Every finding on record at Pleasant Lake Villa

Based on observations and interviews, the facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner and food was properly labeled and dated. This had the potential to affect except three residents (#69, #110, and #207) who received nothing by mouth. The facility census was 170. Findings include:On 05/26/26 beginning at 8:50 A.M. and continuing through 9:13 A.M., a series of observations were conducted in seven kitchenettes with Diet Technician (DT) #603. The following was observed:-At 8:50 A.M. on the Rosewood unit, the freezer contained a large red sticky substance; the refrigerator held an unlabeled clear cup with a milky substance identified only by the handwritten letter N on the plastic lid; and a large clear pitcher containing a small amount of light brown liquid was neither labeled nor dated. The refrigerator also had a moderate amount of frost in the center. The microwave contained a moderate amount of various dried food debris and crumbs inside, and the exterior was heavily soiled with smears. The water/ice machine exhibited a moderate amount of lime buildup. DT #603 verified all findings. -On the Evergreen unit, the freezer contained a cupcake wrapper inside a napkin without a label or date, a moderate amount of frozen pinkish substance on the bottom interior, and an empty clear plastic cup with measurement markings. The water/ice machine showed moderate lime buildup and dried brown splatters. The microwave contained a paper towel with dried brown stains on the plate and a moderate amount of various dried food debris. DT #603 verified all findings. -On 05/26/26 at 8:58 A.M. At 8:58 A.M. on the Oakwood unit, the refrigerator contained melting frost with brownish stains, and the freezer had brown stains and splatters on the interior and inside the freezer door. The microwave had a moderate amount of dried food splatter and debris throughout. DT #603 verified these findings. -At 9:02 A.M. on the Sandalwood unit, the freezer contained a dried red splatter and a Wendy's cup with a frozen red substance that was not labeled or dated. The refrigerator held a balled up paper towel on the bottom shelf of the door, a half gallon of milk with a use by date of 05/12/26, a gray bin containing a plastic bag of melting ice without a label or date, and a larger gray bin of ice containing a clear plastic cup with measurement markings. A plastic container of food in a plastic bag was also present with no label or date. The microwave contained a moderate amount of dried food debris throughout. All observations were verified by DT #603. -At 9:09 A.M. on the Silver Pine unit, the microwave contained a moderate amount of dried food debris and brown stains inside. DT #603 verified these findings. -At 9:13 A.M. on the Woods unit, the microwave contained a paper towel stuck to the microwave plate, and beneath it was a dried yellowish substance. The stovetop contained a moderate amount of food debris and crumbs in the drip pans of all four burners. DT #603 verified these findings.

Based on review of the food committee minutes, observation, interviews, and review of the ServSafe guidelines, the facility failed to ensure that residents received food at palatable temperatures. This deficient practice had the potential to affect all residents except those who received nothing by mouth, residents (#69, #110, and #207). The facility census was 170.Findings include:Review of the Food Committee Minutes for April 2026, residents (not identified) stated the food was not served as hot as the residents would like. Resident interviews conducted on 05/26/26 from 10:54 A.M. to 11:06 A.M. revealed that Residents #97 and #178 reported the food was cold.Review of the lunch menu for 05/28/26 showed items including honey baked ham, baked potato, key west vegetable blend, biscuit, sherbet, coffee or tea, and 2% milk.During an observation on 05/28/26 at 1:26 P.M., a sample test tray evaluated with the Dietary Manager (DM) #431 and Regional Director of Food Services (RFSD) #805 showed the following temperatures: baked potato at 146 degrees Fahrenheit (F), key west vegetable blend at 96 degrees F, honey baked ham at 109 degrees F, milk at 47 degrees F, and coffee at 139.2 degrees F. Although the food tasted flavorful, the ham and vegetables were not hot to taste, and staff verified these temperatures were below expected levels. In an additional interview on 05/28/26 at 1:35 P.M., Resident #63 also stated that the food was cold.Review of regulatory requirements, industry standards such as ServSafe provide guidance on temperatures at which foods are considered palatable when served. Hot foods are generally expected to be served within the 140 degrees F to 180 degrees F range, which helps maintain flavor, aroma, and texture, while cold foods are considered palatable when served between 40 degrees F and 50 degrees F, maintaining freshness and acceptable mouthfeel.This deficiency represents non-compliance investigated under Complaint Number 1280688 (OH00164496).

Based on record review, observation, facility policy review, and interview, the facility failed to ensure orders were in place for oxygen therapy and failed to ensure oxygen therapy orders were implemented appropriately. This finding affected four residents (#95, #122, #207 and #236) of four residents reviewed for oxygen therapy. The facility census was 170. Findings include:1. Review of Resident #95's medical record revealed the resident was admitted on [DATE] with diagnoses including emphysema, hypertension and osteoarthritis.Review of Resident #95's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #95's ineffective breathing patterns care plan dated 04/28/26 revealed an intervention dated 05/28/26 (implemented following the observation) to administer medications and respiratory treatments as ordered, monitor for effectiveness and adverse reactions of the medications/treatments.Review of Resident #95's current physician orders revealed no orders for oxygen therapy.Observation on 05/26/26 at 10:10 A.M. revealed Resident #95 was on oxygen therapy via an oxygen concentrator, and the oxygen was infusing at two liters per minute (LPM) via a nasal cannula (NC).Interview on 05/26/26 at 10:12 A.M. with Licensed Practical Nurse (LPN) #744 confirmed Resident #95's medical record did not contain orders for the resident's oxygen therapy, and the resident was currently receiving oxygen therapy.2. Review of Resident #122's medical record revealed the resident was admitted on [DATE] with diagnoses including centrilobular emphysema, essential hypertension and anxiety disorder.Review of Resident #122's ineffective breathing pattern care plan dated 02/04/26 revealed an intervention dated 02/04/26 and updated 05/19/26 to administer the medications and respiratory treatments as ordered, monitor for effectiveness and adverse reactions of the medications/treatments.Review of Resident #122's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #122's current physician orders revealed no order for oxygen therapy.Observation on 05/26/26 at 10:10 A.M. revealed Resident #122 was on oxygen therapy via an oxygen concentrator, and the oxygen was infusing at two LPM via a NC. Oxy ears were observed on the oxygen tubing above the resident's ears to prevent irritation to the resident's ears. Interview on 05/26/26 at 10:56 A.M. LPN #463 confirmed Resident #122 had been on oxygen for quite a while, and she confirmed there was not an order for oxygen therapy. 3. Review of Resident #207's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease without dyskinesia, chronic obstructive pulmonary disease and pleural effusion.Review of Resident #207's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #207's current physician orders revealed an order dated 11/10/25 for oxygen at three LPM via a NC with oxy ears or posey strap every shift. May titrate to keep oxygen levels greater than 92%.Review of Resident #207's medication administration record (MAR) and treatment administration records (TAR) from 05/01/26 to 05/26/26 revealed the staff had documented the oxygen and oxy ears were in place.Observation on 05/26/26 at 11:04 A.M. with LPN #744 revealed Resident #207 did not have oxy ears in place on the resident's oxygen tubing as ordered to prevent irritation to the resident's ears during oxygen therapy.Interview on 05/26/26 at 11:06 A.M. LPN #744 confirmed Resident #207's oxy ears were not implemented as ordered.4. Review of Resident #236's medical record revealed the resident was admitted on [DATE] with diagnoses including hyperlipidemia and hypothyroidism.Review of Resident #236's current physician orders revealed an order dated 05/23/26 for oxygen at two LPM via NC with oxy ears or posey strap every shift. May titrate to keep oxygen levels equal to or greater than 92%.Review of Resident #236's MAR and TAR from 05/23/26 to 05/26/26 revealed the oxygen and oxy ears were in place as ordered.Observation on 05/26/26 at 12:21 P.M. revealed Resident #236's oxygen was infusing at 2.5 LPM, and the resident did not have oxy ears in place as ordered to prevent irritation to the resident's ears during oxygen therapy.Interview on 05/26/26 at 12:21 P.M. with LPN #747 confirmed Resident #236's oxy ears were not implemented as ordered.Review of the Oxygen Administration policy reviewed 01/06/25 revealed the purpose was to administer oxygen to the resident when insufficient oxygen was being carried by the blood to the tissues.

Based on observations, interviews, and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary resident environment affecting 44 residents (#4, #8, #9, #11, #12, #13, #18, #19, #26, #29, #32, #33, #41, #45, #48, #50, #57, #58, #65, #76, #79, #102, #104, #109, #110, #114, #127, #133, #136, #141, #146, #147, #155, #158, #160, #171, #175, #178, #182, #188, #190, #192, #201, and #205) of 44 residents that resided on the Rosewood unit and had the potential to affect all 170 residents residing in the facility. Findings include: 1. During an interview on 05/26/26 at 10:32 A.M., Resident #32 reported that housekeeping did not routinely pick up trash or sweep and mop the floors. Observation at that time revealed crumbs and stains between, under, and behind both beds; under the heater; along the wall under the window; and between the dressers and the television. Dried stains were also noted on the heater. On 05/28/26 at 2:40 P.M., the Housekeeping Supervisor (HSKS #416) stated residents' rooms and common areas were to be cleaned daily. At that time, the floor near the Rosewood nurses' station was visibly dirty with numerous scratch marks. HSKS #416 confirmed the floor required stripping and waxing. Observation on 05/28/26 at 2:51 P.M. of Resident #32's room with HSKS #416 verified the findings, stating surfaces needed to be wiped down and the floors swept and mopped, particularly along wall edges and under the beds. Review of the daily census dated 05/26/26 provided by the facility confirmed 44 residents (#4, #8, #9, #11, #12, #13, #18, #19, #26, #29, #32, #33, #41, #45, #48, #50, #57, #58, #65, #76, #79, #102, #104, #109, #110, #114, #127, #133, #136, #141, #146, #147, #155, #158, #160, #171, #175, #178, #182, #188, #190, #192, #201, and #205) resided on the rosewood unit. 2. On 05/26/26 at 10:05 A.M., an observation of Residents #57 and #192's shared room revealed multiple brown and yellow stains on the floor throughout the room, as well as dust and debris on the floor around the dressers and on the wall side of the bed. Certified Nursing Assistant (CNA) #763 confirmed the observations and stated housekeeping was expected to clean floors daily. She acknowledged it was evident the floor had not been cleaned recently. A review of the facility policy titled Environmental Cleaning (reviewed 01/06/25) indicated that housekeeping surfaces—including floors and tabletops—must be cleaned regularly, when spills occur, and whenever surfaces are visibly soiled. A review of the policy titled Resident Rights & Facility Responsibilities (reviewed 01/06/25) stated that residents have the right to a safe and clean-living environment. This deficiency represents non-compliance investigated under Complaint Numbers 2993500, 2647553, 2628650, 1280694 (OH00166522), 1280692 (OH00165826), 1280691 (OH00165570), and 1280688 (OH00164496).

