Every finding on record at Sanctuary Pointe Nursing & Rehabilitation Center

Based on observations, staff interviews and policy review, the facility failed to store, prepare, distribute, and serve foods in a sanitary manner and in accordance with the facility policies. This had the potential to affect all 114 residents who received food from the kitchen. Facility census was 114. Findings include: 1. Observations of the facility kitchen on 04/22/24 8:20 A.M., revealed the following areas of concern: a. There was no temperature log of the dishwasher temperatures for the month of April 2024 through the past six months. b. The ice machine, which provided ice to the entire facility, had a pink wet substance on the inside of the ice storage bin which was touching the ice. c. In the walk-in refrigerator, there was no thermometer, and eight bags of undated and unlabeled food. There was a container of opened coleslaw with expiration date of 04/14/24. There were 22 wrapped plates of unlabeled and undated food. The refrigerator temperature log for April 2024 had no daily entry past 04/22/24. d. The walk-in freezer temperature log for April 2024 had no daily entry past 04/22/24. e. In the dry food storage area, there were six boxes of rice with expiration date of April 2022. There were two opened, undated, bottles of vinegar and cooking wine. There was an unlabeled bulk container of dry food. f. The food temperature log, used to ensure food temperatures were safe for meal service, was not completed for multiple dates and meals in April 2024. This included dates, but limited to, lunch and dinner meals of 04/04/24, 04/06/24, 04/08/24, 04,09/24, 04/14/24, 04/15/24, and 04/22/24. Interview on 04/22/24 at 8:30 A.M. with Dietary Manager, (DM) # 300 verified the observations of the kitchen on 04/22/24. DM #300 stated he was an interim DM as the previous DM had vacated the position two weeks ago. The facility confirmed all 114 residents receive their meals/food from the kitchen. 2. Observation on 04/24/24 at 9:30 A.M. revealed Cook #60, put pieces of chicken into the blender with gloved hands. Cook #60 pureed the chicken, and put the chicken into holding container, by touching the blender, the counter, and serving container with gloved hands. Cook #60 proceeded to put more chicken in the blender with the same gloved hands, touching the blender, counter and serving container. Cook #60 took the blender container to the dishwasher and reassembled the blender, by inserting the clean service blade of the blender, with the same gloved hands. Vegetables were added, by Cook #60 touching some of the vegetables, to the service blade of the blender with the same gloved hands. Cook #60 added bread to the vegetables with the same gloved hands and proceeded to puree the vegetables. The observations revealed Cook #60 did not change gloves or perform hand hygiene at any time of the food pureeing process. Interview on 04/24/24 at 10:24 Cook #60 verified he had not changed his gloves and/or did not perform hand hygiene during the entire process of pureeing the chicken and vegetables. Cook #60 verified he should have changed gloves between touching the chicken, touching the bread, and in between reassembling the blender blade. 3. Observations of the kitchen on 04/24/24 at 12:14 P.M. revealed the following areas of concern: a. There were orange, pink and black wet substances, consistent with the appearance of mold, on the walls behind and around the dishwasher and under drain table. b. The floor drains of the three-compartment sink, in the dish room, had orange and black set substances, consistent with the appearance of mold and food debris. c. The stove top had a black, wet buildup of debris under and around the eight stove burners. d. The walls near the pan storage racks had brown dried drips of debris consistent with food spatters. e. The sanitation bucket, used for sanitation of food prep surfaces, tested at 50 parts per million, (PPM) by DM #300. DM #300 stated the sanitation bucket had not been emptied and refilled with sanitizer since the early morning of 04/24/24. Interview on 04/24/24 at 12:14 P.M. DM #300 verified the dish room area, floor drain and walls need cleaned. DM #300 verified the sanitation bucket tested at 50 PPM, should have been changed after each meal and should have tested at 200 PPM. DM #300 verified there were no cleaning schedules for April 2024 and no previous cleaning schedules were provided. 