall two days prior at Resident #23's skilled nursing facility. Resident #23 had been complaining of some right posterior chest wall and back pain over the course of the last two days. Upon arrival, Resident #23 was evaluated with a comprehensive work-up which resulted in discovery of two isolated nondisplaced rib fractures at the right posterior chest wall, #8 and #9 respectively. Resident #23 complained of isolated right posterior chest wall pain and feeling fatigued due to inability to sleep over the last two days. Imaging results noted acute right posterior eighth and ninth rib fractures with additional healing right rib fractures. Resident #23 was noted to be awake and in mild painful distress. Oxycodone immediate release tablet 5 mg every eight hours as needed was ordered for pain. Interview on 03/16/23 at 2:06 P.M. with the Director of Nursing (DON) confirmed Resident #23 was not administered any additional pain medication other than PRN Tylenol from 05/21/22 around 1:00 A.M. through 05/22/22 around 11:30 P.M. (approximately two days) until the resident was sent out to the emergency room for pain management. The DON confirmed the PRN Tylenol medication was marked as ineffective and Resident #23 continued to complain of back pain. The DON confirmed there was also no evidence of any additional non-pharmacological interventions being attempted to reduce Resident #23's pain level. Review of the facility policy, Pain-Clinical Protocol, revised 03/2018, revealed the policy stated, with input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain.

Based on clinical record review, facility investigation review, observation, staff interview, and policy review the facility failed to ensure a safe transfer with a mechanical lift for one (Resident #1). Actual harm occurred when one strap on the lift pad broke, resulting in a fall and subsequent closed cervical (C2) fracture, laceration of the scalp and an acute subdural hematoma. This affected one (Resident #1) of three residents reviewed for falls. The facility identified 10 residents (#1, #4, #9, #10, #37, #38, #71, #74, #63 and #65) who required transfer using a mechanical lift. The facility census was 73. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received hospice services beginning on 03/20/19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had both short and long term memory loss, severely impaired cognition, and was non verbal. Resident #1 required the extensive assistance of two staff and the use of a mechanical (Hoyer) lift for transfers. Review of the nursing note dated 06/22/19 at 11:22 A.M. revealed Licensed Practical Nurse (LPN) #79 was called to the resident's room and found the resident laying face down on the floor between the Hoyer lift legs. Blood was noted on the left side of the resident's scalp and emergency services were called immediately. The emergency service staff applied a cervical collar around her neck and safely transferred her to the hospital. The note stated that during a transfer using a Hoyer lift, the lift pad broke and the resident fell to the floor. Review of the hospital discharge documentation dated 6/24/19 revealed the resident was treated for [REDACTED]. She returned to the facility with orders to continue the cervical collar, [MEDICATION NAME] 325 milligrams two tablets twice daily for pain and [MEDICATION NAME] (used to treat anxiety) 0.5 milligrams as needed every six hours. Review of the investigation completed by the facility revealed two State tested Nursing Assistants (STNAs) #75 and #80 were transferring the resident from her bed using a Hoyer lift on 06/22/19 at 11:22 A.M. The resident was raised in the air above the floor when the sling pad broke causing the resident to fall face down to the floor. On 06/22/19 the Director of Nursing (DON) completed training with the laundry staff to visually inspect the lift pads after washing and the STNAs before using the pads to lift a resident. All lift pads in the facility were inspected and one other lift pad was found damaged and discarded. On 06/22/19 a policy titled Hoyer Pad Monitoring was developed for the Housekeeping/Laundry Supervisor to complete monthly inspections on all hoyer pads. Interview with the Administrator and DON on 06/28/19 at 8:50 A.M. verified there were no other resident falls or fractures the past six months and no concerns with hoyer transfers prior to this incident. There was no formal policy for staff inspecting the condition of the hoyer pads prior to this incident on 06/22/19. Observation