Based on observation, interview and facility policy review, the facility failed to ensure medications were stored appropriately, expired medications were discarded appropriately, and insulin medications were dated and had residents' names on the insulin vials or KwikPens as appropriate. This finding affected one (Resident #120) of 41 residents who receive medications on the Silverpine unit; seven (Residents #4, #9, #13, #102, #155, #160 and #190) of seven residents who receive insulin from the Rosewood unit back hall medication cart; one (Resident #8) of one resident on the Rosewood unit who receives vitamin B-6; one (Resident #189) of 24 residents who receive medications on the Oakwood unit; and three new admissions (Residents #136, #190 and #205) who received tuberculin testing on the Rosewood unit. The facility census was 170.Findings include:1. Observations of the Silverpine unit on 05/26/26 at 10:04 A.M. revealed Resident #120 had dry Metamucil (no water) in a 30 milliliter (ml) plastic cup sitting on her overbed table. The resident confirmed the nurse left the Metamucil on her table for her.During an interview on 05/26/26 at 10:08 A.M., Licensed Practical Nurse (LPN) #644 confirmed she left the Metamucil on the overbed table for Resident #120, and she thought the resident had consumed the Metamucil even though it was not in water.2. Observations on 06/01/26 at 7:52 A.M. of the Rosewood unit back hall medication cart with Med Tech #608 revealed Resident #4's Aspart KwikPen had a date opened of 09/24/25 written in black marker; Resident #102's Lantus insulin vial did not have an open or expiration date; Resident #155's Basaglar KwikPen did not have an open or expiration date; two Lispro insulin Kwikpen's did not have a resident name, an open date or an expiration date; a Novolog insulin vial and a Lispro insulin vial did not have a resident name, open date or expiration date.During an interview on 06/01/26 at 8:00 A.M., Med Tech #608 confirmed all insulins were opened and used. Med Tech #608 confirmed the expired medications and insulins with no resident name or expired dates were not discarded as appropriate.During an interview on 06/02/26 at 12:54 P.M., the Director of Nursing (DON) confirmed seven residents who receive insulin from the Rosewood back hall medication cart including Residents #4, #9, #13, #102, #155, #160 and #190.3. Observations on 06/01/26 at 8:07 A.M. with LPN # 741 of the Rosewood front hall medication cart revealed a bottle of vitamin B-6 100 milligrams (mg) with an expiration date of 03/2026.During an interview on 06/01/26 at 8:10 A.M., LPN #741 confirmed the above findings.4. Observations on 06/01/26 at 8:16 A.M. with Registered Nurse (RN) #698 of the Oakwood front hall medication cart revealed a plastic medication cup in the top drawer with Resident #189's name listed on the side of the cup. Inside the cup were two white capsules.During an interview on 06/01/26 at 8:20 A.M., RN #698 revealed Resident #189's medications were in the top drawer, and she did not know who put them there or what the medications were. The nurse was observed placing the medications in the biohazard box.5. Observations on 06/01/26 at 11:22 A.M. of the Rosewood Med Room with LPN #741 revealed an open vial of Tuberculin and on the box of Tuberculin in black marker had the dates of 04/01/26 as opened and 05/2027 as expired. (Tuberculin solution in expires 30 days once opened.)During an interview on 06/01/26 at 11:25 A.M., LPN #741 confirmed the expired Tuberculin solution was not discarded as appropriate.During an interview on 06/02/26 at 12:54 P.M., the DON confirmed three new admissions received tuberculin including Residents #136, #190 and #205 from the Rosewood med room refrigerator.Review of the Medication Storage policy dated 11/2021 revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed accurately for four residents (#9, #22, #88, and #142) of four residents reviewed for smoking assessments. The facility census was 170.Findings include:1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including hemiplegia/hemiparesis, chronic obstructive pulmonary disease (COPD), diabetes, chronic kidney disease, nicotine dependence, depression, and insomnia. Review of Resident #9's quarterly MDS 3.0 assessment dated [DATE] showed the resident was alert and oriented. Annual MDS assessments dated 07/19/22, 09/27/23, and 07/22/25 documented Smoking Not Noted, despite an active care plan for safe smoking and multiple Smoking Evaluation assessments (09/10/24 through 03/31/26) noting the resident as a Supervised Smoker.2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including hemiplegia/hemiparesis, COPD, diabetes, heart disease, congestive heart failure (CHF), depression, and insomnia.Review of Resident #22's quarterly MDS 3.0 assessment dated [DATE] showed the resident was alert and oriented. Annual MDS assessments from 06/28/18 through 12/23/25 consistently documented Smoking Not Noted, despite an ongoing smoking care plan and extensive smoking assessments from 02/15/22 through 03/31/26 identifying the resident as a Supervised Smoker.3. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including temporal lobe cancer, hemiplegia, convulsions, emphysema, nicotine dependence, hypertension, and tachycardia.Review of Resident #88's quarterly MDS 3.0 assessment dated [DATE] documented the resident as alert and oriented; however, annual MDS assessments dated 12/28/24 and 12/03/25 recorded Smoking Not Noted, despite a safe smoking care plan and documented supervised smoking assessments completed from 08/27/24 through 04/01/26.4. Review of the medical record revealed Resident #142 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, pneumonia, diabetes, chronic respiratory failure, asthma, schizoaffective disorder, CHF, major depressive disorder, bradycardia, insomnia, unspecified psychosis, and history of self-harm.Review of Resident #142's quarterly MDS 3.0 assessment dated [DATE] showed the resident was alert and oriented. Annual MDS assessments dated 01/25/22 through 10/28/25 documented Smoking Not Noted, despite a safe smoking care plan and multiple supervised smoking assessments completed between 06/25/25 and 04/27/26.On 05/28/26 between 11:15 A.M. and 1:30 P.M., interviews with Residents #9, #22, #88, and #142 confirmed they were active smokers and had smoked regularly since admission and went out for all smoke breaks. On 05/28/26 at 2:30 P.M., interviews with MDS Nurses #711, #950, and #448 confirmed Residents #9, #22, #88, and #142 were regular smokers. They reported that if residents did not smoke during the MDS look back period, they documented them as nonsmokers. They also acknowledged residents were not tracked consistently during smoking breaks. On 05/28/26 at 4:15 P.M., interview with the Administrator and Director of Nursing (DON) acknowledged that the facility did not track when or how often residents smoked.Review of the Resident Assessment Instrument (RAI) manual, Section J requires staff to code current tobacco use accurately using information gathered through interview and review of the resident's status during the look back period. This information is essential for identifying associated health risks and developing individualized care plans including safe smoking practices and cessation support when applicable.

Based on record review, observation, interviews, and facility policy review, the facility failed to ensure that indwelling urinary catheter care was completed every shift as ordered and as required by facility policy, resulting in significant accumulation of smegma (body secretion made of oils, sweat, and dead skin cells) and increased risk of infection for one resident (#56) of three reviewed for catheter use. The facility census was 170.Findings include:Review of Resident #56 medical record revealed an admission date of 04/17/26 with multiple orthopedic injuries and a diagnosis of neuromuscular bladder dysfunction.Review of care plan for Resident #56 dated 04/20/26 revealed goals and interventions for risk of infection related to indwelling urinary catheter. Interventions included: assessing the resident for pain/discomfort; checking catheter for patency; enhanced barrier precautions; flushing catheter as needed; use catheter securement device; monitor for signs and symptoms of urinary tract infection; use catheter privacy bag, and provide catheter care every shift per facility policy.Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating Resident #56 had intact cognition. He was dependent on staff for all activities of daily living (ADL), hygiene, transfers, and mobility. Resident #56 had an indwelling urinary catheter and was continent of bowels, had no pressure wounds but had multiple surgical incisions that were well approximated with intact staples.During interview on 05/26/26 at 10:28 A.M., Resident #56 stated staff were not providing catheter care every shift.Observation on 05/27/26 at 9:16 A.M. of catheter care for Resident #56 provided by Certified Nursing Assistant (CNA) #608 revealed a large amount of accumulated smegma in the genital fold and under the foreskin, requiring multiple attempts to remove. CNA #608 confirmed the buildup indicated that catheter care had not been provided every shift.During an interview on 05/27/26 at 1:15 P.M., the Director of Nursing (DON) reviewed CNA task sheets indicating catheter care was marked as completed; however, the DON acknowledged the amount of buildup and the need for staff reeducation.During an interview on 06/02/26 at 8:10 A.M., the DON provided evidence of staff re-education regarding catheter and meatal care.Review of the facility policy titled, Foley Catheter (revised 01/06/25) revealed catheter care would be provided at least twice daily and again after defecation or bowel incontinence. Meatal care would also include assessing the catheter where it enters the meatus for encrusted material and drainage.This deficiency represents non-compliance investigated under Complaint Number 2622273.

