Every finding on record at Salem North Healthcare Center

Based on record review, interviews, review of a facility self-reported incident (SRI) and facility policy review, the facility failed to prevent misappropriation of opioid medication. This affected one resident (#32) out of three residents reviewed for misappropriation. The facility census was 63.Findings include:Review of Resident #32's medical record indicated an admission date of 07/30/20 with diagnoses including acute kidney failure, end stage renal disease, pleural effusion, hypertensive chronic kidney disease Stage V, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, atrial flutter, and dependence on renal dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident was cognitively intact, required supervision for eating, needed partial to moderate assistance with oral hygiene, and was dependent on staff for toileting hygiene, showers, dressing, and bed mobility. Review of the resident's care plan showed the resident had, or was at risk for, pain related to chronic conditions including open skin areas, peripheral vascular disease, double above knee amputations, pleural effusions with a Pleurex drain in place, and diabetic neuropathy. Interventions included providing and evaluating non pharmacological pain measures, completing pain assessments, monitoring for pain each shift, and following physician orders for pain complaints.Review of Resident #32's physician orders date April 2026 revealed the resident was prescribed Oxycodone (opioid pain medication) 5 milligrams (mg) give two tablets every four hours as needed for pain. This medication was discontinued on 04/09/26.Review of the SRI tracking #273271 dated 04/13/26 revealed during the shift change narcotic count completed by Licensed Practical Nurse (LPN) #804 and LPN #801 it was discovered by LPN #801 that Resident #32's card of Oxycodone 5 mg had the pill in slot #2 and slot #6 taped in and were not uniform in color and was not scored like the other pills in the medication card.Review of the witness statements from SRI #273271 revealed LPN #804 stated when she and LPN #801 were counting the narcotics at change of shift, LPN #801 noticed two of the pills in Resident #32's card of Oxycodone 5 mg were taped into slot #2 and #6. The pills taped in were not the same and were smooth with no markings on them. LPN #804 additionally stated LPN #801 called the Director of Nursing (DON) for further instructions. Further review revealed she stated when she counted at the beginning of her shift, she did not pull the medications out of the cart and just looked at them while still in the drawer to ensure the count was still correct.Review of the witness stated written by LPN #801 revealed she stated on 04/10/26 the card of Resident #32's Oxycodone did not have any taped in medications and that when she counted on 04/13/26 she noticed the medications in the #2 and #6 slots were taped, and the medications in those slots did not match the Oxycodone in the remaining slots.Interview on 04/27/26 at 12:45 P.M. with the Regional Director of Clinical Operations (RDCO) revealed through investigation it was discovered the two medications taped into Resident #32's card of Oxycodone were melatonin. The RDCO stated they were unable to identify who took or where the two missing Oxycodone went but stated they were missing. She stated they notified the pharmacy of the missing Oxycodone and wanted to see if the resident was due back any monies. She stated they did this even though the medications were discontinued. When asked why the facility unsubstantiated the allegation of misappropriation, she had no answer.Review of the undated facility policy titled Medication Controlled Drugs and Security revealed the purpose of this policy was to provide direction for the nurse regarding processes of operation for the administration and control of narcotics. Additionally, it stated drug diversion would be treated as misappropriation of Resident Property and the Board of Nursing would be notified as appropriate for known drug diversions or suspected drug diversion after careful review and evidence collection.

Based on record review, observation, interview, review of manufacture's guidelines and facility policy review, the facility did not ensure medications were not left at the bedside for Resident #42. This affected one (Resident #42) of three residents observed for medication administration. The facility also failed to store medications in a manner to preserve efficacy and proper discard time frames affecting eight (Residents #59, #6, #9, #48, #18, #33, #55, and #57) medications observed during medication storage observation. The facility census was 70.Findings include:1. Review of the medical records for Resident #42 revealed the date of admission as 12/19/25. Significant diagnoses included chronic obstructive pulmonary disease (COPD) and acute respiratory failure. Significant orders included Dulera Inhalation 200/5 micrograms per actuation (mcg/act) (a prescription inhaler to reduce inhalation and open airways), two puffs inhale orally two times a day for asthma and Spiriva (a prescription inhaler used for daily maintenance of respiratory conditions) 2.5 mcg/act two puffs one time daily for COPD. There were no orders for the resident to self-administer medications.Review of the assessments completed in the medical record revealed no assessment for self-medication administration for Resident #42.Review of the Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident #42 was cognitively intact.Review of the care plan dated 12/31/25 revealed Resident #42 had COPD with shortness of breath while lying flat. An intervention included administering medications as ordered.An observation on 02/09/26 at 6:56 P.M. revealed Resident #42 to be lying in bed. There were two inhalers (Dulera and Spiriva) on the overbed table next to the resident.An interview on 02/09/26 at 7:00 P.M. with Licensed Practical Nurse (LPN) #355 verified presence of the Dulera and Spiriva inhalers on the overbed table next to Resident #42.An interview on 09/10/26 at 1:00 P.M. with Regional Director of Clinical Operations (RDCO) # 344 verified the lack of a self-medication administration assessment for Resident #42.2. On 02/10/26 at 11:00 A.M. an observation of the medication cart identified as the South Center Cart with LPN #350 revealed a bottle of over-the-counter acidophilus (probiotic), 200 count, opened and unlabeled. The acidophilus was used for Residents #6, #9, #48, and #59. The observation further revealed a bottle of over-the-counter famotidine 10 milligrams (mg) (reduces stomach acid), 300 count that was opened and unlabeled. The famotidine was used for Residents #18, #33, #55 and #57. There was an aspart insulin pen for Resident #59 unlabeled as to when it was opened. There was an open vial of lispro insulin, 10 milliliters (ml) for Resident #59 unlabeled as to when it was open. LPN #350 verified the findings at the time of the observation. An interview with RDCO #344 on 02/10/26 at 11:10 A.M. revealed medications were to be dated when opened.A review of the manufacturers package insert for aspart insulin revealed that a single patient use penfill cartridge should not be used after 28 days of being opened.A review of the manufacturers package insert for lispro insulin revealed that the insulin should not be used after 28 days of being opened.3. An observation of the South medication storage room on 02/10/26 at 11:15 A.M. revealed a one ml vial of Tubersol serum (a serum injected to test for Tuberculosis). The vial was open, unboxed and not labeled as to when it was opened. LPN #349 verified the opened, unboxed and unlabeled vial of Tubersol at the time of the observation.A review of the manufacturers package insert for Tubersol revealed, a vial of Tubersol which has been opened and in in use for 30 days should be discarded.A review of the facility policy titled; Medication Administration that was undated revealed medications should never be left unattended. The policy further revealed for medications that expire, label the date opened on the label (insulin, irrigation solutions etc.).

Based on observation and interview, the facility failed to ensure the smoking area of the courtyard was maintained in a clean and sanitary manner free from cigarette butts. This had the potential to affect all six (Residents #16, #21, #34, #41, #56, and #66) identified by the facility as utilizing the smoking area. The facility census was 70.Findings include:Observation on 02/10/26 at 4:25 P.M. of the courtyard smoking area revealed multiple cigarette butts (more than 50) scattered on the ground and in the snow. Interview at the time of the observation with Licensed Practical Nurse (LPN) #355 verified the observation and stated she was not sure who was responsible for cleaning up the cigarette butts. Observation on 02/10/26 at 4:42 P.M. of the courtyard smoking area with the Administrator and Regional Director of Clinical Operations (RDCO) #344 verified the multiple cigarette butts on the ground and snow. The Administrator stated it was the responsibility of maintenance to ensure the smoking area was clean.

Based on record review, interview, observation and facility policy review, the facility failed to ensure oxygen tubing was changed every seven days. This affected one (Resident #42) of two residents reviewed for respiratory care and had the potential to affect eight additional (Residents #1, #5, #7, #16, #35, #48, #54, and #65) identified by the facility as utilizing oxygen. The facility census was 70.Findings include: A review of medical records for Resident #42 revealed the date of admission as 12/19/25. Significant diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and unspecified acute respiratory failure. A review of significant orders revealed no current physician order for oxygen therapy, including flow rate, method of delivery, indication for use, or parameters for monitoring. No orders for oxygen tubing management.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident #42 was cognitively intact.Review of the care plan dated 12/31/25 revealed Resident #42 had altered cardiovascular status related to combined systolic and diastolic CHF and chronic atrial fibrillation. An intervention included administer oxygen as ordered. Review of a progress note dated 12/31/25 revealed Resident #42 was on two liters per minute of oxygen. Further review of progress notes revealed on 01/30/26, Resident #42 was receiving oxygen via nasal cannula.An observation on 02/09/26 at 7:00 P.M. of Resident #42 revealed he was in bed with oxygen on via nasal cannula (a tube in the nose that delivers oxygen). The tubing was dated 01/24/26. Licensed Practical Nurse (LPN) #355 verified the date of 01/24/26 on the oxygen tubing of Resident #42 at the time of the observation. LPN #355 stated oxygen tubing was to be changed every seven days and as needed if it became soiled.A review of the undated facility policy titled Supplemental Oxygen using Nasal Cannula revealed under section III, subpoint b that nasal cannulas and tubing are changed weekly or when soiled and labeled with date opened.