at that time of the lift pad that was used for Resident #1 when the fall occurred on 06/22/19 revealed one of eight straps had broke away from the lift pad. The facility identified 10 additional residents (#1, #4, #9, #10, #37, #38, #71, #74, #63 and #65) who required hoyer lift transfers. Multiple observations of Resident #1 on 06/28/19 at 9:40 .AM., 11:10 A.M. and 2:35 P.M. revealed the resident was in a bed with her eyes closed. She was wearing a cervical collar and appeared clean and comfortable with no evidence of pain. She had a clean wound with three staples on the back left side of her head and a dime-sized bruise on her left temple. Interview with LPN #79 on 06/28/19 at 11:22 A.M. revealed she was alerted to a fall from the Hoyer lift by the STNAs. She observed Resident #1 on the floor laying on her stomach with her head turned to the left. LPN #79 applied pressure to the wound on the back of the resident's head with a clean cloth and kept the resident still until the emergency team arrived to transfer the resident. Interview with STNA #80 on 06/28/19 at 11:30 A.M. revealed when the resident was suspended in the lift, she was behind the locked wheelchair. One of the straps on the Hoyer pad broke and the resident fell head first to the floor. She stated the same Hoyer pad was used to transfer the resident at breakfast that morning and verified she did not inspect the pad or straps prior to the transfer. Interview with STNA #75 on 06/28/19 at 11:35 A.M. revealed when the resident was up in the lift, she was in front of the Hoyer. The Hoyer strap broke and the resident quickly tumbled out of the sling to the floor with no time to react. She also verified the pad and straps were not inspected prior to the transfer. Interview with Certified Occupational Therapy Assistant (COTA) #81 on 06/28/19 at 11:45 A.M. revealed starting today she was responsible for training the nursing staff to complete appropriate Hoyer transfers which included inspecting the pad and straps for signs of wear and tear prior to the transfer. She was observing each staff person complete a return demonstration and approving their technique for safety. Review of the policy titled Fall Risk and Management Protocol revised on 11/29/17 revealed the residents were to remain as free of accidents/hazards as possible. Review of the policy titled Lifting Safety Precautions dated 07/06 revealed before using lift equipment for resident transfers staff inspected materials for prior to use. This deficiency substantiates complaint number OH 244.

Based on medical record review, observation, staff interview, review of facility's policy and procedure and review of the National Pressure Ulcer Advisory Panel for Prevention and treatment of [REDACTED]. This resulted in Actual Harm when Resident #100's Stage two pressure ulcer (partial-thickness skin loss with exposed dermis) declined to an unstageable pressure ulcer (obscured full-thickness skin and tissue loss). This affected one (Resident #100) of three residents reviewed for pressure ulcers, of six residents in the facility with pressure ulcers. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Stage two pressure ulcer present upon admission. Review of the Skin Documentation Report form dated 08/17/16 revealed the resident's pressure ulcer was described as a skin tear that measured 8.5 centimeters (cm) long, 2.0 cm wide and less than 0.1 cm deep on the right heel. It was described as a skin flap that was intact, no odor and drainage was present. Review of physician orders [REDACTED]. Apply adaptive dressing, cover with [MEDICATION NAME] (non-adherent dressing), apply an ABD pad to pad and protect and wrap with Kling wrap. Review of the treatment administration record (TAR) for August, 2016 revealed the treatment was not documented that it was started until 08/21/16, five days after admission. This was confirmed with the Director of Nursing (DON) on 09/22/16 at 10:50 A.M. Review of the Skin Documentation Report form dated 08/22/16 stated the skin tear on the right heel measured 4.0 cm long, 8.5 cm wide and 0.1 cm deep. It indicated the skin flap was no longer intact, was a red moist wound bed with purulent drainage, and odor was present. The resident had complaints of pain to the area, edges were macerated, and the surrounding skin was intact. Review of the resident's progress notes revealed a wound culture to the right heel was ordered on [DATE] due to foul odor. Review of the progress note dated 08/25/16 revealed the results of the wound culture to the