Based on record review and interview, the facility failed to ensure Resident #233's medications were administered as ordered by the physician. This finding affected one resident (#233) of four residents reviewed for medication administration. The facility census was 170. Findings include:Review of Resident #233's medical record revealed the resident was admitted on [DATE] and discharged home on [DATE] with diagnoses including type one diabetes, anxiety disorder and depression.Review of Resident #233's physician orders revealed an order dated 03/31/26 (discontinued 05/09/26) for amitriptyline (used to treat depression, nerve pain, prevent migraines and an off-label used to treat insomnia, anxiety and other conditions) 100 milligrams (mg) give one tablet by mouth at bedtime for depression (due at 9:00 P.M.).Review of Resident #233's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #233's Psychotropic Medications Care Plan dated 04/06/26 revealed an intervention dated 04/06/26 to administer medications per the physician's order.Review of Resident #233's medication administration record (MAR) from 04/01/26 to 04/30/26 revealed the amitriptyline due at 9:00 P.M. was administered on 04/01/26 at 11:09 P.M.; 04/03/26 at 11:02 P.M.; 04/08/26 at 1:45 A.M.; 04/11/26 at 10:59 P.M., 04/17/26 at 10:45 P.M.; 04/21/26 at 11:28 P.M.; and 04/26/26 at 11:09 P.M.Interview on 05/27/26 at 12:24 P.M. with the Director of Nursing (DON) revealed Resident #233 would not be in her room on multiple occasions and the staff would have to hunt her down to administer the medications. She stated she felt the resident was not available for staff to administer the medications in a timely manner.Review of the Person-Centered Care Med Pass Policy and Procedure dated 05/05/21 revealed the facility, with the Medical Director and Primary Care Physician's approval, will schedule medications twice daily (BID) to the extent feasible, without compromising care to enhance Resident-Centered Care by encourage participation in activities and, establish a medication regimen similar to how residents take medications at home.This deficiency represents non-compliance investigated under Complaint Numbers 2974688, 2792081, 2647553, 2646266, 2622273, 2587155, 1280689 (OH00165091), and 1280686 (OH00164002).

Based on record review, interview, and facility policy review, the facility failed to ensure timely re-weights were obtained and the physician/nurse practitioner were notified of significant weight loss in a timely manner. This affected one resident (#127) of three residents reviewed for weight loss. The facility census was 170. Findings include:Review of the medical record for Resident #127 revealed an admission date of 01/27/26. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other disorders of electrolyte and fluid balance, chronic kidney disease stage 3 (CKD3), mild protein-calorie malnutrition, deficiency of other specified b group vitamins, muscle weakness, dysphagia, difficulty in walking, and cognitive communication deficit. Review of the weights for Resident #127 revealed on 01/28/26 weight was 155 pounds (lbs.), on 02/04/26 weight was 154.7 lbs., on 2/18/26 weight was 154.7 lbs., on 02/27/26 weight was 151.0 lbs., on 03/19/26 weight was 151.2 lbs., on 03/29/26 weight was 151.0 lbs., on 04/07/26 weight was 136.0 lbs., on 04/28/26 weight was 134.0 lbs., and on 05/13/26 weight was 107.6 lbs. Review of the nutrition progress note dated 04/09/26 at 2:02 P.M. revealed a weight warning note indicating the weight obtained on 04/07/26 of 136.0 lbs. triggered a weight loss of -5.0% change (10.1%, 15.2) and -10.0% change (12.3%, 19.0). Dietetic Technician (DT) #603 wrote resident with large weight loss noted at this time. Receiving a regular puree diet. Consuming variable intakes with some refusals. No edema/diuretic therapy noted for the resident. At this time will add supplementation and request reweight for the resident. Will continue to monitor and make changes as needed. Review of Nurse Practitioner (NP) #975's progress note dated 04/21/26 at 9:00 A.M. revealed Resident #127 was seen today for follow-up of acute respiratory failure, CKD3, and hyperlipidemia (HLD). Resident #127 was seen at bedside appearing in no acute distress. He has a history of acute respiratory failure following a cerebral infarction. He was currently on nebulizer treatments as needed and reported his breathing had been fine. Further review of NP #975's progress noted revealed under Review of Systems revealed no weight changes. Review of the plan of care revised 04/23/26 revealed Resident #127 had altered nutritional status as evidenced by sepsis, small bowel obstruction (SBO), Ileus, slow transit constipation, acute kidney injury (AKI). Past medical history of urinary tract infection (UTI), CKD3, cerebrovascular accident (CVA), vitamin B12 deficiency, folic acid deficiency, and vitamin D deficiency. Severe acute illness/injury related malnutrition related to inadequate oral intake as evidenced by weight loss in 30 days, and signs and symptoms of mild depletion of subcutaneous fat loss of orbital fat pads and mild depletion of deltoid and acromion process. Interventions included monitoring and evaluating any significant weight loss; determining percentage lost and notifying the resident and physician; reporting weight loss/gain of 5% or more to the physician and dietitian; and reviewing weights and notifying nurse practitioner (NP)/physician and resident/responsible party regarding significant weight changes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #127 had intact cognition and required set-up/clean up help for eating. The assessment also indicated that the resident weighed 134 lbs., had significant weight loss that was not intentional, and received a mechanically altered diet. Review of NP #975's progress note dated 05/12/26 at 9:30 A.M. revealed Resident #127 was seen today for follow-up of cerebral infarct, HLD, and CKD3. The resident was seen at bedside appearing in no acute distress. He reported he was feeling okay today, and no issues were reported by nursing at this time. Further review of NP #975's progress noted revealed under Review of Systems revealed no weight changes. Review of the nutrition progress note dated 05/14/26 at 9:15 A.M. revealed a weight warning note indicating the weight obtained on 05/13/26 of 107.6 lbs. triggered a weight loss of -5.0% change (19.7%, 26.4) and -10.0% change (30.6%, 47.4). DT #603 wrote unsure of accuracy of weight at this time. Will ask nursing for reweight and follow-up once obtained. During an interview on 05/27/26 at 12:11 P.M., Registered Dietitian (RD) #634 stated weights were obtained on admission and then weekly for four weeks, if stable then monthly after that. RD #634 stated if the resident triggered for significant weight changes, a reweigh would be requested. RD #634 verified Resident #127 weights on 04/07/26 and 05/13/26 should have been reweighed sooner, at least within 24 hours. RD #634 stated they verbally notify the NP of any significant weight changes and verified there were no physician or NP notes indicating Resident #127 weight loss. RD #634 stated she did not know NP #975 and verified the NP's progress notes dated 04/21/26 and 05/12/26, indicated no weight loss. During an interview on 05/27/26 at 12:23 P.M., DT #603 stated she verbally notified the NP and after they were notified, she did not know what happened after that. Review of NP #975's progress note dated 05/27/26 at 12:30 P.M. revealed Resident #127 was seen today for weight loss. The resident was seen at bedside appearing in no acute distress. The dietitian requested an evaluation due to weight loss. Resident #127's weight on 4/28/26 was 134 pounds, and on 5/27/26 was 122.8 pounds, representing a significant weight change over one month. The resident has hemiplegia and hemiparesis following cerebral infarct. He stays in bed most of the time and does not get up. He reported he has a good appetite. The dietitian reported the resident eats 80% of meals and his wounds have been healing. Weight loss most likely reflects muscle loss due to not getting out of bed and not using certain muscles. The resident's vital signs remain stable, and no issues were reported by nursing. Will order complete blood count (CBC), basic metabolic panel (BMP), and thyroid panel for the morning. Will wait on lab work and treat accordingly. Resident #127 will continue to be followed by the dietitian. Will continue orders as written. During an interview on 05/27/26 at 2:57 P.M., NP #975 verified today was the first-time hearing of Resident #127's weight loss. He verified his notes on 04/21/26 and 05/12/26 indicated no weight changes because he was not aware of it until today. NP #975 stated there were other NPs at the facility that may have been made aware but verified there were no other NP or physician notes indicating they were aware. Review of the undated policy titled Nutrition Intervention for Significant Weight Loss, did not indicate notifying the physician or NP when there is a significant weight loss nor does it indicate when to obtain a re-weigh or timeframes for re-weighing.