Based on record review, observation, interview and facility policy review review, the facility failed to ensure falls were thoroughly investigated for Resident #18 and failed to ensure safe smoking practices were followed for Resident #16. This affected one (Resident #18) of three residents reviewed for falls and one (Resident #16) of three residents reviewed for smoking. The facility identified six residents (Residents #16, #22, #34, #41, #56 and #66) in the facility who smoked. The facility census was 70.Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 06/03/24. Diagnoses included congestive heart failure (CHF), diabetes, morbid obesity, hypertension, depression and anxiety. Review of the fall risk assessment dated [DATE] revealed Resident #18 was at risk for falls. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was cognitively intact. She required substantial/maximum assistance with oral hygiene, upper body dressing, personal hygiene, rolling left to right and right to left, sitting to lying and lying to sitting and was dependent on staff for showers, transfers, lower body dressing and applying and removing footwear. She was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 04/16/25 revealed Resident #18 was at risk for falls due to impaired mobility. Interventions included ensuring the room was free of hazards, initiating neurological checks if a fall was unwitnessed, ensuring adequate lighting at night and ensuring the call light was within reach. Review of the nursing progress note dated 05/09/25 at 6:50 P.M. revealed Resident #18 was heard yelling from her room and was found on the floor with her head on her handbag. She complained of severe pain in her right knee, and movement of her right leg was very limited. No changes in mental status or observed, her vital signs included blood pressure 140/60, heart rate 56, temperature 97.1 degrees Fahrenheit (F), respirations 18 and oxygen saturation 97 on room air. She could not explain what happened prior to the fall. The resident's family was notified as well as the unit manager and emergency medical services (EMS) were contacted, and the resident was taken to the emergency department (ED) around 8:20 PM. Neurological checks were initiated and continued until the resident left for the ED. Review of the nursing progress note dated 05/10/25 at 6:18 A.M. revealed Resident #18 was admitted to the hospital with a right distal femur fracture. Review of the undated facility investigation revealed Resident #18 was heard yelling from her room and was found on the floor. She complained of severe pain in her knee; her vital signs were obtained, and she could not recount the events that led to the fall. She was subsequently sent to the ED. Immediate interventions taken were a range of motion assessment, head to toe body check, locked bed wheels and a urine drug screen was ordered. The resident was found on her right side, was last toileted around 6:30 P.M., the environment was quiet, she was barefoot, the alarm was sounding, a mattress was on the floor, and the bed was in the low position. A witness statement obtained from Registered Nurse (RN) #350) who was assigned to Resident #18 at the time revealed after dinner the resident was falling asleep in her wheelchair. He asked her if she wanted to lie down, and she refused. Shortly after that she was heard yelling and observed lying on the floor complaining of pain. There were no other witness statements or descriptions of the event. Interview on 02/11/26 at 10:24 A.M. with the Director of Nursing (DON) revealed Resident #18 was in her wheelchair when she fell but confirmed an immediate intervention was to ensure the bed wheels were locked was added. She could not explain why there were no other witness statements and nothing to address where the resident was located immediately prior to the fall or why this intervention was implemented if the fall occurred from the wheelchair. Interview on 02/11/26 at 11:20 A.M. with Social Service Designee (SSD) #363 revealed she was the certified nurse aide (CNA) assigned to care for Resident #18 at the time of the fall. She revealed Resident #18 was in her wheelchair and was offered to lie down, but she chose not to. She heard screaming from the residents' room and immediately went to find her on the floor. She then notified the nurse. She revealed her call light was not on at the time. She also confirmed she was never asked to provide a witness statement regarding the incident. Interview on 02/11/26 at 10:58 A.M. with Resident #18 revealed she fell from her wheelchair. She could not recall specific details of the event but does recall breaking her leg. Interview on 02/11/26 at 11:36 A.M. with the DON confirmed the fall investigation for Resident #18 was inconclusive and did not provide enough detail, including witness statements, to consider the investigation thorough. Review of the undated facility policy titled Fall Prevention and Management revealed the therapy department would screen residents to assist in identification of potential activities of daily living issues that could be addressed to prevent or minimize their risk of falls as well as make recommendations for equipment, the DON and Executive Director would be notified if a resident was transferred out of the facility due to a fall, the facility would ask the resident what happened when they fell, even if the resident had dementia, identify any witnesses and ask them to write a statement immediately. The facility would attempt to identify why the resident fell, and immediate interventions would be put in place to prevent further falls. 2. Review of the medical record of Resident #16 revealed an admission date of 11/07/25. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, lung cancer, major depressive disorder, dependence on supplemental oxygen, alcohol abuse, anxiety disorder, and nicotine dependence. Review of the smoking acknowledgement form dated 11/07/25 revealed Resident #16 received a copy of the smoking policy for the facility. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition, required supervision or touch assistance with transfers, and used a wheelchair. The assessment also indicated the resident used tobacco. Review of the plan of care revised 02/03/26 revealed Resident #16 utilized nicotine products (cigarettes) and was an independent smoker. Interventions included educating the resident/resident representative (if applicable) to facility smoking policy, obtain resident signature. Review of the smoking assessment dated [DATE] indicated Resident #16 was an independent smoker. Interview on 02/10/26 at 10:38 A.M. with Resident #16 revealed he was independent smoker and kept his own smoking materials. Resident #16 stated the nurses kept the smoking materials for the supervised smokers. No smoking materials were observed at this time in Resident #16's room. Observation on 02/10/26 at 4:13 P.M. of Resident #16 outside in the courtyard smoking with two other residents. At 4:33 P.M. Resident #16 was observed leaving the courtyard smoking area and self-propelling to his room. Interview at this time with Resident #16 revealed he keeps his smoking material on him and showed a pack of cigarettes and lighter sitting on the left side of his wheelchair covered by his jacket. Interview on 02/10/26 at 4:42 P.M. with the Administrator and Regional Director of Clinical Operations (RDCO) #344 revealed the residents and/or family were responsible for purchasing smoking material and when they bring them in they were to turn them into the nurses station. Both the Administrator and RDCO #344 were made aware of Resident #16 observed with his smoking material in his room. The Administrator stated the resident was not supposed to have them on him and that they would need to re-educate the resident. Follow-up interview on 02/11/26 at 9:30 A.M. with the Administrator stated she had talked to Resident #16 on 02/10/26 and after about 45 minutes he handed her his smoking materials. Review of the undated facility policy titled Resident Smoking Guidelines revealed facility staff will store smoking materials in a secure area when not in use by the resident for both independent and supervised smokers. All smoking materials will be maintained by the facility staff and provided to the resident on request. Smoking materials will be returned to the facility staff upon completion of smoking.

Based on record review, observation, interview and facility policy review, the facility failed to ensure accurate and complete clinical documentation and failed to notify the physician of resident refusals of a prescribed cervical collar (C collar). This affected one (Resident #6) of two residents reviewed for orthotic devices. The facility census was 70.Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/17/25. Diagnoses included right femur fracture, dementia, abnormal posture, vertebral fracture, collarbone fracture, pelvis fracture, insomnia and muscle weakness.Review of the physician's order dated 11/18/25 revealed Resident #6 had an order for a C collar (medical device designed to restrict movement of the neck and upper spine to allow injuries to heal, protect against further damage, or provide relief from severe pain) to be in place at all times, only to be removed for showers and to check skin integrity.Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was moderately cognitively impaired. He required substantial to maximum assistance for oral care and was dependent on staff for eating, showering, toileting, dressing and personal hygiene.Review of the care plan dated 12/01/25 revealed Resident #6 had an activity of daily living (ADL) self-care deficit due to multiple fractures. Interventions included ensuring the C collar was in place at all times, only to be removed for skin integrity and showers and ensuring the call light was in reach. Resident #6 was admitted with multiple fractures including cervical, thoracic, vertebral and clavicle fractures. Interventions included orthopedic follow up per orders and encouraging the resident to actively participate in the rehabilitation process.Review of Resident #6's physicians' orders for February 2026 revealed the order for a C collar remained an active order.Review of the Treatment Administration Record (TAR) for February 2026 revealed Resident #6's C collar was checked for placement on day, evening and night shift on 02/01/26, 02/07/26, 02/08/26, 02/09/26 and 02/10/26, on day shift on 02/02/26 on day and evening shift and on night shift on 02/06/26. Resident #6 was in the hospital from [DATE] at 3:18 P.M. until 02/06/26 at 11:51 P.M.Observation and interview on 02/10/26 at 1:01 P.M. with Resident #6 revealed he was lying in bed watching TV. The C collar was noted to be on the nightstand next to the bed. Resident #6 revealed he was no longer required to wear the C Collar.Interview on 02/10/26 at 1:08 P.M. with Licensed Practical Nurse (LPN) #349 revealed Resident #6 no longer wore a C collar and revealed it had been discontinued a few weeks prior.Interview on 02/11/26 at 10:30 A.M. with the Director of Nursing (DON) revealed Resident #6 had been refusing to wear the C Collar since he was told he would only need to wear it for 12 weeks when he was in the hospital. She confirmed that staff had been documenting it was in place, but reported she was told he was removing it after it was checked for placement. She confirmed there was no documented evidence of the refusals or removals. She further revealed Resident #6 had not been seen by the orthopedic team for the C collar since admission, and calls to the doctor's office for advisement regarding the C collar had not been returned. She could provide no evidence of attempts to contact the orthopedic doctor's office.Review of the undated facility policy titled Routine Resident Care revealed the facility would attend to the total medical, nursing, physical, emotional, social and spiritual needs of residents, including licensed staff providing implementation and evaluation of needs, coordinating and overseeing resident care with accountability for nursing interventions, provide routine care including maintaining proper body positioning and alignment and assisting with special devices such as prosthesis and other devices.