4. Observations of on 04/24/24 at 12:47 P.M. through 1:15 P.M. revealed the following areas of concern: a. The Unit 100 resident designated refrigerator did not have temperature log for April 2024. There was a insulated lunch box unlabeled and undated stored in the refrigerator. b. The Unit 400 resident designated refrigerator had a plate of food, unlabeled and undated. Interview on 04/24/24 at 12:50 P.M., State tested Nurse Aide, (STNA) #275 identified the lunch box in Unit 100 resident refrigerator and verified the employees are not permitted to store personal food items in the resident designated refrigerator. Interview on 04/24/24 at 1:15 P.M. Maintenance Director, (MD) #190 verified the employees are not to store personal food items in the resident designated refrigerators and all food items are to be labeled and dated. MD #190 verified all refrigerators should have a daily temperature log to ensure the refrigerator is holding stored foods at a safe temperature. MD #190 verified the ice machine is to be cleaned monthly, including removal any pink substance from inside the ice bin. MD #190 further verified the pink, orange and black substances on the walls around the dish machine and in the floor drain, were consistent with the appearance of mold. MD #190 stated the dish machine hood had not been removing the steam appropriately from the dish machine room. Review of undated facility policy titled, Facility Walk-in and Resident Refrigerator, revealed temperatures will be logged daily in resident refrigerator, and no staff food will be co-mingled with resident foods. Review of facility policy titled, Storage and Dispensing of Ice, dated 2023, revealed the ice dispenser will be cleaned and sanitized inside of the machine at least monthly. Review of facility policy titled, Employee Hygiene for Food Safety, dated 2023, revealed all employees will use utensils to handle food, and will use disposable single use gloves. Hands must be washed prior to using gloves and after removing gloves. Avoid touching items while preparing food. Review of facility policy titled, Food Storage, dated 2021, revealed leftovers will be labeled, dated and used within three days. The DM will review the temperature logs daily. Review of facility policy titled, Equipment Temperature Logs, dated 2021, revealed the dish machine temperatures are taken and recorded with each meal and monitored by the DM. Copies are maintained in the dietary department. Review of facility policy titled, Sanitation Standards: Equipment and Kitchen, dated 2021, revealed the dietary department will establish and maintain standards for sanitation with systematic cleaning and sanitizing procedures to ensure sanitation of equipment, storage areas and work areas are routinely cleaned.

Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were discarded after their expiration date. This affected one (#59) of three residents observed for medication administration and also affected four (#1, #38, #72, and #368) of 30 residents who received medication from the 200 hall medication cart. The facility census was 114. Findings include: 1. Review of the medical record for Resident #59 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus (DM II), Alzheimer's disease, and atrial fibrillation. Review of the physician order dated [DATE] revealed Resident #59 was ordered Novolog Solution 100 unit/milliliter (ml), inject per sliding scale subcutaneously two times a day for diabetes. Observation on [DATE] at 2:48 P.M. of medication cart on 400 hall revealed Resident #59's Novolog vial was opened on [DATE], indicating the insulin was expired. Interview on [DATE] at 2:53 P.M. with Licensed Practical Nurse (LPN) #138 verified Resident #59's insulin was expired. 2. Review of the medical record for Resident #72 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, traumatic subarachnoid hemorrhage without loss of consciousness. Review of the physician order dated [DATE] revealed Resident #72 was ordered Pro-stat one time a day for nutrition support, preventative measure 30 milliliters (ml) via PEG tube daily. Observation on [DATE] at 3:14 P.M. of medication cart on 200 hall revealed Resident #72 was given over-the-counter Pro-stat that had expired on [DATE]. Interview on [DATE] at 3:17 P.M. with LPN #128 verified Resident #72's Pro-stat was expired and needed to be discarded. 