Based on record review, interview, and facility policy review, the facility failed to ensure Resident #217's controlled medications were appropriately monitored and tracked by the facility. This finding affected one resident (#217) of four residents reviewed for medication administration. The facility census was 170. Findings include:Review of Resident #217's medical record revealed the resident was admitted on [DATE] and discharged on 06/13/25 with diagnoses including dementia, atrial fibrillation and anxiety disorder.Review of Resident #217's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #217's progress note dated 06/07/25 at 9:58 P.M. revealed two nurses placed calls to the pharmacy regarding the lacosamide anti-seizure (controlled medication) and narcotic pain medication (controlled medication). The pharmacist stated the medications were shipped at 7:00 P.M. and would be in. The family supplied the medications since admission. The family member was extremely agitated, and the physician was notified.Review of Resident #217's progress note dated 06/08/25 at 6:18 A.M. revealed the lacosamide and narcotic pain medications arrived at the facility and were verified by all nurses.Review of Resident #217's physician orders revealed an order dated 06/04/25 (discontinued 06/14/25) for Vimpat (lacosamide) 100 milligrams (mg) give one tablet by mouth two times a day for seizures.Review of Resident #217's medication administration records (MAR) revealed the Vimpat was documented by the nursing staff as administered on 06/04/25 for the evening dose, 06/05/25 for the morning and evening doses, 06/06/25 for the morning and evening doses, and 06/07/25 for the morning and evening doses.Review of Resident #217's facility issued Controlled Drug Administration Record dated 06/04/25 revealed the facility received Vimpat 100 mg oral tablet from home. The Vimpat medication was administered on 06/04/25 at 11:20 P.M.Review of Resident #217's facility issued Controlled Drug Administration Record dated 06/06/25 revealed the Vimpat 100 mg one dose was received on 06/06/25. The dose was administered on 06/06/25 at 10:08 A.M. with no doses remaining.Review of Resident #217's pharmacy issued Controlled Substance Proof of Use dated 06/08/25 at 6:18 A.M. revealed the lacosamide (Vimpat) 100 mg tablet was received and the facility received 28 tablets. The facility administered two tablets on 06/08/25, two tablets on 06/09/25, two tablets on 06/10/25, two tablets on 06/11/25, two tablets on 06/12/25 and one tablet on 06/13/25.Resident #217's medical record did not have evidence of appropriate controlled medication tracking for the Vimpat medication on 06/05/25 for the morning and evening doses; 06/06/25 for the evening dose; and 06/07/25 for the morning and evening doses.Review of Resident #217's physician orders revealed an order dated 06/04/26 (discontinued 06/14/25) for hydrocodone-acetaminophen 7.5-325 mg (Norco), give 0.5 tablet by mouth two times a day for severe pain and give 0.5 mg tablet by mouth every eight hours as needed for moderate pain.Review of Resident #217's MAR revealed on 06/04/25 the Norco was administered on the evening dose with no pain level identified; on 06/05/25 the morning dose of Norco was administered with a pain level of three; on 06/05/25 for the evening dose with a pain level of zero; on 06/06/25 for the morning dose with a pain level of zero, no documentation the evening dose on 06/06/26 was identified (blank MAR); on 06/07/25 the morning dose of Norco was administered with a pain level of zero; and on 06/07/25 the evening dose of Norco was administered with a pain level of zero.Review of Resident #217's facility issued Controlled Drug Administration Record Tablet dated 06/04/25 revealed the hydrocodone 7.5-325 mg one tablet was administered (1/2 tab) on 06/04/25 at 11:20 P.M. The amount remaining on the form stated zero.Review of Resident #217's facility issued Controlled Drug Administration Record Tablet form dated 06/06/25 revealed the facility received Norco 3.75-162.5 mg (half tablet). The form indicated the Norco was administered on 06/06/25 at 10:20 A.M.Review of Resident #217's pharmacy issued Controlled Substance Proof of Use form dated 06/08/25 at 6:18 A.M. revealed the pharmacy sent hydrocodone-acetaminophen 7.5-325 mg give 1/2 tablet by mouth every eight hours as needed for moderate to severe pain; and give 1/2 tablet by mouth two times a day for severe pain. A total of 54 tablets were received. Two doses were administered on 06/08/25, 06/09/25, 06/10/25, 06/11/25, 06/12/25 and one dose on 06/13/25.Resident #217's medical record did not have evidence of appropriate narcotic tracking for the Norco narcotic pain medication on 06/05/25 for the morning and evening doses; 06/06/25 for the evening dose; and on 06/07/25 for the morning and evening doses.Review of Resident #217's progress note dated 06/13/25 at 12:19 P.M. revealed the admitting facility would provide transportation to the facility at 2:00 P.M. The staff were notified for discharge.During an interview on 05/27/26 at 7:37 A.M., Licensed Practical Nurse (LPN) Unit Manager (UM) #615 revealed Resident #217's family discussed the pain medications with him. LPN UM #715 revealed medications upon admission would be verified by the doctor and if narcotics were prescribed, the doctor wound send the prescription to the pharmacy. LPN UM #615 confirmed the facility did not have the Norco 7.5-325 in their pyxis system and the family provided the Norco narcotic until the facility received the medication from the pharmacy.During a telephone interview on 05/27/26 at 7:40 A.M., LPN UM #615 in attendance of Pharmacist #951 revealed Resident #217's Vimpat script was received on 06/07/25 and supplied on 06/08/25 at 3:18 A.M. (signed by facility staff) for 28 doses or 14-day supply. She also stated the tramadol script was called to the pharmacy on 06/04/25 and (signed by the facility staff on 06/06/25 at 8:14 A.M.) for 30 tablets. Pharmacist #951 confirmed the Norco 7.5-325 mg tablet was written on 06/05/25 and received by the pharmacy on 06/07/25 at 12:01 P.M. Pharmacist #951 confirmed the Norco narcotic pain medication was signed for by the facility on 06/08/25 at 3:18 A.M. for 27 tablets or a 10-day supply.During an interview on 05/28/26 at 10:14 A.M., the Director of Nursing (DON) and Registered Nurse (RN) Assistant Director of Nursing (ADON) #682 revealed the facility nursing staff notified the Nurse Practitioner (NP) and facility staff were able to verify the medication. The DON confirmed the facility did not have the appropriate narcotic flow records for accurate narcotic tracking and Resident #217's family would administer the narcotics to the resident with the nursing staff in attendance, and then the nursing staff would sign off the doses on the MARS. Review of the Miscellaneous Special Situations policy revised 01/2018 revealed that all medication supplies dispensed by a physician or brought in by the resident or family member may (may not) be accepted. When permitted by state and/or federal regulations and facility policies, there must be a current order and the medications must be labeled, packaged and stored in accordance with product requirements, state and/or federal regulations and facility policies. Mediations brought into the facility by physicians or resident family members were reported to the provider pharmacy and added to the resident profile to maintain a complete and accurate drug profile.This deficiency represents non-compliance investigated under Complaint Numbers 2974688 and 1286093 (OH00166448).

Based on record reviews, observations, interviews and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained per order. This affected two residents (#176, #207) out of four residents reviewed for isolation precautions. The facility census was 170.Findings include:1. Record review of Resident #207 revealed an admission date of 08/15/19 with diagnoses of Parkinson's Disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, chronic obstructive pulmonary disease, contracture of hand, history of falling, hyperlipidemia and hypertension, presence of gastrostomy tube.Review of the physician's orders initiated on 03/26/26, revealed an order for EBP for high contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, assisting with toileting, dressing changes, and care of any device (central line, tube feeding, and catheter) to reduce chance of spreading infection.Review of the care plan revised on 05/12/26 revealed interventions for EBP related to enteral feeding tube.Observation of medication administration through gastrostomy tube on 05/26/26 at 10:57 A.M. by Licensed Practical Nurse (LPN) #744 revealed non- compliance with EBP orders while providing care Resident #207 occurred. LPN #744 did not wear an isolation gown per protocol.During an interview on 05/26/26 at 10:57 A.M., LPN #744 revealed she was unaware that she had to wear an isolation gown during the medication administration.2. Record review of Resident #176 revealed an admission date of 11/25/25 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, metabolic encephalopathy, dementia, severe protein-calorie malnutrition, heart disease, major depressive disorder, dysphagia, and non-pressure chronic ulcer of back and left heel.Review of the care plan revised on 05/21/26 revealed goals interventions for EBP related to indwelling urinary catheter, wounds, and peripherally inserted central catheter (PICC).Review of the physician's orders initiated on 05/21/26 revealed an order for EBP precautions for high contact resident including dressing, bathing, showering, transfers, hygiene care, changing linens, assisting with toileting, dressing changes, and care of any device (central line, tube feeding, and catheter) to reduce chance of spreading infection.Observation of intravenous medication administration for Resident #176 on 05/27/26 at 1:25 P.M. by LPN #744 revealed no personal protective equipment was used when performing the intravenous medication administration as ordered.During an interview on 05/26/26 at 1:45 P.M., LPN #744 revealed she was unaware that she was required to don an isolation gown when administering intravenous medications with a resident who had EBP orders. During an interview on 05/27/26 at 1:15 P.M., the Director of Nursing (DON) verified that EBP should have been maintained per orders, and LPN #744 should have been wearing an isolation gown when administering medications per gastrostomy tube for Resident #207 and when administering intravenous medication through the PICC for Resident #176. During a follow-up interview on 06/02/26 at 8:10 A.M., the DON revealed re-education was provided to staff regarding compliance with all isolation residents and isolation policies. The DON provided evidence of sign-in sheets and documentation of policy re-education. DON also provided evidence of follow up and corrective action to LPN #744 regarding non-compliance with EBP personal protective equipment (PPE) per facility policy and Centers for Disease Control and Prevention (CDC) guidelines.Review of the facility policy titled, Enhanced Barrier Precautions revised 01/06/25, revealed EBP were to be used for residents with: wounds or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator). Gowns and gloves are to be used for all high-contact resident care activities.This deficiency represents non-compliance investigated under Complaint Number 2736215.