Based on resident interview, observation, staff interview, record review, and review of the facility policy, the facility failed to ensure foods were served at a palatable temperature. This had the potential to affect 64 of the 66 residents (excluding Residents #16 and #65) who received meals prepared and served by the facility kitchen. The facility census was 66 Findings include: Interview on 12/10/24 at 12:18 P.M. with Resident #38 confirmed foods were not served at the right temperatures Interview on 12/10/24 at 4:00 P.M. with Resident #19 confirmed food and drinks served in the facility did not always keep the desired temperatures by the time the tray got to her. Observation of tray line on 12/11/24 at 12:35 P.M. revealed the final meal trays were plated and placed on the meal cart for the main dining hall next to the kitchen. Surveyor requested a test tray as the last lunch tray was plated. The food cart was taken from the kitchen to the dining room at 12:49 P.M. Staff delivered meals and set-up for residents eating in the dining hall from 12:49 P.M. to 1:09 P.M. Observation on 12/11/24 at 1:10 P.M. revealed Dietary Manager (DM) #384 removed the test tray from the meal cart and took food temperatures. The meatloaf was 121 degrees Fahrenheit (F), the peas were 112.1 degrees F, the au gratin potatoes were 122.9 degrees F, and the cranberry juice was 49 degrees F. The meatloaf tasted slightly warm, the peas were barely tepid, the first bite of potatoes from the bottom center of the scoop was tepid, and the bite of potatoes from the top was cold to taste. Though the juice cup remained cold to touch, the cranberry juice was not cold and not warm but was cooler than room temperature. There was no thermal pellet under the plate of the test tray. Interview on 12/11/24 at 1:15 P.M. with DM #384 confirmed she would like to see the meat temperature maintained at 130 degrees F or higher, but a minimum of 129 degrees F, by the time it reached the residents. DM #384 further confirmed the kitchen ran out of thermal pellets prior to plating the test tray and not all residents received food that was held on the meal cart on a tray which contained a thermal pellet to prevent heat loss prior to serving. Interview on 12/11/24 at 4:50 P.M. with Resident #57 confirmed hot foods got served cold at times. Further interview confirmed she participated in resident council and food committee meetings and food temperatures had been a common concern she felt had not been addressed. Interview on 12/12/24 at 5:00 P.M. with Resident #37 confirmed she felt meals in the facility were always served cold. Interview on 12/12/24 at 9:55 A.M. with DM #384 confirmed the facility was short at least 18 thermal pellets. She had informed the previous Administrator and was told to hold off on ordering more at that time. DM #384 also confirmed that the new Administrator was made aware of the concern of the shortage of thermal pellets on 12/11/24 and she ordered two dozen more for the facility on 12/11/24. Review of the food committee meeting minutes dated 09/20/24 revealed residents reported hot foods were being served cold. Review of the meeting minutes dated 10/18/24 and 11/15/24 revealed residents who participated in food committee meetings continued to report hot foods were served cold. Review of the facility policy titled Dietary Operations-Time and Temperature Control and Recording undated revealed food holding included time spent for transport and delivery of food and the Food and Drug Administration (FDA) required hot foods to be maintained at 135 degrees F or higher and all cold foods to be maintained at 41 degrees F. The policy further revealed food was to be properly covered and any holding units, which included thermal pellets, insulated carts, and holding cabinets were to be preheated and maintained in good repair. The policy also stated it was imperative to limit the time between tray preparation and meal delivery to avoid a negative impact on palatability, temperature and overall satisfaction with the meal. This deficiency represents noncompliance investigated under Complaint Number OH00159860.

Based on medical record review, staff interview, review of online medication resources, and review of facility policy, the facility failed to ensure residents did not receive unnecessary or duplicate medications. This affected one (Resident #67) of three residents reviewed for medication administration. The facility census was 66. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included polyneuropathy, cellulitis of the lower limb, type two diabetes mellitus, lymphedema, weakness, adult failure to thrive, atrial fibrillation, oropharyngeal dysphagia, overactive bladder, Alzheimer's Disease, and vascular dementia. Review of the admission Minimum Data Set (MDS) assessment for Resident #67 dated 07/30/24 revealed the resident had severe cognitive impairment and was dependent on staff for bathing, dressing, toileting hygiene, and personal hygiene. Review of the physician's orders for Resident #67 revealed the following medication orders dated 08/15/24: Aricept five milligrams (mg) for two weeks through 08/29/24) then increase to Aricept 10 mg daily for dementia (beginning 08/30/24). The Aricept order further specified once Resident #67 was on Namenda extended release (XR) 28mg and Aricept 10mg, he could begin taking his home medication, Namzaric 28-10mg (which contained Namenda XR 28mg and Aricept 10mg). Namenda XR 7mg by mouth daily for two days (08/16/24 and 08/17/24), Namenda XR 14mg by mouth daily for dementia until 08/20/24, Namenda XR 21mg daily until 08/23/24, then Namenda XR 28mg by mouth daily for dementia. The order further specified once Resident #67 was on Namenda extended release (XR) 28mg and Aricept 10mg, he could begin taking Namzaric 28-10mg from his home medication supply. Namzaric 28-10 mg (Namenda-Aricept), one capsule by mouth one time a day for dementia. The order further specified that Resident #67's wife was to supply the Namzaric, and Aricept and Namenda were to be discontinued at that time. Review of the Medication Administration Record (MAR) for Resident #67 dated August 2024 revealed the resident reached the desired dose of Namenda XR 28mg on 08/24/24 and received a daily dose of Namenda XR 28mg from 08/24/24 through 08/31/24. Further review of the August 2024 MAR revealed Resident #67 received a dose of Aricept 10mg on 08/30/24 and 08/31/24 and started receiving Namzaric 28-10mg on 08/31/24. Review of the MAR for Resident #67 dated revealed documentation Resident #67 was administered Aricept 10mg, Namenda XR 28 mg, and Namzaric ER ,d+[DATE]mg (Namenda-Aricept) on 09/02/24, 09/03/24, 09/04/24, and 09/06/24. Interviews on 12/12/24 with Licensed Practical Nurse (LPN) #335 at 9:24 A.M., with LPN #337 at 12:00 P.M., with LPN #323 at 12:10 P.M. confirmed the MAR documentation indicated Aricept 10mg, Namenda XR 28mg, and Namzaric ER ,d+[DATE]mg were marked as administered to Resident #67 on 08/31/24, 09/02/24, 09/03/24, 09/04/24, and 09/06/24. Interview on 12/12/24 at 12:47 P.M. with the Director of Nursing (DON) confirmed the medication orders dated 08/15/24 indicated once Resident #67 was on the desired dose of Aricpet (10mg) amd Namenda XR (28mg), he was allowed to begin taking his Namzaric 28-10, brought in from his home, but the Aricept and the Namenda were supposed to be discontinued once he started taking the Namzaric 28-10mg daily. The DON further confirmed the August 2024 MAR contained documentation Resident #67 was given Aricept 10mg, Namenda XR 28mg, and Namzaric 28-10mg on 08/31/24 and the September 2024 MAR showed Resident #67 was given Aricept 10mg, Namenda XR 28mg, and Namzaric 28-10mg on 09/02/24, 09/03/24, 09/04/24, and 09/06/24. Review of the on-line manufacturer patient Information sheet for Namzaric at https://www.rxabbvie.com/pdf/namzaric_pi.pdf#page=36 revealed the active ingredients in Namzaric were memantine HCl (Namenda) and donepezil HCl (Aricept) and that Namzaric should not be taken with any other medications that contained any of the ingredients in Namzaric. Review of the facility policy titled Medication Administration revealed medications were to be administered only as prescribed by the ordering provider and should follow acceptable standards of nursing practice. This deficiency represents noncompliance investigated under Complaint Number OH00159860.