3. Review of the medical record for Resident #368 revealed an admitted [DATE]. Diagnoses congestive heart failure (CHF), type two diabetes mellitus (DM II), and peripheral vascular disease (PVD). Review of the physician order dated [DATE] revealed Resident #368 was ordered Pro-stat 30 milliliters (ml) two times a day for low pre-albumin level. Observation on [DATE] at 3:21 P.M. of medication cart on 300 hall revealed Resident #368 was given over-the-counter Pro-stat that had expired on [DATE]. Interview on [DATE] at 3:24 P.M. with Registered Nurse (RN) #74 verified Resident #368's Pro-stat was expired and needed to be discarded. 4. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included congestive heart failure (CHF), atrial fibrillation, type two diabetes mellitus (DM II), and moderate-protein calorie malnutrition. Review of the physician order dated [DATE] revealed Resident #1 was ordered Pro-stat 30 milliliters (ml) twice a day for low pre-albumin level. Observation on [DATE] at 3:25 P.M. of medication cart on 300 hall revealed Resident #1 was given over-the-counter Pro-stat that had expired on [DATE]. Interview on [DATE] at 3:26 P.M. with RN #74 verified Resident #1's Pro-stat was expired and needed to be discarded. 5. Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), osteoporosis, emphysema, and anxiety disorder. Review of the physician order dated [DATE] revealed Resident #38 was ordered Fish Oil Capsule 1000 milligrams (mg), give one capsule by mouth one time a day for supplement. Observation on [DATE] at 3:27 P.M. of medication cart on 300 hall revealed Resident #38 was given over-the-counter Fish Oil 1,000 mg that had expired in [DATE]. Interview on [DATE] at 3:28 P.M. with RN #74 verified Resident #38's Fish Oil was expired and needed to be discarded. Review of the facility policy titled, Medication Storage, dated [DATE] revealed medications and biological's were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order existed.

Based on medical record review, staff interviews and policy review, the facility failed to ensure blood work was completed as ordered. This affected two (#23 and #88) out of five residents reviewed for laboratory services. Facility census was 114. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included dementia, peripheral vascular disease (PVD), psychosis, atrial fibrillation, anxiety disorder, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require supervision with eating, dependent with toileting, bathing, dressing, and transfers. Review of the physician order dated 10/13/23 revealed Resident #23 was ordered to obtain complete blood count (CBC), complete metabolic panel (CMP), thyroid stimulating hormone (TSH), Fasting Lipid Panel (FLP), creatine kinase (CK), A1C, Vitamin D, Folate, and Vitamin B12 every four months. Review of the laboratory work order dated 10/17/23 revealed Resident #23 received the blood work ordered by the physician. Further review of Resident #23's laboratory work revealed the facility did not obtain the ordered laboratory work as ordered in February 2024. Interview on 04/24/24 at 12:43 P.M. with the Director of Nursing (DON) revealed Resident #23 had labs drawn on 10/17/23 and the order was for the resident to receive the blood work every four months. The DON confirmed the facility did not obtain Resident #23's labs in February 2024 as ordered. 34290 2. Review of the medical record for Resident #88 on 04/24/24 revealed she was admitted to the facility on [DATE] with a diagnosis of benign neoplasm of meninges, diabetes type II, major depressive disorder, hypertensive retinopathy, and repeated falls. Review of the Resident #88's MDS assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 10/18/23 revealed laboratory work (complete blood count, comprehensive metabolic panel, and hemoglobin A1C to be completed every four months on the 18th. Review of the laboratory work orders revealed the facility failed to complete the blood work in February 2024 as ordered. Interview with the Administrator on 04/24/24 at 11:58 A.M. revealed the facility is changing laboratory companies next month and the blood work was missed in February 2024 for Resident #88. Review of the facility policy titled, Laboratory Testing dated 01/09/21 revealed physician ordered laboratory testing will be completed timely and results will be communicated to the physician.