Based on medical record review, observation, staff interview, and review of the facility's Coronavirus (COVID-19) policy, the facility failed to ensure personal protective equipment (PPE) was donned correctly for Resident #193, who was on droplet precautions to potentially prevent the spread of COVID-19 infections. This had the potential to affect 29 residents (Residents #165, #166, #167, #168, #169, #170, #171, #172, #173, #174, #175, #176, #177, #178, #179, #180, #181, #182, #183, #184, #185, #186, #187, #188, #189, #190, #191, #192, and #193) who resided on the Sandalwood unit. The facility census was 189. Findings include: Review of the medical record for Resident #193 revealed an admitted [DATE] with diagnoses including kidney transplant, type one diabetes mellitus with chronic diabetic kidney disease, pressure ulcer of the left heel, pressure ulcer to the right heel, and history of urinary tract infections. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #193 had moderately impaired cognition, and was dependent on staff for bed mobility, toileting, and transferring. Resident #193 rejected care one to three days during the look back period. Observation on 03/03/25 at 10:33 A.M. with Resident #193 revealed there was PPE hanging on her door with a sign stating the resident was on droplet precautions. Certified Nursing Assistant (CNA) #201 went into Resident #193 to provide care and did not have PPE on. Registered Nurse (RN) #205 donned PPE to assist CNA #201. CNA #201 and Registered Nurse (RN) #205 were positioning Resident #193 for lunch. Interview on 03/03/25 at 10:45 A.M. with CNA #201 confirmed she did not were a gown, N-95 mask or face shield into Resident #193's room and stated the resident was on precautions for COVID-19. CNA #201 stated she cannot breathe in an N-95 mask. CNA #201 stated her assignment for the day was the Sandalwood unit. Review of the facility policy titled, COVID-19 Transmission based precautions- Droplet Precautions Quick Guide, dated 06/26/23 revealed staff were to utilize PPE which included-95 mask, eye protection, gowns, and gloves. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, interview and record review, the facility failed to ensure Resident #135's nails were clean, and her chin was free of hair. This affected one resident (Resident #135) out of three residents (Residents #51, #135, and #187) reviewed for activities of daily living (ADLs). The facility census was 158. Findings include: Review of the medical record for Resident #135 revealed an admitted [DATE] with diagnoses including diabetes mellitus, Alzheimer's disease, and anxiety disorder. Review of the Care Plan dated 04/14/22 revealed Resident #135 had a self-care deficit related to cognition and generalized weakness. Interventions included nail care as needed. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/06/24, revealed Resident #135 had moderately impaired cognition and required substantial/maximal assistance with ADLs. Observation and interview on 09/14/24 at 9:40 A.M. with Resident #135 revealed she was lying in bed; her fingernails were long and dirty and she had hairs growing on her chin. Resident #135 stated that she liked the length of her nails, but she wished that they were cleaner, and she was embarrassed by having hairs on her chin. Resident #135 stated that she used to make sure that they were taken care of when she was at home. Interview on 09/14/24 at 9:41 A.M. with Licensed Practical Nurse (LPN) #371 verified the Resident #135's dirty nails and the hairs on her chin. Review of the facility policy dated 11/30/23 titled, Activity of Daily Living (ADL's), revealed maintaining personal hygiene included planning the task and gathering supplies, combing and/or styling hair, washing face and hands, brushing teeth, shaving or applying make-up, oral hygiene, self-manicure (safety awareness with nail care and/or application of deodorant or powder). This deficiency represents non-compliance investigated under Complaint Number OH00157469.

Based on observation, interview, record review, and facility policy review revealed the facility failed to ensure multiple dose medications were dated when opened. This affected five residents (#39, #54, #81, #88 and #285) of 15 residents reviewed with insulin pens and two medication carts (Rosewood back and Oakwood front) of five medication carts reviewed. The facility census was 181. Findings Included: 1. Review of the medical record revealed Resident #285 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. Review of the physician orders for June 2024 revealed an order for Insulin Glargine (long-acting insulin)100 unit/milliliter (ml) solution pen-injector. Observation on 06/06/24 at 10:01 A.M. of Oakwood front medication cart revealed Resident #285's insulin Glargine pen was dispensed on 04/25/24 and not dated to indicate when it was opened. Interview on 06/06/24 at 10:05 A.M. with Registered Nurse (RN) #995 verified Resident #285's insulin was dated when it was opened, and the dated insulin dispensed from pharmacy was 04/25/24. 2. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. Review of the physician orders for June 2024 revealed Humalog (short-acting insulin) 100 unit/ml inject as per sliding scale. 3. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. Review of the physician orders for June 2024 revealed Humalog injection solution per sliding scale. 4. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with a diagnosis of type II diabetes. Review of the physician order for June 2024 revealed Humalog 100 unit/ml inject as per sliding scale. 5. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnosis of type II diabetes. Review of the physician order for June 2024 revealed Humalog 100 unit/ml inject as per sliding scale and Basaglar Kwik Pen solution 100 unit/ml (long-acting insulin) inject 21 units subcutaneously one time a day. Observation on 06/06/24 at 10:26 A.M. of Rosewood back medication cart for medication storage revealed Resident #88 Humalog flex pen, Resident #54's Humalog flex pen, Resident #39's Humalog flex pen and Resident #81's Humalog and Basaglar flex pens were opened and were not dated to indicate when they were opened. Interview on 06/06/24 at 10:30 A.M. with the Director of Nursing (DON) verified insulin was to be dated when it is opened and should not be used after the manufactures expiration date. The DON verified Resident's #39, #54, #81, #88 and #285 insulins were in use and were not dated per the facility policy. Review of the facility policy titled Medication Storage in the Facility, dated 11/2021, revealed that nurses shall place a date opened on medications. The manufacture's expiration date will be followed.

Based on observation, interview, record review, and facility policy review the facility failed to ensure recommended guidelines were followed for changing disposable respiratory equipment for Residents #12, #15, and #83. This affected three residents (#12, #15, and #83) of six residents reviewed for respiratory care. The facility census was 181. Finding include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including pneumonia, epilepsy, heart failure, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had short-term and long-term memory problems and used oxygen daily. Review of Resident #12's physician's orders revealed an order dated 05/14/24 to change the oxygen tubing and clean the filter weekly per facility policy and change the aerosol tubing and setup and clean the filter weekly per facility policy. Review of the medication administration record (MAR) for May 2024 revealed aerosol treatments were signed off as administered as ordered, and Resident #12 required oxygen daily. Review of the treatment administration record (TAR) for May 2024 revealed Resident #12's aerosol mask and tubing and oxygen tubing was last changed on 05/29/24. Observation on 06/03/24 at 12:13 P.M. of Resident #12 revealed the resident was wearing oxygen via nasal cannula that was not dated. The aerosol mask and tubing hooked up to the nebulizer was not in a bag and was not dated. The tubing dated 05/29/24 was in a clean bag on top of the oxygen concentrator. The bag with the new aerosol tubing and mask was still in the bag sitting on top of side table, not in use. Interview on 06/03/24 at 12:14 P.M. with Licensed Practical Nurse (LPN) #916 revealed oxygen tubing, aerosol masks, and tubing were to be replaced weekly and should be dated when changed. LPN #916 verified Resident #12's oxygen tubing, aerosol mask, and tubing were not dated to indicate when they were last changed, and the new tubing, dated 05/29/24, was still in the bag, not in use. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including dementia, heart disease, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had impaired cognition and used oxygen. Review of Resident #15's physician's orders for June 2024 revealed there was no order to change oxygen tubing weekly. A new order was put in on 06/04/24 to change the oxygen tubing, after surveyor intervention. Observation on 06/03/24 at 2:15 P.M. of Resident #15's oxygen tubing with LPN #916 revealed the oxygen tubing was dated 03/05/24. LPN #916 verified the date on the tubing and stated the oxygen tubing should be changed weekly. Interview on 06/03/24 at 2:17 P.M. with Director of Nursing (DON) verified oxygen tubing was to be changed weekly due to infection control. The DON verified Resident #15 did not have an order to change her oxygen tubing weekly, and there was no documented evidence that Resident #15's oxygen tubing had been changed since 03/05/24. 3. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure. Review of Resident #83's physician orders for June 2024 revealed an order to administer oxygen via nasal cannula at three liters per minute. There was no order to change the oxygen tubing weekly. Observation 06/04/24 at 10:18 A.M. revealed Resident #83 in bed with oxygen on via nasal cannula at 2.5 liters per minute. There was no date on the nasal cannula tubing to indicate when it was last changed. The date on the storage bag for the oxygen tubing and nasal cannula was 4/30/24. Interview with LPN #909 at the time of the observation verified there was no date on the oxygen tubing and stated nasal cannula tubing was to be changed weekly. Review of the facility policy titled Operational Policy and Procedures- Respiratory Service, dated 07/06/2021, revealed oxygen cannulas, oxygen humidifier bottles, oxygen supply line, and nebulizer kit for aerosols should be changed weekly and disposable supplies need to be dated when changed.

Based on interview and record review the facility failed to ensure wound treatments were completed as ordered. This affected one of three residents (Resident #152) reviewed for wound treatments. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admitted [DATE]. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, depression, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition and was dependent or required maximal assistance for activities of daily living. Review of the treatment orders for April 2024 revealed an order to cleanse skin tear to right elbow once daily with normal saline, apply four by four and border gauze dressing daily, every day shift for wound care. Review of the Medication Administration Record (MAR) for February 2024 revealed documentation indicating the dressing to right elbow was completed on 02/28/24. There was no documentation the wound care was completed on 02/29/24 through 03/04/24. The MAR for April 2024 revealed no documentation the dressing change was completed on 04/01/23. Review of physician orders dated 03/03/24 revealed a new order for doxycycline 100 milligram (mg) tablet twice a day for wound infection. Review of the wound assessment dated [DATE] revealed no odor, no drainage and no signs of infection to the right elbow noted. Interview on 04/01/24 at 3:29 P.M. with Registered Nurse (RN) #450 revealed dressing changes were to be completed as ordered, usually daily, and all dressing changes were dated and initialed at time of dressing change. During an interview on 04/02/24 at 9:50 A.M. with Resident #152, Resident #152 was confused regarding the events of how she sustained the skin tear; she said she was chasing her son and fell . Resident #152 was unable to provide information regarding treatments/dressing changes. Interview on 04/02/24 at 10:09 A.M. with the Director of Nursing (DON) revealed Resident #152 had a skin tear to elbow which became infected. Resident #152 was put on doxycycline (antibiotic). The DON verified Resident #152 had not received the dressing change to her right elbow from 02/28/24 through 03/02/24 as ordered. Interview on 04/02/24 at 11:35 A.M. with Licensed Practical Nurse (LPN) #350 revealed dressing changes were completed according to physician orders. All dressings were to be initialed, dated and documented as completed at the time of the dressing change. Interview on 04/02/24 at 11:52 A.M. with LPN #449 revealed Resident #152 received a skin tear to her right elbow. There was an order for the dressing to be changed daily. LPN #344 stated nurses were to change wound dressings as ordered, the dressing should be initialed and dated, and nurses were to document the treatment was completed. This deficiency represents non-compliance investigated under Complaint Number OH00152308.