Based on closed medical record review, review of telehealth progress notes, Life flight progress notes, policy review, and interviews, the facility failed to provide adequate and necessary care to meet the total care needs of Resident #70. The facility failed to consistently monitor blood (sugar) glucose levels as ordered, failed to administer insulin as ordered and failed to monitor Resident #70, who was assessed as being severely cognitively impaired and dependent on staff for activities of daily living, after an acute/significant change in condition. This resulted in Immediate Jeopardy and actual harm with the potential for serious impairment and/or death beginning on [DATE] at 4:18 P.M. when Resident #70's blood glucose level was elevated at 517 milligram/deciliter [mg/dl] (normal-,d+[DATE] mg/dl). Insulin was administered per physician order, however no additional assessment or monitoring was documented as being completed. At 6:00 P.M., Resident #70 was assessed to be clammy and having tremors with abnormal vital signs. Resident #70's blood sugar was 324 with no intervention/insulin administered at that time. At 8:00 P.M., Resident #70's blood sugar was 274 with no additional assessment of the resident's condition at that time. On [DATE] at 5:00 A.M., no blood sugar monitoring was completed as ordered and there was no evidence Resident #70 was assessed. On [DATE] at 9:40 A.M. Resident #70's blood sugar was checked and registered high on the facility glucometer. The physician was notified and an order for additional insulin was obtained; however, no additional assessment or monitoring of the resident was completed. At 10:55 A.M., Resident #70's blood sugar was rechecked and remained high. Resident #70's vital signs were abnormal (the resident was hyperglycemic, tachycardic, diaphoretic, and unresponsive), and she was transferred to the local hospital. Upon arrival at the local hospital, it was determined Resident #70 was in diabetic ketoacidosis (life threatening complication of diabetes mellitus), had severe hypernatremia (high sodium levels indicative of dehydration) and was in septic shock (widespread infection causing organ failure and dangerously low blood pressure). Resident #70's body temperature had risen to 105.6 degrees Fahrenheit (F). Resident #70 was assessed to require emergent transport to a regional hospital. Resident #70 was subsequently airlifted to a regional hospital where she was admitted to the intensive care unit (ICU) for continued stabilization and treatment. A concern that did not rise to an Immediate Jeopardy was identified when the facility failed to ensure adequate diabetic care and monitoring (including the administration of insulin) was provided for Resident #71 and Resident #2. This affected three residents (#2, #70 and #71) of 12 residents reviewed for a change in condition. On [DATE] at 5:27 P.M., the Interim Administrator, Regional Director of Clinical Operations (RDCO) #7 and Assistant Director of Nursing (ADON) #1 were notified Immediate Jeopardy began on [DATE] when Resident #70 was noted to have an acute change in condition with lack of evidence of timely and necessary monitoring and intervention/treatment. On [DATE] at 11:04 A.M. Resident #70 was noted to be tachycardic and unresponsive with an elevated blood sugar over 500 mg/dl requiring an emergent transfer to the hospital. The resident was subsequently transferred to the local hospital and was diagnosed with diabetic ketoacidosis (due to elevated blood sugar), severe hypernatremia and septic shock. While at the hospital, her body temperature continued to rise to 105.6 degrees F when the decision was made to intubate (placement of a tube into the trachea to keep the airway open) and Life Flight her to a larger hospital where she was admitted to the ICU. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions. On [DATE] at 11:04 A.M. 911 was called and Resident #70 was subsequently transferred to the hospital for medical intervention due to an acute/significant change in condition. The resident did not return to the facility. On [DATE] at 6:00 P.M. Medical Director #20 was notified of the State agency concerns related to Resident #70. On [DATE] between 6:00 P.M. and 7:00 P.M., all licensed nurses were educated by ADON #1 and Registered Nurse (RN) #21 on the facility ' s policy of Notification of Change in Condition with emphasis on timely identification, ongoing monitoring and interventions provided to treat the change in condition. On [DATE] between 6:00 P.M. and 7:00 P.M., all licensed nurses were educated by ADON #1 and RN #21 on the facility policy identified as, Physician Orders with emphasis on medication administration of insulin and monitoring of blood glucose levels. On [DATE] at 6:30 P.M., ADON #1 educated Licensed Practical Nurse (LPN) #4 (the nurse identified to be involved with Resident #70 ' s care) on how to contact Information Technology (IT) (for computer issues), physician orders, notification of change in condition, clinical documentation standards, blood glucose monitoring, and managing diabetic change in condition. On [DATE] at 7:00 P.M., the Director of Nursing (DON)/designee audited the last 14 days of residents who had physician orders for insulin administration. Any resident found to have an omission of insulin administration had their physician and family notified. All concerns were addressed, and new orders were transcribed immediately. On [DATE] at 9:00 P.M., the DON/designee, RDCO #7 and ADON #1 audited the last 14 days of residents who had physician orders for blood glucose monitoring and/or antidiabetic medications. Any resident found to have a blood glucose outside their parameters and not with the appropriate follow up had their physician and family notified. All concerns were addressed, and new orders were transcribed immediately. On [DATE] at 10:00 P.M., the DON/designee audited the last 14 days of residents ' progress notes for a change in condition. Any resident identified with a change in condition and found not to have interventions provided had their physician and family notified. All concerns were addressed, and new orders were transcribed immediately. On [DATE] at 6:00 A.M., ADON #1 re-educated LPN #4 in person on how to contact IT, physician orders, notification of change in condition, clinical documentation standards, blood glucose monitoring, and managing diabetic change in condition. On [DATE] at 2:45 P.M., an Ad Hoc Quality Assurance Performance (QAPI) meeting was held with the Interim Administrator, DON, RDCO #7, ADON #1, RN #21 and Medical Director #20 to discuss the concerns involving Resident #70 and a facility corrective action plan. On [DATE], LPN #4 received a final written warning corrective action for performance/policy violation related to medication administration, notification of change in condition, and resident monitoring. Failure to document and monitor resident in change in condition. Beginning on [DATE] the DON/designee would audit for change in condition by reviewing the progress notes in the daily clinical meeting. This would be an ongoing process. Beginning on [DATE] the DON/designee would complete an audit for missed/omitted insulin/antidiabetic medications and blood glucose monitoring in the daily clinical meeting. This would be an ongoing process. Beginning on [DATE] the DON/designee would begin audits on nurses completing blood glucose checks, administering insulin as needed, and documenting the process by observing three nurses weekly for four weeks then randomly thereafter. The Administrator and DON would continue to monitor compliance in the monthly QAPI meetings for three months then as needed for one year. RDCO #7 would continue to monitor compliance during monthly visits for three months then on an as needed basis. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: 1. Review of the closed medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Temefactive Multiple Sclerosis (MS), Type 1 diabetes mellitus, autistic disorder, attention-deficit hyperactivity, narcolepsy, anxiety disorder, transient alteration of awareness, other symptoms involving cognitive functions and awareness, and aphasia. Resident #70 and was discharged to the hospital on [DATE]. Review of the Nursing Admission Evaluation assessment dated [DATE] revealed Resident #70 arrived at the facility on [DATE] at 12:29 P.M. with an admitting diagnosis of MS, was confused/disoriented and had a gastrostomy tube with a nocturnal enteral feeding. Resident #70 was assessed as being severely cognitively impaired. Review of the hyperglycemia care plan dated [DATE] revealed Resident #70 was admitted with Type 1 diabetes with hyperglycemia with history of long-term insulin dependence. Resident #70 had utilized an insulin pump, however had lost the insulin pump. Interventions included administer insulin injections per orders; administer medications per medical provider's orders; report abnormal findings to medical provider and resident/resident representative; observe for signs and symptoms of hyperglycemia including increased thirst, fatigue, frequent urination, dry skin, muscle cramps, abdominal pain, kussmual (deep rapid and labored) breathing, acetone breath, stupor, and obtain blood sugars per order. Review of the MS care plan dated [DATE] revealed Resident #70 was admitted with newly diagnosed MS with spastic hemiplegia with lesions. Interventions included monitor vital signs as needed and report abnormal findings to medical provider and resident/resident representative. Review of the physician orders from [DATE] revealed Resident #70 was ordered Insulin Glargine-yfgn (a long-acting insulin) subcutaneous solution pen-injector 100 unit/milliliters (ml) inject 10 units subcutaneously two times a day for diabetes scheduled in the morning between 7:00 A.M. and 10:00 A.M. and at bedtime between 9:00 P.M. and 10:00 P.M.; the order was entered on [DATE] at 9:52 P.M. into the electronic medical record (EMR). Additionally, Resident #70 was ordered Insulin Lispro [NAME] Kwikpen (a short-acting insulin) solution pen-injector 100/ml inject as per sliding scale: notify physician if [blood sugar] less than 70, if 150 - 200 give two units; 201 - 250 give four units; 251 - 300 give six units; 301 - 350 give eight units; 351 - 400 give 10 units; notify physician if greater than 401, subcutaneously four times a day for diabetes; the order began on [DATE] at 3:50 P.M. In addition, Resident #70 was also ordered Prednisone (a steroid) oral tablet 40 milligrams in the morning via feeding tube for MS. (Steroid medications can raise the glucose levels of residents with diabetes). Review of the nursing note dated [DATE] timed 5:39 A.M. revealed Resident #70's blood sugar was 545 mg/dl, the physician was notified. The note further indicated the nurse was looking through hospital paperwork. Resident #70 was on Lispro (a short-acting insulin) in hospital with last dose being given on [DATE]. Discharge orders were only for Lantus (a long-acting insulin) 10 units twice a day. The physician gave one time order for eight units of Lispro. The note indicated that the nurse would continue to monitor. Review of the [DATE] Medication Administration Record (MAR) revealed on [DATE] Resident #70's blood sugar was not obtained, and the long-acting insulin (Insulin Glargine-yfgn) was not administered as ordered. On [DATE] at 8:00 P.M. Resident #70 ' s blood sugar was not obtained as ordered to determine if the sliding scale dosage of short acting insulin (Insulin Lispro [NAME] Kwikpen) was needed, and on [DATE] at bedtime Resident #70's blood sugar was not checked to see if the sliding scale dosage of short acting insulin was needed and the ordered long-acting insulin was not administered. Review of the nurse's notes and nursing assessments in the hard chart and electronic medical record (EMR) from [DATE] to [DATE] revealed there was no corresponding documentation to support the resident's blood sugar was taken and if insulin was administered on [DATE] at bedtime for long-acting insulin and on [DATE] at 8:00 A.M. and bedtime for the short-acting or the long-acting insulin. Review of the nurse's note dated [DATE] timed 9:05 A.M. revealed a late entry admission nurse note indicating Resident #70 was admitted to the facility on Friday, [DATE] at 1:00 P.M. Review of the Medication Administration Record (MAR) from [DATE] revealed Resident #70 ' s blood sugar was not obtained, and insulin was not administered on the following six dates and times: On [DATE] at 4:30 P.M. short-acting insulin On [DATE] at 8:00 P.M. bedtime for short-acting and long-acting insulin On [DATE] at 5:00 A.M. short-acting insulin On [DATE] at 5:00 A.M. short-acting insulin On [DATE] at 8:00 P.M. and bedtime short-acting and long-acting insulin On [DATE] at 5:00 A.M. short-acting insulin Review of the eMAR - Medication Administration Note for Insulin Glargine-yfgn dated [DATE] timed 12:42 P.M. and 12:57 P.M. revealed blood sugar high, telehealth notified, additional insulin administered as ordered. Record review revealed no additional assessment of the resident's overall condition at this time related to the incident of hyperglycemia (elevated blood sugar). Review of the Telehealth physician progress note dated [DATE] timed 1:08 P.M. revealed blood sugar reading high, give additional 10 unites now, recheck in 30 minutes, call if remains above 400 mg/dl. Review of the nurse's notes, nursing assessments and weights/vital signs tab in the EMR from [DATE] revealed there was no evidence Resident #70's blood sugar was rechecked in 30 minutes. Review of Certified Nurse Practitioner (CNP) #2's progress note dated [DATE] revealed Resident #70 had been admitted to the facility on [DATE] from acute rehabilitation following a prolonged inpatient hospitalization for recently diagnosed MS with a presentation of aphasia, right hemiparesis and new demyelinating lesions on MRI. Review of systems was unable to be obtained due to aphasia, responses were limited to yes or no answers and resident did not follow commands. Type 1 diabetes with very poor glycemic control, most recent HbA1C (a blood test that measures a person's average blood sugar level over the past two to three months) was 10.1 percent (normal range below 5.7 percent) with a plan to continue basal insulin glargine 10 units twice a day, continue sliding scale insulin, continue to monitor blood glucose levels closely and hold nocturnal feedings as resident was eating 75 percent to 100 percent of all meals therefore, at this point, would not add more insulin. Review of the nurse's notes and nursing assessments in the hard chart and EMR from [DATE] to [DATE] revealed there were no corresponding evidence to show if the blood sugar was taken and if the short acting insulin was administered on [DATE] at 4:30 P.M., on [DATE] at 8:00 P.M. and bedtime for the short-acting and long-acting insulin, on [DATE] at 5:00 A.M. for the short-acting insulin, on [DATE] at 5:00 A.M. for short-acting insulin, on [DATE] at 8:00 P.M. and bedtime for the short-acting and long-acting insulin, and on [DATE] at 5:00 A.M. for the short-acting insulin. In addition, review of the eMAR - Medication Administration Note for Insulin Lispro dated [DATE] timed 12:53 P.M. revealed blood sugar read high, administered 14 units as ordered by the nurse practitioner after notification. Review of the eMAR - Medication Administration Note for Insulin Lispro dated [DATE] timed 4:18 P.M. authored by RN #3 revealed nurse practitioner notified, and order received to give 14 units of Humalog (short-acting insulin) now. Record review revealed no additional assessment of the resident's overall condition at this time related to the incidents of hyperglycemia (elevated blood sugar) noted on [DATE]. Review of the Amount Eaten documentation for Resident #70 revealed Resident #70 refused dinner on [DATE]. Review of the nurse's note dated [DATE] timed 9:26 P.M. authored by RN #3 revealed at 6:00 P.M., Resident #70 was cool and clammy, restless as in tossing head back and forth on pillow, tremors noted to all extremities. Vital signs included temperature 97.7 degrees F, pulse 124 pulse (normal 60 to 100), respirations 24 (elevated), blood pressure ,d+[DATE] (normal blood pressure ,d+[DATE]), and blood sugar 324 mg/dl. When asked if she was experiencing pain, resident indicated, yes. Medicated with Tylenol which was ordered as needed at 6:30 P.M. Updated CNP #2 on change in status. New order received for Norco ,d+[DATE] (opioid pain reliever) by mouth every six hours as needed. Resident #70 was observed lying in bed at present time without tremors. Respirations were quiet and even, skin cool and dry. Review of the Skilled Documentation assessment dated [DATE] timed 8:12 A.M. authored by ADON #1 revealed the assessment incorrectly indicated Resident #70 did not have any insulin changes in the last 24 hours. There was no evidence Resident #70's vital signs were monitored, or the resident was correctly comprehensively assessed. Review of the nurse's notes, nurse's assessments, MAR from [DATE] and weights/vitals tab in the EMR revealed there was no evidence Resident #70's vital signs were monitored, or the resident was comprehensively assessed after 6:00 P.M. on [DATE] until [DATE] at 9:31 A.M. Review of the Telehealth Physician #17 progress note dated [DATE] timed 9:31 A.M. revealed the nurse called because Resident #70's blood sugar reading high, Orders were given to administer 15 units of insulin, recheck blood sugar in one hour and call if above 400 mg/dl. Review of the nurse's note dated [DATE] timed 9:40 A.M. authored by RN #6 revealed Resident #70's blood sugar read high. Telehealth was called and administered 15 units of insulin Lispro as ordered. Review of the Telehealth CNP #18 progress note dated [DATE] timed 10:53 A.M. revealed hyperglycemia high. Resident #70 received 15 units of Lispro earlier, still reading high. The note reflected the resident was on a high dose of Prednisone. Orders given to administer 10 units of Lispro now and recheck in one hour and call back if still over 400 mg/dl. Vital signs were taken with a blood pressure of ,d+[DATE]. Review of the nurse's note dated [DATE] timed 10:55 A.M. authored by RN #6 revealed Resident #70 ' s blood sugar rechecked and still read high. Contacted Telehealth. Order given for 10 units of insulin Lispro. Review of the Telehealth CNP #19 progress note dated [DATE] timed 11:07 A.M. revealed the note indicated it was okay to send the resident to the emergency room due to unresponsiveness. Review of the nurse's note dated [DATE] timed 11:20 A.M. authored by RN #6 revealed order was received for Resident #70 to be transferred out to the emergency room after contacting Telehealth. The family was notified, and the resident was transferred to the emergency room . Vital signs included the resident's blood pressure was ,d+[DATE] (low), pulse 126 (high), respirations 16 and temperature was 98.2 degrees F. Review of the nurse's note dated [DATE] timed 4:23 P.M. revealed received a call from the nurse at hospital stating, the resident was being life flighted to another hospital with diagnoses of diabetic ketoacidosis (DKA), septic shock and hypernatremia. Review of CNP #2's progress note dated [DATE] timed 5:59 P.M. revealed on [DATE] at 11:04 A.M., the nurse notified her by phone Resident #70 was tachycardic to the 140's, diaphoretic, unresponsive with myoclonus (sudden involuntary muscle spasms) and blood glucose reading high. Order given to send resident to the emergency room . Review of the Minimum Data Set (MDS) 3.0 Discharge - Return Not Anticipated assessment dated [DATE] revealed Resident #70 had short term memory problems, was moderately impaired for daily decision making, and needed partial/moderate assistance with transfers from the bed to the chair, needed substantial/maximal assistance for eating, oral hygiene, bathing, and personal hygiene and was totally dependent on staff with toileting, lower body dressing and putting on and taking off footwear. Review of the emergency department physician note dated [DATE] revealed patient [Resident #70] was a type 1 diabetic with poor control with a history of MS who presented via emergency medical services (EMS) for altered mental status and high blood sugar. Facility reported that today she was only responsive to pain and her blood sugar read high on the meter. EMS reported they were unable to get a blood pressure and route. Resident with altered mental status with history and exam consistent with sepsis unclear source in the setting of diabetic ketoacidosis (DKA). The resident was placed on 15 liters non-rebreather due to her skin mottling although she was not in any respiratory distress. Intraosseous (IO) was placed and fluid resuscitation was initiated. Initial cardiac rhythm on monitor was 180 narrow complex tachycardia; patient was hypotensive. Per Advanced Cardiovascular Life Support (ACLS) protocol, she was given six milligrams of adenosine without improvement followed by 12 milligrams of adenosine while attempting to obtain an EKG. No improvement in heart rate. EKG was obtained and rhythm was revealed to be a sinus tachycardia. Continued volume resuscitation. Skin mottling improved. Mental status began to improve and her eyes would flutter open upon saying her name. Heart rate improved from 180's to 130's with fluid resuscitation and blood pressures improved from the 80's to the 100's systolic after two liters of fluid. Foley catheter placed. After three liters of fluid, the resident had not yet had any urine output. Patient hypernatremic 180 with correction for hyperglycemia and was changed to ,d+[DATE] normal saline. Hyperkalemia and hyperglycemia so insulin glucose tolerance test initiated. Rapid drop in insulin so insulin glucose tolerance test was discontinued and dextrose ,d+[DATE] normal saline was initiated. Patient was felt to have symptoms concerning for potential infection based on heart rate greater than 170, blood pressure less than 80 systolic noted at the time of initial triage. Labs were obtained .and were notable for leukocytosis greater than 20 concerning for systemic inflammatory response (SIRS). Based on findings, SIRS criteria and presumed urinary infectious source, the patient was felt to meet criteria for sepsis. The patient had corrected glucose of 166 few hours after initial presentation. This was a significant drop. Concern for rapid correction therefore considered hypertonic saline verse sodium bicarbonate. Patient was given one ampoule of sodium bicarbonate. Repeat point-of-care glucose within normal limits. Temperature went up to 105 F. Discussed case with intensivist at [regional hospital], given worsening temperature and likely neurologic cause of symptoms versus [NAME] hyperthermia, decision was made to intubate the patient and paralyze her. The resident was subsequently transferred to another hospital due to her medical needs. Review of the Life Flight CNP's progress note dated [DATE] timed 7:46 P.M. revealed Resident #70 was a resident of a skilled nursing facility (SNF) with baseline mental status that was unclear at the time. On emergency room evaluation today, Resident #70 was found to have glucose over 500 mg/dl. She was initially tachycardic (fast heart rate), hypotensive (low blood pressure) and febrile. Given adenosine (used to convert tachycardia to normal rhythm) with no change. Central line placed and volume resuscitated with three liters of normal saline and two liters of half normal saline for diabetic ketoacidosis and placed on insulin infusion. Resident #70 was also noted to have severe hypernatremia. Insulin infusion stopped after precipitous decline in glucose over one hour (>500 to 178). Ultimately, Resident #70 placed on norepinephrine (used to treat low blood pressure) for blood pressure support. Resident #70 continued to decline, becoming more somnolent and continued with rise in body temperature (temperature maximum of 105.6 F). Resident #70 intubated for airway protection. Given Dantrolene for possible neuroleptic malignant syndrome. At that time, the physician managing Resident #70 requested transfer to a larger hospital for tertiary and/or quaternary services unavailable at the referring facility. Resident #70's condition at time of exam was documented as acutely ill and critically ill. Air medical transport was requested to reduce the out-of-hospital time (22 minutes by air vs approximately 83 minutes by ground) and Resident #70's condition required emergent procedure or evaluation not available at the referring facility. Interview on [DATE] at 11:05 A.M. with CNP #2 revealed on [DATE], CNP #2 was notified Resident #70's blood sugar was greater than 500 mg/dl and CNP #2 ordered sliding scale insulin (short-acting insulin). On [DATE], CNP #2 assessed Resident #70 who was only able to provide yes/no answers and did not appropriately answer. On [DATE], CNP #2 assessed Resident #70 again who was still having hyperglycemia, so CNP #2 ordered to increase long-acting insulin to 14 units twice a day. On [DATE] at 6:22 P.M., RN #3 sent CNP #2 a text message that Resident #70 was agitated, cold and clammy, tremoring and the nurse aides were telling RN #3 that was unusual for Resident #70. RN #3 thought the resident was in pain so CNP #2 advised RN #3 to try Tylenol and CNP #2 would call in an order for Norco. CNP #2 stated she did not hear any more about Resident #70 the rest of the evening and night, so CNP #2 thought everything was fine. On [DATE] at 11:04 A.M., ADON #1 called CNP #2 saying Resident #70 ' s blood sugar was reading high, she was tachycardic in the 140 ' s, and her eyes rolled back in the back of head. CNP #2 verified Resident #70 ' s blood pressure, pulse and respirations were a little high on the evening of [DATE]. CNP #2 indicated although vital signs were not ordered, the nurses could have continued to monitor Resident #70 ' s vital signs on [DATE] into [DATE] as a nursing intervention. Interview on [DATE] at 11:55 A.M. with RN #3 revealed on [DATE], RN #3 worked from 2:00 P.M. to 6:00 P.M., which was her first time working with Resident #70. The prior nurse had reported to RN #3 the resident was having trouble with elevated blood sugars. RN #3 obtained the resident ' s blood sugar between 4:00 P.M. and 5:00 P.M. and called CNP #2 because the blood sugar was high and obtained orders to administer additional insulin and recheck the blood sugar again. RN #3 rechecked the blood sugar and it had lowered to 274 mg/dl. That evening, the nurse aides reported Resident #70 was not acting the same as she usually did. When the nurse aides were sitting and talking with Resident #70 the resident ' s tremors would cease. RN #3 did not think she rechecked Resident #70 ' s vital signs after texting with CNP #2 on [DATE] at 5:22 P.M. regarding the change in condition. RN #3 stated Resident #70 was thirsty when RN #3 administered the Tylenol to the resident. Resident #70 did not eat her dinner on [DATE] and RN #3 had to hold the cup of water and put the medication on a spoon for Resident #70 that evening. RN #3 stated she notified LPN #4 (the oncoming nurse) that something was going on with Resident #70 and keep an eye on her. Interview on [DATE] at 12:20 P.M. with RN #6 revealed on [DATE] when RN #6 arrived at the facility, Resident #70 was okay. However, after RN #6 checked her blood sugar and obtained vital signs and called Telehealth services Resident #70 was not okay and was slow to respond so the resident was sent to the hospital. Interview on [DATE] at 12:50 P.M. with Resident #70 ' s mother/resident representative revealed the Resident #70's boyfriend visited with the resident on Tuesday ([DATE]) and they video chatted with Resident #70. During this video chat Resident #70 ' s mother observed Resident #70's lips were cracked, and her skin was dry; it looked like she was dehydrated. On [DATE], Resident #70 was diagnosed with diabetic ketoacidosis and sepsis and was severely dehydrated when she arrived at the hospital, and she had to be intubated and sedated. Resident #70 ' s mother stated Resident #70 spent several weeks in the ICU at the hospital and almost died . Resident #70's mother felt Resident #70 was neglected at the facility. Interview on [DATE] at 3:35 P.M. with State tested Nursing Assistant (STNA) #12 revealed Resident #70 was learning how to eat again and at times, the resident had to be fed and other times, the resident was supervised with eating. At times, a staff member had to hold the beverage cup for her to drink fluids. Resident #70 was incontinent and wore an incontinence brief. Interview on [DATE] at 3:50 P.M. with LPN #5 revealed the staff had to provide mostly all activities of daily living care for Resident #70 and on a couple of occasions, the resident had to be fed her meals. LPN #5 did not remember much from working night shift on [DATE] into [DATE] and she did not remember if Resident #70 ' s blood sugar was obtained but did remember the resident ' s blood sugars were fluctuating. Interview on [DATE] at 3:55 P.M. with LPN #4 revealed Resident #70 was having an extremely hard time with her blood sugars and her blood sugars were through the roof the first couple of days she was at the facility. Resident #70 had to be fed. LPN #4 did not remember anything specific from working night shift on [DATE] into [DATE] other than he was in and out of Resident #70 ' s room and gave her the nighttime medications. Interview on [DATE] at 4:15 P.M. with STNA #15 revealed Resident #70 was able to answer yes/no to questions and had to be dressed and fed meals. At times, Resident #70 was able to pick up her fluid cup and other times, staff had to assist her with fluids. Interview on [DATE] at 11:35 A.M. with RDCO #7 verified there was no evidence Resident #70's blood sugars were checked and/or administered insulin on the following dates and times: on [DATE] at bedtime, on [DATE] at 8:00 P.M. and bedtime, on [DATE] at 4:30 P.M., 8:00 P.M. and bedtime, on [DATE] at 5:00 A.M., on [DATE] at 5:00 A.M., on [DATE] at 8:00 P.M. and bedtime and on [DATE] at 5:00 A.M. RDCO #7 also verified Resident #70 ' s vital signs/overall condition was not monitored from [DATE] at 6:00 P.M. to [DATE] at 9:40 A.M. A follow up interview on [DATE] at 2:15 P.M. with RDCO #7 revealed LPN #4 was assigned to care for Resident #70 during eight of the 10 missed blood sugar checks and insulin administrations. LPN #4 wrote a statement dated [DATE] that he did check blood sugars and administered medications on [DATE] into [DATE] from 6:00 P.M. to 6:00 A.M., [DATE] into [DATE] from 6:00 P.M. to 6:00 A.M., [DATE] into [DATE] from 6:00 P.M. to 6:00 A.M. and [DATE] into [DATE] from 6:00 P.M. to 6:00 A.M. However, LPN #4, indicated there was a technical error with the EMR and his documentation was not saved. RCDO #7 revealed there was no IT ticket or nursing progress note(s) to support this claim. RDCO #7 felt it could have been a user error on LPN #4 ' s part. Interview on [DATE] at 9:45 A.M. with ADON #1 revealed ADON #1 was notified Resident #70 was having a change in condition (on 09XXX,d+[DATE]), so ADON #1 came to the facility and went straight to Resident #70 ' s room. Resident #70 was diaphoretic and non-responsive. ADON #1 had already spoken to CNP #2 and obtained an order to send Resident #70 to the emergency department. Review of the facility's undated Bl[TRUNCATED]