Based on medical record review, staff and physician interviews, and review of facility policy, the facility failed to notify a physician of a resident's change in condition. This affected one (#110) of three residents reviewed for death. The census was 108. Findings include: Review of Resident #110's closed medical record revealed an admitted [DATE]. Diagnoses included diverticulosis, hypertension, atrial fibrillation, carotid stenosis, congestive heart failure, and chronic obstructive pulmonary disease. Resident #110 passed away in the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was receiving Hospice services. Review of progress notes dated [DATE] at 10:41 A.M. revealed Resident #110's oxygen (O2) level was at 79 percent (%) on four liters upon waking. A breathing treatment was administered. Supervisor and Hospice were notified of the low O2 level. Review of progress notes dated [DATE] at 4:33 P.M. revealed Resident #110's Granddaughter was notified. Hospice nurse was in to see Resident #110. Hospice recommendations were STAT (urgent) chest X-ray and breathing treatment routinely every four hours. Order was faxed to physician and were awaiting a response. Review of a calender revealed [DATE] was a Sunday. Review of progress notes dated [DATE] at 5:49 A.M. revealed Resident #110 expired at 5:40 A.M. Director of Nursing (DON) and physician were made aware. Further review of Resident #110's closed medical record revealed no documentation was found of Resident #110's physician being notified of Resident #110's low O2 level on [DATE]. During an interview on [DATE] at 2:00 P.M. Registered Nurse (RN) #150 stated Resident #110 was out in the common area for breakfast and lunch on [DATE]. Resident #110's oxygen levels dropping on [DATE] was an acute change in health status. During a phone interview on [DATE] at 3:51 P.M. Physician #200 stated faxes to this office on weekends would not be addressed until Monday. Physician #200 stated an on-call physician service was used on weekends and he would not be called directly. An on-call physician would be called. During an interview on [DATE] at 4:41 P.M. the Administrator confirmed the Hospice recommendation of a STAT chest X-ray was faxed to the physicians office. The Administrator confirmed the fax was sent on Sunday, [DATE] and would not be have been addressed until Monday, [DATE]. The Administrator confirmed Resident #110's physician was not called regarding her significant change in condition on [DATE]. Review of the facility's policy titled Change in Resident Condition, Family and Physician Notification dated [DATE] revealed the physician and responsible party will be notified in a timely manner regarding any significant change in a resident's physical, mental, or psychosocial status (which warrants an alteration in treatment, possible transfer to an acute care setting, or discharge from the facility) regardless of code status. The nurse will notify the resident, the resident's attending physician and responsible party when there has been a significant change in the resident's physical, emotional or psychosocial status. A significant changes are defined as a decline or deterioration in health, mental or psychosocial status in either life-threatening situations or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00148377.

Based on medical record review, staff and physician interviews and policy review, the facility failed to coordinate hospice care to ensure hospice recommendations were timely implemented. This affected one (#110) of three residents reviewed for death. The census was 108. Findings include: Review of Resident #110's closed medical record revealed an admitted [DATE]. Diagnoses included diverticulosis, hypertension, atrial fibrillation, carotid stenosis, congestive heart failure, and chronic obstructive pulmonary disease. Resident #110 passed away in the facility on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was receiving Hospice services. Review of progress notes dated [DATE] at 10:41 A.M. revealed Resident #110's oxygen (O2) level was ar 79 percent (%) on four liters upon waking. A breathing treatment was administered. Supervisor and Hospice were notified of the low O2 level. Review of progress notes dated [DATE] at 4:33 P.M. revealed Resident #110's Granddaughter was notified. Hospice nurse was in to see Resident #110. Hospice recommendations were STAT (urgent) chest X-ray and breathing treatment routinely every four hours. Order was faxed to physician and were awaiting a response. Review of a calender revealed [DATE] was a Sunday. Review of progress notes dated [DATE] at 5:49 A.M. revealed Resident #110 expired at 5:40 A.M. Director of Nursing (DON) and physician were made aware. Further review of Resident #110's closed medical record revealed no documentation of a chest X-ray being completed before Resident #110's death on [DATE]. No documentation was found of Resident #110's physician being notified of Resident #110's low O2 level or the Hospice recommendations on [DATE]. During a phone interview on [DATE] at 3:51 P.M. Physician #200 stated faxes to this office on weekends would not be addressed until Monday. Physician #200 stated an on-call physician service was used on weekends and he would not be called directly. An on-call physician would be called. During an interview on [DATE] at 4:41 P.M. the Administrator confirmed the Hospice recommendation of a STAT chest X-ray was faxed to the physicians office. The Administrator confirmed the fax was sent on Sunday, [DATE] and would not be have been addressed until Monday, [DATE]. The Administrator confirmed the physician was not called on [DATE]. Review of a facility policy titled Hospice Services, Coordination, revised [DATE] revealed when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident ' s highest practicable physical, mental, and psychosocial well-being. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident ' s needs, goals, and recognized standards of practice in consultation with the resident ' s attending physician/practitioner and resident ' s representative, to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00148377.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen was administered as ordered. This affected three Residents (#11, #12, and #13) out of four residents reviewed for working oxygen concentrators. The census was 108. Findings include: 1. Review of Resident #11's medical record revealed Resident #11 was admitted on [DATE] with diagnoses including congested heart failure, acute kidney failure, and chronic respiratory failure. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #11 had moderate cognitive deficits and required extensive assistance with activities of daily living (adl). Review of Resident #11's care plan, dated 07/13/23, revealed Resident #11 had oxygen therapy related to congestive heart failure and respiratory failure with interventions to monitor for respiratory distress and to give medicine as ordered by the physician. Review of Resident #11's physician order, dated 07/31/23, revealed an order for oxygen at two liters per minute via nasal cannula continuously due to shortness of breath. Observation on 08/02/23 at 9:37 A.M. during medication administration revealed Resident #11's oxygen concentrator was set to four liters per minute. Observation on 08/02/23 at 11:53 A.M. revealed Resident #11's oxygen concentrator was set to four liters per minute. Interview on 08/02/23 at 11:54 A.M. with Licensed Practical Nurse (LPN) #20 verified Resident #11's physician order was for two liters per minute and reported that Resident #11's oxygen concentrator was on the wrong setting. 2. Review of Resident #12's medical record revealed Resident #12 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, sleep apnea, asthma, and respiratory disorders. Review of Resident #12's Annual MDS assessment, dated 07/11/23, revealed Resident #14 was cognitively intact and required extensive assistance with adls. Review of Resident #12's care plan, dated 03/16/18, revealed Resident #12 had oxygen therapy related to diagnosis with interventions which included oxygen settings: Resident #12 had oxygen via nasal cannula at three and half liters continuously. Keep oxygen saturation greater than 92%. Resident #12 used continuous positive airway pressure (CPAP) during night hours and call Resident #12's daughter if at any hour Resident #12 declines the oxygen mask. Review of Resident #12's physician order, dated 08/30/22, revealed an order for Resident #12 to receive oxygen at three and a half liters per minute via nasal cannula continuously due to shortness of breath. Observation on 08/02/23 at 12:10 P.M. of Resident #12's oxygen concentrator revealed it was set to four and a half liters per minute. Interview on 08/02/23 at 12:18 P.M. with LPN #21 verified Resident #12's concentrator was set to four and a half liters per minute and should be set to three and a half liters per minute. 3. Review of Resident #13's medical record revealed Resident #13 was admitted on [DATE] with diagnoses including COPD, respiratory disorders, and cerebrovascular disease. Review of Resident #13's Significant Change MDS assessment, dated 07/19/23, revealed Resident #13 had severe cognitive impairment and required extensive assistance with adls. Review of Resident #13's care plan, dated 06/26/23, revealed Resident #13 had altered respiratory status and difficulty breathing related to episodes of shortness of breath with exertion or when lying flat. Resident #13 had continuous oxygen therapy and remained at risk for associated complications and fluctuations with care needs related to progression of COPD and respiratory disorders. Interventions included to provide oxygen as ordered. Review of Resident #13's physician order, dated 05/30/23, revealed an order for Resident #13 to receive continuous oxygen at two and a half liters per minute. Observation on 08/02/23 at 12:25 P.M. of Resident #13's oxygen concentrator revealed it was set to four liters per minute. Interview on 08/02/23 during observation with LPN #21 verified Resident #13's oxygen concentrator was set on four liters per minute and it should have been set to two and a half liters per minute. Review of the Oxygen Administration Policy, dated 02/28/20, revealed oxygen therapy can be initiated as a nursing judgement, if the resident's condition warrants, until notification to the physician is made and the order is obtained, otherwise, oxygen therapy is administered to the resident upon the written order of a licensed physician. This deficiency represents non-compliance investigated under Complaint Number OH00144713.

Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure a dignified dining experience for residents. This affected one (#35) of three residents reviewed for dignity. The facility census was 105. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE] with diagnoses including multiple sclerosis and dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #35 dated 03/13/23 revealed the resident was cognitively intact and required supervision with activities of daily living (ADL's). Review of the medical record for Resident #38 revealed an admitted [DATE] with a diagnosis of diabetes mellitus (DM.) Review of the MDS for Resident #38 dated 03/13/23 revealed resident was cognitively intact and required extensive assistance of one staff with ADL's. Review of the April 2023 monthly physician orders for Resident #38 revealed an order dated 02/27/23 for resident to receive insulin at meals based on a sliding scale. Observation on 04/04/23 at 8:22 A.M. revealed Resident #35 was seated directly across the table from Resident #38 and both residents were eating breakfast. Licensed Practical Nurse (LPN) #875 told Resident #38 she needed to check her blood sugar to determine if resident needed insulin per the sliding scale order. Resident #38 consented to have her blood sugar taken at the breakfast table. LPN #875 did not obtain consent from Resident #35 who was eating at the same table and was at a distance of approximately three feet from Resident #38. Resident #38 placed her right hand on the breakfast table and the nurse stuck her middle finger with a lancet which produced a large drop of blood which nurse pulled into the glucometer and got a reading of 119. Resident #35 gasped when she saw the blood and said it hurt her just to see that, and she was glad she didn't have to get stuck with a needle. LPN #875 cleaned Resident #38's finger off and left the table. Interview on 04/04/23 at 8:40 A.M. with LPN #875 confirmed she obtained consent from Resident #38 to have her blood sugar taken at the table but she had not asked Resident #35, resident's tablemate how she felt about the procedure occurring at the breakfast table. Interview on 04/04/23 at 8:45 A.M. with Resident #35 confirmed she would prefer not to have to see blood or see people getting stuck with needles, especially while she is eating her breakfast. Interview on 04/04/23 at 2:32 P.M. with the Director of Nursing (DON) confirmed nurses should obtain permission from all residents at the table before checking blood sugars during mealtime. Review of the facility policy titled Dignity dated 01/26/21 revealed the facility would ensure that each resident was cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. This deficiency represents non-compliance investigated under Complaint Number OH00141229.

Based on record review, observation and resident representative and staff interview, the facility failed to ensure immediate access to residents. This affected one (#33) of three residents reviewed for resident rights. The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's.) Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the facility did not always respond to phone calls including requests to access the resident/facility after hours in a timely manner. Observation on 04/05/23 at 5:46 A.M. revealed the front entrance to the facility was locked and there was a typed sign posted on the door which indicated the door was locked from 8:00 P.M. to 8:00 A.M. and to gain entrance to the facility the visitor had to call and request entrance. There were two local phone numbers posted. One was the main number for the facility, and the other number was for a call phone. Surveyor called the facility's main number at 5:48 A.M. and the phone rang multiple times but there was no answer. Surveyor called the cell phone number at 5:52 A.M. and the phone rang multiple times and then a voicemail greeting indicated the number had a voice mail box which had not been set up yet. Surveyor called the facility's main number at 5:52 A.M. and the phone rang multiple times with no answer. Surveyor called the cell phone number again at 5:54 A.M. with no response. Surveyor called the Administrator's cell phone (which was not posted) at 5:55 A.M., and the Administrator answered. Surveyor requested access to the facility, and the Administrator said she would reach out to staff in the building and have someone unlock the door so surveyor could access the facility. Observation revealed State tested Nursing Assistance (STNA) #495 unlocked the front door and permitted Surveyor to enter the facility at 6:03 A.M. Interview on 04/05/23 at 6:03 A.M. with STNA #495 confirmed the cell phone number posted on the front door was for the supervisor's cell phone and there was no nursing supervisor on duty at the moment. Interview on 04/05/23 at 1:30 P.M. with the Administrator confirmed representatives of the State and resident representatives should be permitted immediate access to the residents. Administrator apologized for the delay the Surveyor experienced in gaining entry to the facility. Administrator confirmed they kept the building locked from 8:00 P.M. to 8:00 A.M. for security reasons and provided the main number so visitors could call to request access and the supervisor's cell phone number was also provided as a backup option. This deficiency represents non-compliance investigated under Complaint Number OH00140514.