Based on medical record review and interview the facility failed to ensure Resident #152 was not administered expired medication (budesonide) and the medication was available for administration. This affected one of three residents (Resident #152) reviewed for medication administration. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admitted [DATE]. Diagnoses included but were not limited to eosinophilic esophagitis (an allergic inflammatory condition of the esophagus), diabetes mellitus, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition. Review of the physician orders for February 2024 revealed orders for budesonide liquid 10 milliliters (ml) by mouth (corticosteroid, gastrointestinal) one hour before meals for eosinophilic esophagitis. Started on 02/11/24 and discontinued on 03/29/24. Review of the February and March 2024 medication administration record (MAR) revealed the budesonide liquid was not administered on March 1, 2, 3, 4, 5, 14 and 19. The budesonide was discontinued on 02/11/24 and restarted on 02/25/24 after Resident #152 returned from the hospital. The budesonide liquid expiration date was 02/21/24 and medication was given until 03/01/24 and then the medication was not available until 03/05/24. Interview on 04/02/24 at 10:09 A.M. with the Director of Nursing (DON) verified the bottle of budesonide liquid medication had an expiration date of 02/21/24 and this was not identified until 03/01/24. The unit manager (Licensed Practical Nurse #369) came to her on 03/01/24 and stated Resident #152's budesonide was expired, the family was notified and the doctor was contacted. The nurses were educated on checking medications to ensure that expired medications were not being given to residents. The DON confirmed Resident #152 received expired budesonide medication for six days. The DON stated after it was realized the medication was expired it took a few days to get more of the medication due to the medication was a specialty medication and only a specialty pharmacy could make the budesonide liquid. This deficiency represents non-compliance investigated under Complaint Number OH00152308.

Based on medical record review and interview the facility failed to ensure Resident #152 received an anticoagulant medication to prevent the formation of blood clots as ordered. This affected one of three residents (Resident #152) reviewed for medication administration. The facility census was 171. Findings Included: Review of the medical record for Resident #152 revealed an admitted [DATE]. Diagnoses included but were not limited to diabetes mellitus, dependence on renal dialysis, pulmonary hypertension, absence of right leg below the knee, and calciphylaxis (calcium accumulates in small blood vessels of the fat and skin tissues. Calciphylaxis causes blood clots, painful skin ulcers and may cause serious infections that can lead to death.) Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/24, revealed Resident #152 had intact cognition. Review of the physician orders for February 2024 revealed orders for apixaban (anticoagulant) 2.5 milligrams (mg) tablet by mouth two times a day for atrial fibrillation. Review of the February and March 2024 medication administration record (MAR) revealed apixaban 2.5 mg tablet was started on 02/11/24. The morning doses of apixaban were not administered on February 12, 14,16,19,20,21,23, and 28 and on March 1, 6, and 14 (11 doses). Interview on 04/03/24 at 10:13 A.M. with Director of Nursing (DON) revealed Resident #152 was receiving dialysis three times a week in the mornings. The DON verified on dialysis days the nurses were not giving Resident #152 her apixaban. The DON verified apixaban was not being given as ordered. Review of Medscape website revealed if a dose of apixaban was not taken at the scheduled time, the dose should be taken as soon as possible on the same day and twice daily administration should be resumed. Premature discontinuation of any oral anticoagulant, including apixaban, increased the risk of thrombotic events. Because of the high plasma protein binding apixaban was not expected to be dialyzable. This deficiency represents non-compliance investigated under Complaint Number OH00152308.