Based on closed medical record review, policy review and interview, the facility failed to timely notify Resident #70's representative of an acute change in condition. This affected one resident (#70) of 12 residents reviewed for notification of change. Findings include: Review of the closed medical record for Resident #70 revealed the resident was admitted to the facility on [DATE] with diagnoses of Temefactive Multiple Sclerosis (MS), Type 1 diabetes, autistic disorder, attention-deficit hyperactivity, narcolepsy, anxiety disorder, transient alteration of awareness, other symptoms involving cognitive functions and awareness and aphasia. Resident #70 was discharged to the hospital on 09/07/24. Review of the Nursing Admission Evaluation assessment dated [DATE] revealed Resident #70 arrived at the facility on 08/30/24 at 12:29 P.M. with an admitting diagnosis of MS, was confused/disoriented and had a gastrostomy tube with a nocturnal enteral feeding. Resident #70 was assessed as being severely cognitively impaired. Review of the nurse's note dated 09/06/24 timed 9:26 P.M. authored by Registered Nurse (RN) #3 revealed at 6:00 P.M., Resident #70 was cool and clammy, restless as in tossing head back and forth on pillow, tremors note to all extremities. Vital signs: 97.7 Fahrenheit (F), 124 pulse (normal pulse 60 to 100), 24 respirations (normal respirations 18), 148/104 blood pressure (normal blood pressure 120/80) , 324 blood sugar. When asked if she was experiencing pain, resident said, yes. Medicated with Tylenol as needed order at 6:30 P.M. Updated Certified Nurse Practitioner (CNP) #2 on change in status. New order received for Norco 5-325 by mouth every six hours as needed. Resident was observed lying in bed at present time, no tremors. Respirations were quiet and even, skin cool and dry. The nurse's note was silent to Resident #70's mother/resident representative notified of the change in condition. Interview on 10/07/24 at 12:50 P.M. with Resident #70's mother/resident revealed she was unaware of Resident #70 having tremors, being cool and clammy and tossing her head back and forth on the pillow during the evening of 09/06/24. Interview on 10/07/24 at 1:00 P.M. with RN #3 verified she did not notify Resident #70's representative of the resident's change in condition during the evening of 09/06/24. Interview on 10/08/24 at 11:35 A.M. with Regional Director of Clinical Operations (RDCO) #7 verified Resident #70's family should have been notified of Resident #70's change in condition (tremors and abnormal vital signs) on 09/06/24. Review of the facility's undated Notification of Change in Condition policy revealed the center must inform the resident, consult with the resident's physician and/or notify the resident's representative, authorized family member, or legal power of attorney/guardian when there was a change requiring such notification. Circumstances requiring notification included but were not limited to: a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including but not limited to: clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00157701.