right heel was positive for a staph infection and the physician ordered the [MEDICATION NAME] daily for two weeks. Review of a consult from a podiatry and surgery center by Physician Assistant (PA) #100, dated 08/25/16, revealed the PA noted the resident said it was a blister then it opened. The PA assessed it as a deep tissue injury (DTI) (persistent non-blanchable deep red, maroon or purple discoloration) that measured 6.0 cm long, 6.0 cm wide and 0.1 cm deep. The wound was described as purulent (any product of inflammation that contains pus) with odor, 76-100% adherent yellow slough and adherent soft black eschar. The PA recommended to continue the treatment as ordered on [DATE]. Review of the Pressure Ulcer (PU) Record form dated 08/29/16 revealed the resident now had a DTI that measured 10.0 cm long, 6.5 cm wide and unknown depth on the right heel. The wound was described as maroon/purple center with outer portion red. It was moist with a small amount of sero-sanguineous drainage (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage). Review of the nutrition progress dated 09/06/16 revealed it was reported in the nutrition at risk and skin meeting that Resident #100's right heel wound was declining and would recommend to start Prostat Advanced Wound Care supplement, 30 milliliters (ml) twice daily for added protein support. Review of the physician orders [REDACTED]. Review of a wound consult by another wound instititution dated 09/19/16 revealed the resident had an unstageable pressure ulcer and changed the treatment to cleanse the wound with wound cleanser, apply mesalt wound dressing, then rolled gauze and ABD pad daily. Review of the September 2016 TAR revealed the treatment was not documented it was completed on 09/20/16. Observation with Registered Nurse (RN) #53 on 09/21/16 at 8:34 A.M. confirmed the resident's right heel treatment was dated 09/19/16 indicating the resident did not receive a wound treatment on 09/20/16. Interview with the Director of Nursing (DON) on 09/21/16 at 8:56 A.M. stated the treatment nurse worked the floor on 09/20/16 so the floor nurses had to do their own treatments. On 09/21/16 at 2:39 P.M., an observation of the resident's right heel wound with Licensed Practical Nurse (LPN) #22 and the DON revealed LPN #22 measured the wound. The heel wound measured 4.5 cm long, 4.2 cm wide and unknown depth. The necrotic area on the wound measured 2.3 cm long and 3.4 cm wide. There was blood and serosanguineous drainage. Interview with LPN #22 on 09/21/16 at 3:15 P.M. confirmed she assessed the right heel wound upon admission as a skin tear. She said it was open and there was a flap attached to it. She said a unit manager found out that it used to be a Stage two blister. Interview with the DON on 09/21/16 at 3:25 P.M. confirmed the wound treatment was missed on 09/20/16. Interview with Registered Dietitian (RD) #95 on 09/22/16 at 8:40 A.M. stated she reviewed the resident's medical record on 09/19/16 and saw that the Prostat AWC recommended on 09/06/16 was not ordered yet by the physician. The RD said she found the recommendation in the physician (MD) box but it was not acted upon by the MD. The RD said she called his office and got the MD order at that time. Interview with LPN #12 on 09/22/16 at 9:14 A.M. confirmed he did not do the treatment on 09/20/16 and said he forgot to pass it on to the next shift as he did not have time to complete it on his shift. Review of the facility's undated policy on skin care prevention and pressure management revealed the facility would ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and the normal aging process. The facility's policy described a stage two PU as partial-thickness loss with exposed dermis. The wound bed is visible, pink or red, moist and may also present as an intact or ruptured serum-filled blister. The DTI description stated if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, Stage 3 or Stage 4). Residents at risk for skin breakdown interventions included to increase protein intake and act quickly to alleviate deficits. Review of the National Pressure Ulcer Advisory Panel for Prevention and treatment of [REDACTED]. It stated open wounds from various etiologies (e.g. venous ulcers, neuropathic ulcers, incontinence associated [MEDICAL CONDITION], skin tears and intertigo) may appear similar to a pressure ulcer; however, the treatment of [REDACTED]. Another recommendation was to to provide a high protein diet to a resident with a PU with a stage 3 or stage 4 or multiple PUs.