Based on observation, interview, record review, review of the facility policy and review of the Centers for Disease Control (CDC) and Prevention guidelines, the facility failed to maintain an adequate infection control program to prevent the spread of infection. The facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to entering the room of and providing wound care to Resident #156 who had tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB). Furthermore, the facility failed to ensure Resident #155, who tested positive for CRAB washed his hands before leaving his room. This affected two sampled residents (#156 and #155) who tested positive for CRAB and had the potential to affect 42 additional residents (#1, #4, #10, #12, #26, #33, #34, #40, #45, #46, #54, #55, #56, #59, #60, #67, #68, #74, #80, #83, #89, #90, #93, #97, #98, #100, #102, #106, #109, #110, #112, #115, #116, #119, #121, #129, #137, #148, #150, #159, #160, #170) residing on the unit Resident #156 resided on and 22 residents (#2, #13, #19, #25, #43, #71, #86, #88, #91, #95, #96, #122, #127, #133, #134, #145, #147, #151, #158, #161, #163, #167) residing on the nursing unit Resident #155 resided on. The facility census was 170. Findings include: 1. Review of Resident #156's medical record revealed an admitted [DATE] and diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, carrier of Carbapenem-resistant Acinetobacter baumannii (does not respond to common antibiotics and some are resistant to all available antibiotics), and unspecified intellectual disabilities. Review of Resident #156's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #156 did not have a Brief Interview for Mental Status completed due to Resident #156 was rarely or never understood. Resident #156 required extensive assistance of one staff member for bed mobility, total dependence of two staff members for transfers, and extensive assistance of two staff members for toilet use and personal hygiene. Review of Resident #156's physician orders dated 10/03/23 revealed an order to cleanse areas to the left buttock extending to the right thigh with normal saline and pat dry with a four-by-four gauze, apply TRIAD (skin protectant) and leave open to air (LOTA). Line bed with a chuck (disposable pad), no (incontinence) brief. Monitor for pain, discomfort with treatment, use prn (as needed) meds and, or contact the physician or Nurse Practitioner. Further review revealed to cleanse areas to right buttock extending to the right thigh with normal saline and pat dry with a four-by-four gauze, apply TRIAD and LOTA, line bed with a chuck and no brief. Monitor for pain and discomfort with treatment, use prn meds and or contact the physician or Nurse Practitioner. Review of facility laboratory report results revealed a swab of Resident's #156's axilla and groin was collected from 10/16/23 through 10/18/23 and reported on 10/23/23. Resident #156's Carbapenem-resistant Acinetobacter baumanni colonization culture showed Acinetobacter baumannii (A), this isolate tested positive for OXA-24/40-like carbapenemases by PCR (polymerase chain reaction which detect genetic material from the virus). Review of Resident #156's care plan dated 10/24/23 included Resident #156 had a CRAB (Carbapenem-resistant Acinetobacter baumannii) infection. Resident #156's infection would resolve with no adverse reactions to treatment. Interventions included contact isolation precautions; follow facility protocols for contact isolation for duration of treatment, monitor for increased withdrawal, social isolation; monitor wound for changes in color, odor, inflammation, exudate, and complaints of pain. Review of Resident #156's physician orders dated 10/24/23 revealed an order for contact precautions related to CRAB. Post a See Nurse Before Entering Sign on the door, provide personal blood pressure cuff, stethoscope, thermometer, wear gloves, mask, and gown as needed, and wash hands when touching environment and with direct patient care. Review of Resident #156's progress notes dated 10/24/23 at 11:35 A.M. revealed the nurse practitioner was asked to see Resident #156 due to CRAB positive. Resident #156's plan was to continue infection prevention measures, hand hygiene, environmental cleaning and Resident #156 was placed on enhanced barrier precautions (EBP). Interview on 11/06/23 at 9:34 A.M. of Licensed Practical Nurse/Staff Development/Infection Preventionist (LPN/SD/IP) #526 revealed the facility had quite a few residents positive with CRAB, and it had been going on for months. LPN/SD/IP #526 stated the Cuyahoga County Board of Health and Ohio Department of Health visited the facility on 04/2023 and gave recommendations and guidance for CRAB. LPN/SD/IP #526 stated she received a call from the Ohio Department of Health and Cuyahoga County Board of Health on 09/26/23. LPN/SD/IP #526 stated she was advised by the Ohio Department of Health and the Cuyahoga County Board of Health to test all the residents in the facility for CRAB. LPN/SD/IP #526 indicated most of the residents (some refused) were tested for CRAB over a three-day period from 10/16/23 through 10/18/23. LPN/SD/IP #526 revealed eight residents (Resident #57, #61, #92, #101, #113, #114, #155 and #156) tested positive for CRAB and were placed in private rooms or cohorted in a semi-private room. LPN/SD/IP #526 stated none of the eight residents who tested positive for CRAB had symptoms. LPN/SD/IP #526 stated staff washed their hands and wore isolation gowns and gloves when providing resident care for residents positive for CRAB. LPN/SD/IP #526 stated the facility was going to retest the residents in six months for CRAB. Observation on 11/07/23 at 9:10 A.M. of Resident #156's room revealed there was a small red sign to the right of the door which stated to Ask the Nurse before entering the room. There were personal protective equipment (PPE) supplies on the door to the room including isolation gowns. Further observation revealed Wound Physician (WP) #588, Registered Nurse/Wound Nurse (RN/WN) #447 and Med Tech (MT) #487 walked in Resident #156's room and did not don PPE. Observation revealed WP #588 and RN/WN #447 were standing next to Resident #156's bed and had not donned PPE. MT #487 was wearing gloves, no isolation gown and was leaning over Resident #156's bed and applying cream to Resident #156's right and left buttocks and upper thighs. MT #487's clothing was touching Resident #156's bed while she applied the cream. When asked about the sign and PPE on the door to Resident #156's room MT #487 stated Resident #156 did not have CRAB and that was why she did not have an isolation gown on. WP #588 stated Resident #156's roommate (Resident #114, also positive for CRAB) had some kind of urine bacteria and that was what the PPE was for. WP #588 stated Resident #114 was not in the room, so it was not a problem. Observation revealed Resident #114 was not in the room. Interview on 11/07/23 at 11:04 A.M. of RN/WN #447 confirmed Resident #156 was CRAB positive and she should have donned PPE before entering Resident #156's room with WP #588 and MT #487 to provide wound care. Interview on 11/07/23 at 1:48 P.M. of Medical Director #589 revealed he was aware the facility had an increase in CRAB cases. Medical Director #589 stated he talked to the Director of Nursing about the increase in CRAB cases today (11/07/23) and agreed with the measures the facility was taking to control the spread of CRAB. Medical Director #589 stated he had no additional recommendations for measures the facility should take. When asked if there should have been additional testing, screening when there were CRAB positive cases in 05/2023 and 08/2023 Medical Director #589 stated he could not recall anything regarding what was done about CRAB in the facility, and he could not comment on the residents who were positive in May and August 2023, and he could not comment if screening should have been done because it was too long ago. Medical Director #589 stated he attended scheduled monthly meetings and more often if needed. Interview on 11/08/23 at 3:36 P.M. of the Administrator, the Director of Nursing and LPN/SD/IP #526 revealed when asked why Resident #156's door did not have a Contact Precaution sign on the door and had a small red sign to the right of door stating to Ask a Nurse before entering the room LPN/SD/IP #526 stated the red sign says to see a nurse and the nurse would tell the person Resident #156 was on Contact Precautions. LPN/SD/IP #526 stated that was the way the facility had always done it. 2. Review of Resident #155's medical record revealed an admitted [DATE] and diagnoses included epilepsy, carrier of carbapenem-resistant Acinetobacter baumannii (CRAB), and alcoholic cirrhosis of the liver with ascites. Review of Resident #155's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #155 was cognitively intact. Resident #155 required setup or clean-up assistance for toileting and walking in his room or a corridor. Resident #155 used a manual wheelchair or scooter. Review of Resident #155's care plan dated 10/24/23 included Resident #155 had a CRAB infection. Resident #155's infection would resolve with no adverse reactions to treatment. Resident#155 would follow facility protocols for contact isolation for duration of treatment, monitor for increased withdrawal, social isolation; utilize PPE (personal protective equipment) as appropriate. Interview on 11/07/23 at 8:05 A.M. of LPN/SD/IP #526 revealed Resident's #57, #61, #92, #101, #113, #114, #155 and #156's were instructed that they should wash their hands before leaving the rooms they resided in. Observation on 11/07/23 at 4:10 P.M. of Resident #155 revealed he used a wheeled walker, walked out of his room into the hall and into the common area used by other residents and did not wash his hands before leaving the room. Interview on 11/07/23 at 4:10 P.M. of Resident #155 revealed he shared a room with Resident #113 and confirmed there was PPE supplies hanging on the door to his room. Resident #155 stated the PPE was on the door because both he and Resident #113 were swabbed and tested positive for something in their arm pits. Resident #155 indicated a person came by with the results and told him he would be tested again. Resident #155 stated he was not told he should do anything like washing his hands before leaving his room or to do anything different than he had been doing before he tested positive. Resident #155 confirmed he did not wash his hands before leaving his room. Review of the facility policy titled Isolation Precautions dated 06/08/22 included it was the policy of the facility, when necessary, to prevent the transmission of infections within the facility using Isolation Precautions. The 2007 Centers for Disease Control and Prevention (CDC) guidelines for Isolation Precautions would be utilized in the facility with some modifications. In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that could be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care areas. In some instances, residents colonized with these organisms may also require Contact Precautions. The above includes epidemiologically important organisms (multidrug-resistant organisms). Handwashing (hand hygiene) was the single most important precaution to prevent the transmission of infection from one person to another. Wash hands with soap and water before and after each resident contact and after contact with resident belongings and equipment. Alcohol-based hand rub could be used if hands were not visibly soiled. All personal protective equipment should be used once and discarded in either the trash or used linen receptacle before leaving the room. Review of the Centers for Disease Control and Prevention (CDC) Information for facilities titled CRAB Carbapenem-resistant Acinetobacter baumannii, An Urgent Public Health Threat included Acinetobacter baumannii was a species of bacteria that was an opportunistic pathogen. It could cause a variety of different types of infections. Infections caused by carbapenem-resistant A. baumannii (CRAB) don't respond to common antibiotics and some CRAB were resistant to all available antibiotics. Carbapenemase-producing CRAB had the potential to spread rapidly and was frequently associated with outbreaks. CRAB spreads through direct and indirect contact with patients infected or colonized with CRAB or contaminated environmental surfaces and equipment. It was usually transmitted from person to person, often via the hands of healthcare personnel or on contaminated shared medical equipment like blood pressure machines. CRAB could cause large outbreaks in healthcare facilities. Colonization meant that an organism was found in or on the body but was not causing any symptoms or disease. CRAB primarily colonized the digestive tract, respiratory tract, skin, and, or wounds but could colonize other body sites. Patients who were colonized with CRAB could be a source of spread to other patients. They were also at higher risk of developing CRAB infection than patients who were not colonized. And because patients colonized with CRAB don't have signs or symptoms, CRAB colonization could go undetected and contribute to silent spread of resistant bacteria. Colonization was detected by a screening test for patients and residents who were at risk of CRAB colonization or infection. Follow public health recommendations for CRAB colonization screening. Wear a gown and gloves when caring for patients with CRAB. CRAB could contaminate your hands and clothes while you care for a patient infected or colonized with CRAB or work in their environment. This puts the patients you care for afterward at risk of getting CRAB. Review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) included Contact Precautions were intended to prevent transmission of infectious agents, like MDROs, that were spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions required the use of gown and gloves on every entry into a resident's room. The resident was given dedicated equipment (e.g., stethoscope and blood pressure cuff) and was placed into a private room. When private rooms were not available, some residents (for example, residents with the same pathogen) may be cohorted, or grouped together. This deficiency represents non-compliance investigated under Complaint Number OH00147595.