Based on observation, staff interview, and review of the facility policy, the facility did not ensure frozen foods in the reach-in freezer were labeled and dated appropriately to prevent food spoilage. This had the potential to affect 70 residents who received food from the kitchen. The facility identified three residents (#19, #22, and #30) as receiving nothing by mouth (NPO). The facility census was 73. Findings include: Observation of the kitchen on 03/12/24 from 8:35 A.M. to 8:55 A.M. with Dietary Director (DD) #320 revealed the reach in freezer in the dry storage room had multiple items in original manufacturer packaging bags that had been opened, resealed and were undated. These items included: one bag which was one fourth full of unbaked dinner rolls, one half-full bag of crinkle cut French fries, a one-fourth full bag of cauliflower, two half-full bags of broccoli florets, one one-fourth full bag of ravioli, and one bag with four pancakes in it. In addition, there was a one gallon storage bag of two unidentifiable round patties unlabeled and undated, and one undated, large gallon storage bag with a half of boneless turkey breast and several slices of turkey in it. At the time of observation DD #320 confirmed all items opened and resealed should be labeled and dated and she had been working with her new staff on the importance of dating and labeling items when opened. Review of the facility policy Receiving, revised February 2023, revealed safe handling procedures for time and temperature would be practiced in the storage of all food items, which included appropriately labeling and dating items, and all food items would be stored in a manner that ensured appropriate and timely utilization based on the principles of first in-first out inventory management. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00150637.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 10.7% and included three medication errors out of 28 medication administration opportunities. This affected two residents (#27 and #29) out of two residents observed during medication administration. The census was 65. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including but not limited to heart failure, gastroesophageal reflux disease, and vitamin D deficiency. Review of Resident #29's April 2023 physician orders revealed Resident #29 had orders to receive omeprazole (proton pump inhibitor) 20 milligrams (mg) in the morning and multivitamin with minerals one daily. Observation on 05/01/23 at 9:20 A.M. revealed Registered Nurse (RN) #109 was administering medications to Resident #29. RN #109 removed omeprazole 20 mg from a bubble pack which included a message to take before eating and on an empty stomach, as well as a multivitamin (MVI) with minerals from a stock bottle which had a best by date of March 2023. When the medications were ready for administration, it was brought to the attention of RN #109 that the MVI with minerals were retrieved from a bottle which had a best by date of March 2023. Interview on 05/01/23 at 9:41 A.M. with State tested Nurse Aide (STNA) #102 revealed Resident #29 received her breakfast tray around 7:50 A.M. Interview on 05/01/23 at 10:48 A.M. with RN #109 verified she was going to administer the multivitamin with mineral which was from a stock bottle that was past the best by date. The interview further verified the omeprazole 20 mg was administered to Resident #29 after breakfast and was not administered before eating and on an empty stomach as directed. 2. Review of Resident #27's medical record revealed an admitted [DATE] and a readmitted [DATE] with diagnoses including but not limited to end stage renal disease, type two diabetes, and gastroesophageal reflux disease. Review of Resident #27's April 2023 physician orders revealed Resident #27 had an order for omeprazole delayed release 20 milligrams (mg) in the morning. Observation on 05/01/23 at 9:09 A.M. revealed RN #78 was administering medications to Resident #27. RN #78 removed omeprazole 20 mg from a bubble pack which included a message to take before eating and on an empty stomach and prepared the medication for administration to Resident #27. Interview 05/01/23 at 10:50 A.M. with RN #78 verified she was going to administer the omeprazole delayed release 20 mg to Resident #27 after breakfast and not before eating and on an empty stomach as directed. Review of the facility's undated policy titled Liberalized Medication Administration, revealed proton pump inhibitors (omeprazole) will be administered 30 minutes prior to meals or at the evening medication pass. This deficiency represents non-compliance investigated under Complaint Number OH00141844.