Based on observation, record review and staff interview, the facility failed to act on a nutritional supplement order. Actual Harm occurred to Resident #117 when she was not started on an ordered supplement and had a significant 8.6% weight loss in eight days. This affected one (Resident #117) of three residents reviewed for nutrition. Findings include: Review of Resident #117's medical record revealed the face sheet indicated she was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of resident's diet order revealed she was on a regular diet with diet liberties on special occasions. There were no documented supplements in her current diet. Review of Dietary Notes dated 09/06/16 revealed Resident #117 had a body mass index (BMI) of 17.4 and was considered underweight. She was 99 pounds when she was admitted from the hospital. The note indicated the resident's current food intake was reported as poor. Most meals she ate 25%. Recommendations made by the dietician included to change the diet order to regular and add MedPass 2.0 supplement,120 milliliters (ml) twice daily. This would add 480 calories and 20 grams of protein to her intake each day. Recommendations were given to the doctor. Review of Dietary Solutions Individual Nutrition Recommendations/Response form dated 09/06/16 had the recommendation change diet to regular and add MedPass 2.0, 120 ml twice daily. The physician agreed with the recommendations and signed the form on 09/06/16. This order was found in the resident's chart. Review of Resident #117's Minimum Data Set (MDS) assessment dated [DATE] revealed she was independent with eating and only needed minimal help with setting up. Weights were recorded as follows: 09/04/16 - 100.3 pounds; 09/05/16 - 101 pounds; 09/12/16 -104 pounds; and 09/20/16 - 95 pounds - 8.6% weight loss from 09/12/16. Review of the Meal and Fluid Intake Record for September 2016 revealed a steady decline in Resident #117's food intake. At the beginning of the month, the resident ate all or at least 75% of her meals. Since 09/16/16, Resident #117 either ate 25% of her meals or refused. Observation on 09/19/16 at 12:31 P.M. revealed Resident #117 had not eaten any of her lunch. Her sister who was in the room with her, stated the resident had not eaten anything and hadn't eaten much for the last three days. Review of Dietary Notes dated 09/20/16 revealed the resident had declined in food intakes. Her current body weight was 95 pounds. The dietician planned to leave a question for the resident's physician to review the resident's medications. The dietician recommended Magic Cup twice daily in addition to the MedPass supplement. Interview with Food Services Manager (FSM) #57 on 09/21/16 at 3:39 P.M. indicated she knew Resident #117 was a small eater. The resident's preference was to eat more ham salad and grilled cheese sandwiches. FSM #57 confirmed Resident #117 had a regular diet order. She stated residents were able to ask for substitutions if they wanted. FSM #57 was not aware that Resident #117 had refused any meals, but she didn't eat a whole lot. She confirmed a Magic Cup and supplement during med pass had been added a couple days ago. She stated she was not aware of an order for [REDACTED]. Interview with Registered Nurse (RN) #13 on 09/21/16 at 4:02 P.M. verified the dietician recommended Resident #117 receive a Magic Cup and MedPass 2.0 120 ml on 09/20/16. RN #13 was shown the 09/06/16 order for the MedPass 2.0 supplement, and she stated she had never seen that order before. Interview with Director of Nursing (DON) on 09/21/16 at 4:29 P.M. confirmed the order for the MedPass 2.0 supplement for Resident #117 written on 09/06/16 had not been started until the dietician reordered it on 09/20/16. Interview with Dietician #98 on 09/22/16 at 8:47 P.M. revealed she was in the facility at least once a week. They had weekly meetings with the dietary manager and others who reviewed the weights and food intakes to discuss a course of action if needed. She stated she got the information about Resident #117 being a poor eater either from her family or the hospital paperwork. On 09/20/16 she noticed the MedPass 2.0 order was not being given, noticed the resident's weight loss, so she made the order for MedPass again along with the Magic Cup.

Based on review of the clinical record, staff interview, review of the fall policy and procedure and falling star program the facility failed to provide supervision and ensure fall interventions were in place to prevent Resident #78 and Resident #67 from falling. Resident #78 sustained a fractured hip. This affected two, Residents #78 and #67, of three residents reviewed for falls. The facility census was 70. Harm occurred when Resident #78 did not have the care plan measures in place, including non-skid socks and non-skid strips to the floor, resulting in a fall and hip fracture. Findings include: 1. Review of the clinical record for Resident #78 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment was completed on admission on 02/09/15 with a score of 14 indicating the resident was at high risk for falls. A score of 10 or greater indicated high risk for falls. A nurse's note on 05/08/15 revealed the resident needed extensive assistance of one for activities of daily living, transfers, bed mobility and toileting. She used a walker for ambulation with a slow steady gait noted. Nurse's note dated 05/09/15 at 7:20 A.M. revealed a state tested nurse aide (STNA) notified this nurse that Resident #78 was on the floor. Upon entering the room the resident was noted in the doorway sitting on the floor with legs out in front of her with the left knee bent and left leg turned out to the side and walker on top of her. Resident was also noted to have a skin tear to the outer left knee. Upon further investigation the resident was noted with no grippy socks or shoes on at the time of the fall. Resident had regular socks on at the time of the fall and this nurse believes that resident slipped on the floor