Based on interview, record review and review of the facility policy, the facility failed to ensure Resident #172 and his Responsible Party were given a transfer notice when Resident #172 was transported from the facility via Emergency Medical Services to the local hospital for evaluation. This affected one resident (Resident #172) out of three residents reviewed for transfers and discharges. The facility census was 170. Findings include: Review of Resident #172's medical record revealed an admitted [DATE] and diagnoses included unspecified dementia with agitation, restlessness and agitation, and type two diabetes mellitus. Resident #172 was discharged from the facility on 11/03/23. Review of Resident #172's Admission Assessment and Baseline Care Plans dated 11/01/23 at 6:44 P.M. included Resident #172 had cognitive impairment with poor decision making skills and had a diagnosis of dementia. Resident #172 was alert, quiet and cooperative. Resident #172 could ambulate independently and did not have a history of elopement. Review of Resident #172's progress notes dated 11/01/23 at 3:24 P.M. included Resident #172 was transported from the local hospital to the facility. Resident #172 had dementia and Alzheimer's Disease with agitation. Resident #172 was alert and oriented to time, place, person and spoke mainly Spanish with very little English. Resident #172 was resting peacefully and safety measures were maintained. Review of Resident #172's progress notes dated 11/02/23 at 10:37 A.M. included Resident #172 was pacing to and from his room on the nursing unit earlier this morning. At this time Resident #172 was off the nursing unit and pressing elevator buttons. Resident #172 was redirected and returned to his room without incident. Resident #172 was alert to self, pleasant and cooperative. One-to-one initiated for monitoring. Resident #172's Responsible Party was notified and updated. Review of Resident #172's progress notes dated 11/02/23 at 10:50 A.M. completed by an Advanced Practice Nurse included Resident #172 had dementia with agitation, was sitting on the side of his bed and was alert and oriented times two. Resident #172 was Spanish speaking and understood some English. Nursing reported some manic behaviors and pacing in his room and hallways. Resident #172 was admitted from the local hospital behavioral unit and had increased confusion and agitation. Resident #172's family reported agitation, aggression and abusive patterns. Review of Resident #172's progress notes dated 11/02/23 at 12:07 P.M. included Resident #172 was confused, independent with ambulation, combative with staff and was wandering in other resident's rooms. Interventions attempted and failed were to offer drink, one to one supervision, expression of feelings. The CNP (Certified Nurse Practitioner) gave an order for Resident #172 to return to the local hospital psychiatric unit. Resident #172's Responsible Party was contacted and updated. Review of Resident #172's progress notes dated 11/02/23 at 2:53 P.M. included Resident #172 had a change in condition including behavioral symptoms of agitation and psychosis. Resident #172 was confused and independent with ambulation. Resident #172 was verbally and physically combative with staff, wandering to other units and exit seeking. Attempts to redirect Resident #172 caused increased agitation. During attempts at redirection Resident #172 shoved a staff member. The Nurse Practitioner was notified and Resident was sent via Emergency Medical Services to the local hospital for a psychological evaluation. Review of Resident #172's progress notes dated 11/03/23 at 1:29 A.M. revealed Resident #172 was discharged from the facility. There was no documentation a transfer notice was sent with Resident #172 when he left the facility and there was no documentation Resident #172's Responsible Party was provided a transfer notice. Interview on 11/08/23 at 10:26 A.M. of Family Member (FM) #590 revealed she was Resident #172's daughter and also his Responsible Party. FM #590 stated Resident #172 was admitted to the facility on [DATE] she was told he was doing well, she visited him and he was very happy and calm. FM #590 stated on 11/02/23 she was told Resident #172 was doing well and a short time later she was called and told she needed to pick his belongings because was at the local hospital. FM #590 stated the facility nurse told her Resident #172 was entering other resident rooms and the staff could not be chasing after him. FM #590 stated the nurse told her Resident #172 attacked two people and shoved someone else's shoulder. FM #590 stated Resident #172 didn't mean anything by his actions. FM #590 indicated Resident #172 was cared for by her daughter before he was admitted to the local hospital behavioral unit. FM #590 stated she admitted Resident #172 to the local hospital because the neighbor upset him and he hit her daughter. FM #590 stated she was not given a 30 day notice, a transfer notice or any paper. FM #590 stated she received no communication from the facility other than Resident #172 was being transported to the local hospital. FM #590 stated the situation was very upsetting to her. FM #590 indicated the facility called her and told her she needed to sign paperwork so the insurance could be billed. Interview on 11/08/23 at 11:34 A.M. of the Administrator revealed Resident #172 was recently admitted from the local hospital psychiatric unit and had a history of beating up his grandchild. The Administrator stated Resident #172 became combative and physically aggressive at the facility and was sent to the local hospital for evaluation. The Administrator stated Hospital Liaison and Marketing (HLM) #591 evaluated Resident #172 and said he was appropriate for admission to the facility. The Administrator stated Resident #172 probably needed alternative placement other than the facility and the hospital would have a conversation with the family. The Administrator stated the facility did not get Resident #172's referral back from the hospital and if Resident #172 was discharged to the hospital he would not be a bed hold. Interview on 11/08/23 at 1:53 P.M. of Registered Nurse (RN) #423 revealed she was working on 11/02/23 when Resident #172 was sent to the hospital via Emergency Medical Services. RN #423 stated Resident #172 was fine in the morning but later in the day he became verbally and physically aggressive and started wandering into other resident rooms. RN #423 stated Resident #172 was exit seeking and pushed an aide into the double door. RN #423 stated she updated FM #590 about the situation with Resident #172 and told FM #590 that Resident #172 was going to be transported to the local hospital for evaluation. RN #423 stated she worked until 3:00 P.M. on 11/02/23 and told the daughter before she left the facility that Resident #172's belongings would stay in his room and she would lock his cell phone in the medication cart. RN #423 stated she went home and did not know what happened after that. Interview on 11/08/23 at 2:10 P.M. of Business Office Manager (BOM) #421 revealed Resident #172 had a medicaid insurance plan. BOM #421 stated she did not hold his bed or send a bed hold notice to Resident #172 or his Responsible Party because he did not have his admission paperwork signed and because he went to the hospital due to medical needs. BOM #421 indicated a transfer letter would have gone with the nurses packet. Interview on 11/08/23 at 2:32 P.M. of the Director of Nursing revealed Resident #172 was admitted to the facility on [DATE] from the local hospital psychiatric unit. The DON indicated on 11/02/23 Resident #172 was placed on one-to-one care because he was aggressive and yelling and walking into other resident rooms. The DON stated she knew Spanish and tried talking to Resident #172 in Spanish but he told her to get out of his room and slammed the door. The DON stated FM #590 was contacted and updated on the situation with Resident #172. The DON stated Resident #172 was not placed in the secured unit because he needed to be assessed before he was put on a unit of vulnerable residents. The DON stated Resident #172 was transported via Emergency Medical Services to the local hospital for evaluation. The DON confirmed a Transfer Letter should be located in Resident #172's electronic medical record and the Transfer Letter was not in the electronic medical record. Review of the facility policy titled Transfer or Discharge Notice reviewed 06/08/22 included the facility should provide a resident and, or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Except as specified below, a resident and, or his or her representative would be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility: the transfer was necessary for the resident's welfare and the resident's needs could not be met at the facility; the safety of individuals in the facility was endangered; an immediate transfer or discharge was required by the resident's urgent medical needs; the resident had not resided in the facility for 30 days. The resident and, or the representative would be provided with the following information, including the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident was being transferred or discharged , the name, address, and telephone number of the state long-term care ombudsman. This deficiency represents non-compliance investigated under Complaint Number OH00148150.

Based on observation, record review and interview, the facility failed to implement a comprehensive and individualized pain management program for Resident #243 to treat the resident's gout. Actual harm occurred when Resident #243 experienced extreme pain, moaning and yelling out due to pain in toes related to a medical [DIAGNOSES REDACTED].M. and 11/19/19 at 8:00 P.M. This affected one resident (#243) of three residents reviewed for pain. Findings include: Resident #243 was admitted to this facility on 10/31/19. On 11/06/19 the resident was sent out to the hospital for mental status change. He was readmitted to this facility on 11/13/19. His admitting [DIAGNOSES REDACTED]. On 11/18/19 at 8:30 [NAME]M. the resident's significant other approached this surveyor stating that she needed to get the doctor to come and look at her husband. She stated he was in terrible pain and no one was doing anything. On 11/18/19 at 8:35 [NAME]M. Licensed Practical Nurse (LPN) #300 was informed the resident was having severe pain and needed to be seen. She was observed entering the resident's room at 8:45 [NAME]M. Observation on 11/18/19 at 8:50 [NAME]M. revealed the resident sitting up on the left side of the bed with his feet positioned on the floor. The resident was not wearing socks. The resident was rocking back and forth on the bed moaning. When asked if he was in pain, the resident stated it's awful, it really hurts. The right and left great toes were red along with redness on the top of both feet to the arch of both feet. Interview with LPN #300 on 11/18/19 at 9:10 [NAME]M. revealed that she was going to contact the physician for medication for this resident. Observation on 11/18/19 at 9:35 [NAME]M. the resident was repositioned in semi- fowlers position in bed. His feet were in bed and he was yelling at his significant other to take the covers off his feet because his toes really hurt. Observation on 11/18/19 at 11:00 [NAME]M. revealed the resident sitting up at the side of the bed. His feet were observed on the floor. The resident was again rocking back and forth. This surveyor approached the resident, and he stated he did not want to talk because his toes hurt. Per interview with his significant other at this time, the physician was supposed to come in to see him. She verified the resident was still in pain. Interview with LPN #300 on 11/18/19 at 11:40 [NAME]M. revealed that she had contacted the physician, and the nurse practitioner was going to see him. She stated she did medicate him with Tylenol (pain medication). Review of the physician order [REDACTED].M. stated the resident was receive [MEDICATION NAME] 0.625 milligrams (mg), an anti-[MEDICAL CONDITION] medication, twice a day. Review of nursing progress notes dated 11/18/19 at 12:39 P.M. revealed documentation from the nurse practitioner stating the resident was found sitting up in bed in no acute distress. The resident was calm and cooperative. The resident complained of gout to his great toes on both feet. Interview with the resident's significant other on 11/19/19 at 9:50 [NAME]M. revealed he was in a lot of pain. She stated she was constantly calling the nurse yesterday to get the medication for him due to his gout pain. She was very frustrated and stated she could not get anyone to help him. Observation of the resident on 11/19/19 at 11:00 [NAME]M. revealed the resident asleep in bed. The resident's significant other stated the resident had finally fallen asleep, and she hoped he slept for awhile because he was not feeling good and still having pain, and had not eaten anything. When asked if he got the medicine for his gout, she stated no. She stated he had not received anything for pain. She stated he now had other things going on and was now having bad abdominal pain on top of the gout pain. Further review of the physician orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Review of the MAR for the [MEDICATION NAME] for the month of (MONTH) 2019 revealed the resident was ordered the [MEDICATION NAME] twice a day at 11:30 [NAME]M. on 11/18/19. He had not received the evening dose of [MEDICATION NAME] on 11/18/19 or the morning dose of [MEDICATION NAME] on 11/19/19. Review of the nursing progress notes dated 11/18/19 at 10:58 P.M. revealed the [MEDICATION NAME] had not been given because it was not available. Review of the nursing progress notes dated 11/19/19 at 8:00 [NAME]M. revealed the [MEDICATION NAME] was not given because it had not been delivered from the pharmacy. Review of the MAR indicated [REDACTED]. Interview with LPN #304 on 11/21/19 at 10:00 [NAME]M. revealed she took care of the resident on Monday (11/18/19) night shift. She stated the resident was complaining of gout pain, but she could not remember if he was showing signs and/or symptoms of pain. She verified she did not give the resident his ordered dose of [MEDICATION NAME] because she did not have the medication. She also stated there was a discrepancy with the order because the nurse practitioner ordered 0.625 mg, and [MEDICATION NAME] only comes in 0.6 mg. She contacted the physician the night of 11/18/19 to verify the ordered dosage amount and how often it should be given. She stated the physician did call her back, and he clarified the order to read [MEDICATION NAME] 0.6 mg two times a day. She then contacted the pharmacy and told them the correct order, and she told them she needed the medication delivered. When questioned if the she had given the resident anything for pain since she did not have the [MEDICATION NAME], she stated she did not remember. She stated if she had given the resident Tylenol, she would have signed it off. Interview on 11/21/19 at 12:30 P.M., State tested Nursing Assistant (STNA) #305 stated she had taken care of Resident #243 on 11/19/19. When asked if he had complained of pain, she stated sometimes it was hard to tell because he had behaviors. She stated he had a habit of screaming out a lot, and when he screamed out it could be because he needed help getting him to the bathroom or due to pain. The STNA did remember while she was taking him to the bathroom, he complained of gout pain and constipation. Interview with the Director of Nursing (DON) on 11/21/19 at 1:30 P.M. revealed the resident has behaviors. She stated he always yelled out but that does not mean he is yelling out in pain. When asked how staff knew the difference, she stated the staff go in to see what he needs. When asked about the resident being in pain and not getting his medication for his gout, she verified one nurse stated she gave him Tylenol. When the DON reviewed the MAR, she verified nothing was signed off showing the resident received Tylenol, and the [MEDICATION NAME] indicated it was not administered on 11/18/19 and 11/19/19.