Based on observation, interview and record review, the facility failed to ensure Resident #38 received proper assistance with activities of daily living to prevent a fall, failed to thoroughly assess the resident after a fall, and failed to investigate the root cause of the fall. This affected one resident (Resident #38) out of three residents reviewed for falls. Findings include: Review of Resident #38's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus type two, chronic kidney disease with dependence on renal dialysis, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non dominant side. Review of Resident #38's Fall Risk Observation Tool, dated 12/26/22, revealed the resident was non ambulatory, incontinent, and was at risk for falling. Review of Resident #38's Care Plan, dated 01/12/23, revealed she had an activities of daily living (ADL) self-care performance deficit, requiring assistance with ADL care related cerebral infarction with left dominate hemiplegia, incontinent of bowel and bladder. Intervention included staff assistance of two with bed mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident required extensive assistance of two staff for toileting assistance and bed mobility. Review of Resident #38's Post fall Evaluation, completed by Clinical Manger #123, revealed on 01/20/23 at 4:00 P.M. Resident #38 had a fall resulting in a trip to the emergency department. The assessment indicated mechanical bed failure as the suspected root cause. The bed was noted as being in a normal position. The assessment also noted an injury did not occur related to the fall. The evaluation failed to investigate the preceding factors leading up to the fall including the incontinence care the resident was being provided, positioning of the resident prior to her fall, the bed in an elevated level, call light placement, and witness statements from the STNA who was providing incontinence care and the witness statements from the resident who was interviewed. A skin assessment was not completed indicating whether the resident had skin impairments including bruising. Review of Resident #38's nursing note dated 01/20/23 at 8:00 P.M., revealed Resident #38 rolled out of bed at 4:00 P.M. onto the floor. STNA #125 found the resident who was alert. The resident was lifted via a Hoyer into a chair. All her vitals were obtained, and bruising was noted to her chin, chest, and knee. The resident's bed was switched out for a new bed due to the remote. The resident insisted she was ok, but after speaking with family she wanted to be sent to the hospital for evaluation. Review of Resident #38's nursing note dated 01/21/23 at 1:08 A.M., revealed the resident returned from the emergency department with a diagnoses of a closed head injury with no concussion. Review of Resident #38's Skin Check Assessment, dated 1/21/23, revealed the resident had a bruise to her right forehead, a bruise to her chin, a bruise to her left chest, and red areas to her bilateral knees. The assessment did not indicate the color, size, or whether edema was present. Continue review of the resident's record revealed this was the only documentation available related to the resident's injuries. Observation on 02/02/23 at 9:36 A.M. of Resident #38 revealed she was resting in bed. The resident was unable to move the left side of her body. She had a baseball size area of yellowing bruising her to upper left chest. Interview on 02/02/23 at 9:36 A.M. with Resident #38 revealed State tested Nurse's Aide (STNA) #125 came into her room to provide incontinence care. STNA #125 raised the bed and had her turn on her left side. During the incontinence care STNA #125 realized that the resident needed a new patch for her bottom. She left the resident in the position she was in and walked out of the room to obtain the patch. While gone the resident received a phone call and while reaching for the phone on her bedside table the movement caused the top of her bed to drop causing her to roll out of bed onto the floor. She stated she hit her head and had bruising to her left chest. She stated STNA #125 and Licensed Practical Nurse (LPN) #113 helped her back into bed. She continued that she went to the hospital to be evaluated after the incident. The resident continued that staff were aware that her bed had not be functioning appropriately. Interview on 02/02/23 at 10:30 A.M. with STNA #126 stated she frequently cares for Resident #38. She revealed the resident's bed had not been working properly prior to her fall. She stated maintenance was aware of the malfunctioning bed. Interview on 02/02/23 10:50 A.M. with STNA #25 revealed on 01/20/23 she went into Resident #38's room to perform incontinence care. She stated that she had the resident turn to her side and realized she needed a new patch for her bottom. She stated she left the bed in the position it was in and walked out of the room to obtain a new patch. When she returned to the room the resident had rolled out of bed and was lying on the floor. She confirmed that she did not lower the bed before leaving and did not obtain a second staff member to assist her while performing incontinence care. She stated the resident's bed didn't always work correctly, and maintenance had been aware of the issues related to bed before the residents fall. Interview on 02/02/23 at 10:55 A.M. with LPN #113 stated STNA #125 asked her for assistance when Resident #38 had her fall out of bed on 01/20/23. She confirmed that when she entered the room the bed was raised since she was just receiving incontinence care, but the head of the bed was low where it malfunctioned. Interview on 02/02/23 at 11:05 A.M. with Maintenance Director #131 revealed he was not aware of Resident #38 having any issues with her bed prior to her fall. He stated he has had issues with the beds in the facility not functioning properly due to overheating and the motor not working correctly. He stated that he has told the STNA to switch out the beds when this happens. He also stated he does not have any work orders for the resident's bed and usually just fixes things when staff tell him something is not working properly. He confirmed he does not always document when he fixes things in the facility. Interview on 02/02/23 at 11:10 A.M. with Maintenance Worker #130 revealed it is a reoccurring issue with some of the beds in the facility not functioning properly. He continued that the workers know if you lower the beds down to the bottom and then raise them again, they will usually work appropriately. Interview on 02/02/23 at 11:20 A.M. with STNA #119 stated that prior to Resident #38's fall her bed would slope down, and buttons would not always work. Interview on 02/02/23 at 11:25 AM with the Director of Nursing (DON) confirmed the facility did not complete a thorough investigation into Resident #38's fall including correctly documenting preceding factors leading to the fall, the resident being assisted with one staff when her care plan indicated two staff for bed mobility, and not completing a compressive assessment on the resident's injures upon her return from the hospital. Interview on 02/02/23 at 11:40 A.M. with Occupational Therapy Assistant #127 revealed when working with Resident #38 in November 2022 she was aware that the resident's bed had issues causing it to get stuck at times when raising it. She stated that if you lowered it all the way down and then lifted it again it would usually work again. Interview on 02/02/23 at 12:20 P.M. with Clinical Manager #123 revealed she completed Resident #38's fall investigation. She confirmed that she did not obtain witness statements from the STNA who was providing care or the resident. She stated she did not include that STNA #125 was providing incontinence care and left the resident to obtain a patch, because she did not think it contributed to the residents fall. She also confirmed the investigation left out that STNA #125 was proving incontinence alone when the care plan indicated that she should have two-person physical assistance for toileting and bed mobility. Review of the facility policy, Fall Prevention and Management, dated 06/01/22, revealed a fall investigation should begin once the resident is safely transferred. The facility should ask the resident what they were doing when they fell . Identify if there were any witnesses to the fall. Ask them what they saw and have them write a statement if possible. The interdisciplinary team should review all information for all falls, potential causes of the fall, interventions put in place and if they are effective. This deficiency represents non-compliance investigated under Complaint Number OH00139615.

Based on interview and record review the facility failed to ensure Resident #38's bed was functioning appropriately resulting in a fall. This affected one resident (Resident #38) out of three residents reviewed for falls. Findings include: Review of Resident #38's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus type two, chronic kidney disease with dependence on renal dialysis, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for toileting assistance and bed mobility. Review of Resident #38's Post fall Evaluation, completed by Clinical Manger #123, revealed on 01/20/23 at 4:00 P.M. Resident #38 had a fall resulting in a trip to the emergency department. The assessment indicated Mechanical bed failure as the suspected root cause. Review of Resident #38's Care Plan, dated 01/12/23, revealed she had an activities of daily living (ADL) self-care performance deficit, requiring assistance with ADL care related cerebral infarction with left dominate hemiplegia, incontinent of bowel and bladder. Intervention included staff assistance of two for bed mobility. Observation on 02/02/23 at 9:36 A.M. of Resident #38 revealed she was resting in bed. The resident was unable to move the left side of her body. She had a baseball size area of yellowing bruising her to upper left chest. Interview on 02/02/23 at 9:36 A.M. with Resident #38 revealed State tested Nurses Aide (STNA) #125 came into her room to provide incontinence care. STNA #125 raised the bed and had her turn on her left side. During incontinence care STNA #125 realized that the resident needed a new patch for her bottom. She left the resident in the position she was in and walked out of the room to obtain the patch. While gone the resident received a phone call and while reaching for the phone on her bedside table the movement caused the top of her bed to drop causing her to roll out of bed onto the floor. She stated she hit her head and had bruising to her left chest. She stated STNA #125 and Licensed Practical Nurse (LPN) #113 helped her back into bed. She continued that she went to the hospital to be evaluated after the incident. The resident continued that staff were aware that her bed had not be functioning appropriately. Interview on 02/02/23 at 10:30 A.M. with STNA #126 stated she frequently cared for Resident #38. She revealed that the resident's bed had not been working properly prior to her fall. She stated maintenance was aware of the malfunctioning bed. Interview on 02/02/23 10:50 A.M. with STNA #25 revealed on 01/20/23 she went into Resident #38's room to perform incontinence care. She stated that she had the resident turn to her side and realized she needed a new patch for her bottom. She stated she left the bed in the position it was in and walked out of the room to obtain a new patch. When she returned to the room the resident had rolled out of bed and was lying on the floor. She stated the resident's bed didn't always work correctly and maintenance had been aware of the issues related to bed before the residents fall. Interview on 02/02/23 at 10:55 A.M. with LPN #113 stated STNA #125 asked her for assistance when Resident #38 had her fall out of bed on 01/20/23. She confirmed that when she entered the room the bed was raised since she was just receiving incontinence care but the head of the bed was low where it malfunctioned. She stated maintenance changed out her bed after the incident. Interview on 02/02/23 at 11:05 A.M. with Maintenance Director #131 revealed he was not aware of Resident #38 having any issues with her bed prior to her fall. He stated he has had issues with the beds in the facility not functioning properly due to overheating and the motor not working correctly. He stated that he has told the STNA to switch out the beds when this happens. He also stated he does not have any work orders for the residents bed and usually just fixes things when staff tell him something is not working properly. He confirmed he does not always document when he fixes things in the facility. Interview on 02/02/23 at 11:10 A.M. with Maintenance Worker #130 revealed it was a reoccurring issue with some of the beds in the facility not functioning properly. He continued the workers know if you lower the beds down to the bottom and then raise them again they will usually work appropriately. Interview on 02/02/23 at 11:20 A.M. with STNA #119 stated prior to Resident #38's fall her bed would slope down, and buttons would not always work. Interview on 02/02/23 at 11:40 A.M. with Occupational Therapy Assistant #127 revealed when working with Resident #38 in November 2022 she was aware that the residents bed had issues causing it to get stuck at times when raising it. She stated that if you lowered it all the way down and than lifted it again it would usually work of. This deficiency represents non-compliance investigated under Complaint Number OH00139615.