Based on record review, observation, resident representative and staff interview, and review of the facility policy, the facility failed to ensure resident representatives were notified promptly of changes in resident's condition. This affected one (#33) of three residents reviewed for resident rights. The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the April 2023 monthly physician orders for Resident #33 revealed an order dated 02/07/23 for resident to receive Isosource via feeding tube from 6:00 P.M. to 6:00 A.M. daily, an order dated 02/07/23 for resident to receive a bolus tube feeding of one 250 milliliter (ml) container of Isosource at 1:00 P.M. daily, and an order dated 12/26/22 for resident to receive gabapentin three times daily at 6:00 A.M., 1:00 P.M. and 6:00 P.M. Review of the April 2023 Medication Administration Record (MAR) for Resident #33 revealed the Isosource nocturnal tube feeding for 04/02/23 to 04/03/23 , the 1:00 P.M. bolus feeding of Isosource for 04/03/23, and the 1:00 P.M. dose of gabapentin were signed off as ordered. Review of the nurse progress note for Resident #33 dated 04/03/23 timed at 5:44 P.M. per Licensed Practical Nurse (LPN) #590 revealed resident's gastrostomy (g-tube) needed to be replaced and staff were not able to give med's or bolus tube feeding without it coming out the other side. Review of the nurse progress note for Resident #33 dated 04/04/23 timed at 6:32 A.M. revealed resident returned to facility from an emergency room visit for malfunctioning of g-tube. The resident's feeding tube was changed at the hospital and resident's tube was intact and functional. Review of hospital notes for Resident #33 dated 04/04/23 timed at 6:28 P.M. revealed resident arrived at the hospital via squad and presented with problems with his feeding tube. Resident #33 reported his feeding tube had been leaking since last night and the end cap of the tube was missing. Resident #33 was unsure what happened to the tube. Hospital replaced resident's g-tube and confirmed placement via x-ray, and the resident was returned to the facility on [DATE] at 5:23 A.M. Interview on 04/04/23 at 1:11 P.M. with Resident #33 and resident's representative confirmed he wanted his representative to be notified promptly of all changes in his care. Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the resident's gastrostomy tube had malfunctioned on 04/03/23 in the early morning hours and she was not notified in a timely manner of the resident's change in condition. Resident #33's representative confirmed the facility should notify her of all changes in condition and she learned of problem with resident's g-tube on 04/03/23 at approximately 6:00 P.M. when she came to visit the resident and the staff was getting ready to send him out to the hospital to have the tube replaced. Resident #33's representative confirmed the nurse told her resident had not received his afternoon tube feeding or his afternoon dose of gabapentin because the tube was non-functioning. Interview on 04/05/23 at 9:13 A.M. with LPN #590 confirmed when she arrived at the facility on 04/03/23 at approximately 7:00 A.M. the night shift agency nurse told her Resident #33's g-tube was not functioning properly and his tube had been leaking all night. When LPN #590 went in to assess the resident at approximately 7:15 A.M. the nocturnal tube feeding was disconnected and there was a piece broken off the g-tube. LPN #590 confirmed she asked the supervisor if they could send the resident out to the hospital to have his tube replaced but supervisor told her to wait because she was going to try to figure out a way to repair the tube with replacement parts. LPN #590 confirmed they were not able to repair the tube and she tried to give resident a bolus feeding at 1:00 P.M. but it didn't work-the tube feeding would not go into the tube. LPN #590 confirmed she did not give the 1:00 P.M. dose of gabapentin. LPN #590 confirmed Resident #33's representative arrived to visit on 04/03/23 at approximately 6:00 P.M. which was at the same time the supervisor informed her the attending physician had given an order for resident to go to the hospital to have his g-tube replaced. LPN #590 confirmed Resident #33's representative expressed concern that no one had informed her Resident #33's g-tube had been non-functional since the nightshift on 04/03/23. LPN #590 confirmed the facility did notify Resident #33's representative in a timely manner that his feeding tube was non-functional and resident was unable to receive tube feeding and medications. Review of the facility policy titled Change of Resident Condition, Physician and Family Notification dated 01/2021 revealed the resident's responsible party will be notified in a timely manner regarding any significant change in status which warrants an alteration in treatment and possible transfer to an acute care setting. This deficiency represents non-compliance investigated under Complaint Number OH00141716.