while ambulating unassisted. Resident was unable to state what happened. Nurse's noted at 7:48 A.M., received order to send out to hospital. There was no documentation as to what time the resident left the facility in the clinical record. New interventions: staff reprimand. Review of the plan of care, revealed potential for injury, history of falls. Observe, record and report all unsafe conditions and situation, place call light in reach of resident when in room or bed, encourage resident to wear non-skid footwear, i.e. grippy socks daily. Falling star program, red = very high risk for falls. Should not be up, including using the bathroom without assistance. Review of the physician's orders [REDACTED]. Minimum Data Set admission/correction, assessment, dated 02/18/15 revealed the resident needed extensive assistance of one for bed mobility, transfers and walking in room. Interview on 05/26/15 at 9:55 A.M. with the Director of Nursing (DON) indicated the incident report did not state if the call light was in reach and if it was on prior to the fall. She stated the resident had dementia and may have not thought to use it that early in the morning but admitted she had no way to know. She confirmed the call light within reach when in room or in bed was a fall intervention that was supposed to be in place according to the plan of care. She also confirmed the resident was not wearing the non-skid footwear and stated that one staff member was educated about checking up on residents when coming on duty. She stated the night shift aide had been reprimanded because she was the one who dressed the resident for the morning and told the oncoming aide she was all ready for the day. She also confirmed there was no evidence the resident had antiskid strips to the floor as per the physician order [REDACTED]. She stated the resident sustained [REDACTED]. She stated the resident was transported to the emergency room at 7:45 A.M., 25 minutes after the resident fell but confirmed this was not in the nurses notes as to what time the resident left. The physician's orders [REDACTED].M. 2. Review of the clinical record for Resident #67 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Nurses note dated 04/26/15 Resident was alert and able to make needs known, continent of bowel and bladder, extensive one person assist with activities of daily living, bed mobility, transfers and toileting. Resident has been using call light appropriately. Nurse notes regarding fall on 05/10/15 at 8:40 P.M., aide came and got this nurse stating that resident was sitting on floor. Resident was found sitting beside of bed with feet out in front of her. Resident did not have non-skid footwear on at this time. Resident gets herself ready for bed and removed her non-skid foot wear. Resident stated that she lost her balance and just sat down. Explained to resident the need to keep on the non-skid footwear. Resident agreed. Resident had full range of motion, no complaint of pain or discomfort. Upon further investigation this nurse feels that resident truly did lose her balance when she was turning down the covers on her bed as evidence by resident stated to this nurse that she was turning down her covers, she grabbed the bedside table and lowered herself to the floor. She stated that she sat down real easy. Resident had no complaints of pain or discomfort. She has full range of motion to bilateral lower extremities with no pain or grimacing noted. Fall occurred in resident room. New intervention put in place: Call, don't fall signage placed in room above resident 's bed. Current interventions, encourage non-skid footwear. Minimum Data Set Admission assessment dated [DATE] with a Brief Interview Mental Status (BIMS) score of 5 indicating severe cognitive deficit. Bed mobility and transfers revealed resident needed extensive assistance of one person and needed limited assistance of one to walk in room. Care plan revealed potential for injury related to history of falls at home prior to admission. Goal was to have no serious injury as result of fall. Interventions included, call light in reach when in room and bed, encourage resident to wear non-skid footwear, call don't fall sign in room. Fall risk assessment dated [DATE] revealed a score of 10. Score above 10 indicates high risk for falls. Evidence reveals resident was getting self ready for bed independently according to the nurses notes. The care plan states resident needs assistance for all activities of daily living. There was no evidence the nursing assistants ensured resident was wearing non-skid footwear and did not provide assistance as per the plan of care. Interview on 05/26/15 at 3:10 P.M., with the DON was asked if resident was wearing non-skid footwear at this time of the fall, was call light in place and was resident ambulating independently. She confirmed the care plan stated the resident needed assistance with activities of daily living and did not receive assistance the evening of the fall. She did not know if the call light was in reach or on at the time of the fall. She confirmed the care she received was not carried out according to the plan of care. She agreed the nurse stated the non-skid footwear was not on at the time of the fall. Review of the Falling Star Program - Red = very high risk for falls/frequent faller. Not allowed to be up without assistance. Be on high alert. Check on frequently. Anticipate needs. Do not leave in bathroom by themselves. Does not consistently use call light. Review of the fall risk protocol dated 02/03 and revised 08/06. The policy is to ensure that residents in our environment remain as free of accidents and hazards as is possible. The facility will take proactive measures to prevent accidents and will respond aggressively soul an accident occur. Residents identified as High Risk with a total score of 10 or higher will have a fall prevention protocol initiated immediately and documented in the plan of care. This deficiency substantiates Complaint Number OH 063.