Based on observation and interview the facility failed to maintain sanitary conditions during observations of meal preparations . This affected all residents except for Resident #18 and Resident #21 who do not receive food prepared in the kitchen. The facility census was 57. Findings include: Observation on 12/20/22 at 11:55 A.M. of Cook #809 preparing to puree Swedish meatballs. She placed the meatballs into the RoboCoup blender which was setting on the sink counter. The sink was observed to have water and food particles present. Cook #809 used a large spatula to stir the meatballs and laid it directly on the sink counter. She then continued to puree the meatballs, stop the blender, sir the meatballs with the same spatula and then laid it directly on the counter. Cook #809 then used the spatula to scoop the meatballs into a tray on the steam table. Cook #809 then scooped noodles into a clean RoboCoup blender. Some of the noodles were observed protruding from the top. She used an unwashed and ungloved hand to push the noodles into the blender. She then blended the noodles, grabbed a new spatula, stirred the noodles, and sat the spatula down on counter. She repeated this two more times. At 12:10 P.M. She began to check the temperature of each food item. She began by putting the thermometer into the meatballs. After obtaining the temperature she walked the thermometer to the sink and dipped it into a prefilled bucket of sanitizer solution and then again in another prefilled bucket of water with a visible rag at the bottom. Cook #809 tapped the thermometer on the inside of the sink to remove the excess water and then checked the temperature of the noodles. She completed this same process after checking each food item (beets, mixed vegetables, hamburgers, gravy, pureed meatballs, and pureed beets). Interview on 12/20/22 at 12:37 P.M. Corporate Dietitian #810 confirmed proper sanitation practices were not in place during meal preparation.

Based on observation, interview, and record review, the facility failed to ensure Resident #60's fall interventions were in place to help prevent falls. This affected one Resident (#60) out of one Resident reviewed for accidents. The facility census was 57. Findings include: Review of Resident #60's medical record revealed an admitted [DATE]. Diagnoses included psychotic disorder with delusions, delusional disorders, cognitive communication deficit, difficulty in walking, and weakness. Review of Resident #60's Admission Minimum Data Set 3.0 assessment, dated 11/30/22, revealed the resident had impaired cognition and needed physical extensive assistance of two persons for bed mobility, transfers, and walking. Review of Resident #60's initial fall risk evaluation, dated 11/30/22, revealed the resident had a moderate risk for falls. Review of Resident #60's 48-hour admission care plan, dated 11/23/22, revealed the resident was at risk for falls. Interventions included place call bell within reach and keep the bed in the lowest position. Observation on 12/19/22 at 10:52 A.M. Resident #60 was observed lying in bed. Her call light was out of reach, positioned at the bottom of her bed between the wall and her bed. Observation on 12/21/22 at 2:25 P.M. Resident #60 was lying in bed asleep. Her bed was in a high position. Her call light was out of reach, positioned at the bottom of her bed between the wall and her bed. Interview and observation on 12/21/22 at 2:35 P.M. with Licensed Practical Nurse #813 confirmed Resident #60's bed was in a high position, and her call light was out of reach. Interview on 12/21/22 at 3:03 P.M. with the Director of Nursing confirmed that Resident #60's fall interventions of bed in low position and call light within reach were not in place for Resident #60.

Based on medical record review and staff interview, the facility failed to ensure laboratory testing was obtained prior to initiating antibiotic therapy for a resident with a possible infection. This affected one (Resident #32) of five residents reviewed for infections. The facility census was 57. Findings include: Review of Resident #32's medical record revealed an admitted [DATE] with admission diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus and hypertension. Further review of the medical record including physician's orders revealed on 09/30/22 Resident #32 was initiated on Cipro (antibiotic) 500 milligrams (mg) twice daily until 10/05/22 for bacteremia (infection). Review of the Antibiotic Assessment completed on 09/30/22 indicated Resident #32 had pain with urination, a urinalysis was positive for infection and the resident was initiated on Cipro for a urinary tract infection (UTI). The antibiotic assessment indicated the resident met criteria for antibiotic use for a UTI. Review of the resident's laboratory results found no evidence of a urinalysis obtained or located within the medical record. Interview with the Director of Nursing on 12/21/22 at 9:10 A.M. revealed the resident was receiving hospice services upon admission and a hospice nurse ordered the antibiotic and advised the facility the urinalysis was positive for infection. Additional interview at 2:15 P.M. with the DON verified there was no evidence obtained by the facility there was a urinalysis completed for the resident as indicated in the antibiotic assessment.

Based on medical record review, observation and staff interview, the facility failed to follow physician's orders for tube feed formula infusion time and proper labeling of tube feed formula. This affected one Res(Resident #18) of one Resident reviewed for tube feedings. The facility census was 57. Findings include: Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease with dementia, adult failure to thrive, cerebrovascular accident and percutaneous endoscopic gastrostomy tube. Further review of the medical record revealed a physician's order on 12/22/21 to label feeding tube formula with resident name, date and time and nurse's initials. A physician's order on 12/07/22 indicated Resident #18 was to receive Jevity 1.2 (nutritional supplement formula) at 65 milliliters per hour (ml/h) per feeding tube for 18 hours from 5:00 P.M. to 9:00 A.M. and disconnect resident from feeding tube at 9:00 A.M. every day. Observation of Resident #18 on 12/19/22 at 11:16 A.M. revealed a tube feeding pole, tube feed pump and bag of tube feed formula. The bag of tube feed formula had no evidence of a label indicating the type of formula, the date and time opened or a nurses signature. Additional observation of Resident #18 on 12/20/22 at 12:50 P.M. revealed tube feeding infusing and no evidence of a label on the tube feed formula indicating type of formula, date and time prepared and nurse signature. Interview with Registered Nurse (RN) #814 on 12/20/22 at 12:53 P.M. verified Resident #18's tube feed formula was still infusing and should be disconnected at 9:00 A.M. as per physicians orders. RN #814 also verified the tube feeding container was not labeled with the type of formula, date and time of preparation and nurse signature as per physician's order.

Based on medical record review and interview the facility failed to complete hemoccult testing (testing to detect the presence of occult blood in the stool) as ordered for Resident #71 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#71) of three residents reviewed for change of condition. Findings include: Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician history and physical (PHP) progress note, dated 08/17/21 at 4:33 P.M. revealed the nurse practitioner was called into the resident's room to evaluate her bloody bowel movement. There was a scant amount of blood on the toilet paper. The assessment was unremarkable, the resident's vital signs were stable, and orders placed for laboratory testing in the morning and medication. Review of the PHP progress note, dated 08/18/21 at 8:33 A.M. revealed the resident was complaining of frequent loose stools and blood was noted on the toilet paper after a bowel movement. The resident had not had any nausea or vomiting. The note revealed the resident's hemorrhoid irritation was exacerbated by frequent loose bowel movements and the resident's order for [MEDICATION(S)] tablets (stool softener) was changed from daily to as needed to decrease the number of bowel movements. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a hospital form titled Nursing Facility and Home Health Transfer Form Physician Documentation, dated 09/21/21 revealed Resident #71 was admitted to the hospital with [CONDITION(S)] and [CONDITION(S)]. The resident's medications were adjusted, the resident remained on oxygen and was referred to the nursing home. Hospital discharge orders included laboratory testing, a complete blood count (CBC), basic metabolic panel (BMP), magnesium level and for stool testing; hemoccult stools times three. Review of the medical record revealed no evidence the hemoccult stools were done as ordered. Review of the modification to the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/08/21 revealed Resident #71 had moderately impaired cognition, required extensive assistance of two staff members for bed mobility and transfers and extensive assistance of one staff member for dressing, eating, toilet use and personal hygiene. The assessment revealed the resident was incontinent of bladder and bowel. On 12/16/21 at 2:57 P.M. interview with the Administrator verified there was no evidence the hemoccult stools were completed for Resident #71 as noted on the hospital discharge orders dated 09/21/21. This deficiency substantiates Complaint Number OH 000.

Based on observation and interview, the facility failed to ensure the lunch meal was served at a palatable temperatures. This finding had the potential to affect all 63 residents residing in the facility who ate food/meals served by the kitchen. Findings include: Observation of a test tray for palatability on 12/03/21 at 12:14 P.M. with Kitchen Manager #215 revealed a meal consisting of coffee, milk, tropical fruit, shrimp Alfredo and a broccoli/cauliflower blend. The test tray revealed the coffee was 119.8 degrees, milk was 44.2 degrees, tropical fruit was 57.3 degrees, shrimp Alfredo was 120 degrees and broccoli/cauliflower blend was 108 degrees. The food items were also tasted and the milk, shrimp Alfredo and broccoli/cauliflower blend were warm to taste and served at room temperature. Interview on 12/03/21 at 12:20 P.M. with Kitchen Manager #215 confirmed the meal was luke warm or at room temperature and could have tasted better if the food was hotter and the milk was colder. Cold food items were to be served at or below 41 degrees. This deficiency substantiates Complaint Number OH 647.