Based on record review, observation, resident representative and staff interview, and review of the facility policy, the facility failed to ensure proper care and functioning of gastrostomy tubes (g-tubes.) This affected one (#33) of three residents reviewed for tube feedings. The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the care plan for Resident #33 dated 10/12/22 revealed resident had a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding related to dysphagia. Resident #33 has had to go to the emergency room to have tube replaced. Resident #33 had a history of pulling and tugging on the tube. and jamming the tip of the tube. Interventions included: abdominal binder if needed and as tolerated by resident, monitor tube feeding tolerance and document any gastrointestinal issues, provide tube feeding per orders, administer medications as ordered, monitor/document for side effects and effectiveness, provide local care to the g-tube site and monitor for any signs of infection Review of the April 2023 monthly physician orders for Resident #33 revealed an order dated 02/07/23 for the resident to receive Isosource via feeding tube from 6:00 P.M. to 6:00 A.M. daily, an order dated 02/07/23 for resident to receive a bolus tube feeding of one 250 milliliter (ml) container of Isosource at 1:00 P.M. daily, and an order dated 12/26/22 for resident to receive gabapentin three times daily at 6:00 A.M., 1:00 P.M. and 6:00 P.M. Review of the April 2023 Medication Administration Record (MAR) for Resident #33 revealed the Isosource nocturnal tube feeding for 04/02/23 to 04/03/23 , the 1:00 P.M. bolus feeding of Isosource for 04/03/23, and the 1:00 P.M. dose of gabapentin were signed off as ordered. Review of the nurse progress note for Resident #33 dated 04/03/23 timed at 5:44 P.M. per Licensed Practical Nurse (LPN) #590 revealed the resident's gastrostomy (g-tube) needed to be replaced and staff were not able to give med's or bolus tube feeding without it coming out the other side. Review of the nurse progress note for Resident #33 dated 04/04/23 timed at 6:32 A.M. revealed resident returned to facility from an emergency room visit for malfunctioning of g-tube. The resident's feeding tube was changed at the hospital and resident's tube was intact and functional. Review of hospital notes for Resident #33 dated 04/04/23 timed at 6:28 P.M. revealed the resident arrived at the hospital via squad and presented with problems with his feeding tube. Resident #33 reported his feeding tube had been leaking since last night and the end cap of the tube was missing. Resident #33 was unsure what happened to the tube. Hospital replaced resident's g-tube and confirmed placement via x-ray, and the resident was returned to the facility on [DATE] at 5:23 A.M. Observation on 04/04/23 at 1:11 P.M. of Resident #33 revealed #33 resident was resting in his room with his representative at the bedside and his feeding tube was in place and intact. The tube was not hooked up to a tube feeding at the time of the observation. Interview on 04/04/23 at 1:11 P.M. with Resident #33 and resident's representative confirmed he wanted his representative to be included in discussions regarding his care. Resident #33 confirmed he had his g-tube replaced at the hospital the night before and the new tube was functioning properly. Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the resident's gastrostomy tube had malfunctioned on 04/03/23 in the early morning hours and she learned of problem with resident's g-tube on 04/03/23 at approximately 6:00 P.M. when she came to visit the resident and the staff was getting ready to send him out to the hospital to have the tube replaced. Resident #33's representative confirmed the nurse told her the resident had not received his afternoon tube feeding or his afternoon dose of gabapentin because the tube was non-functioning. Resident #33 representative confirmed prior to going to the hospital on 04/03/23 the caps were broken off the tube and it was covered with a plastic glove to keep stomach contacts from leaking out. Interview on 04/05/23 at 9:13 A.M. with LPN #590 confirmed when she arrived at the facility on 04/03/23 at approximately 7:00 A.M. the night shift agency nurse told her Resident #33's g-tube was not functioning properly and his tube had been leaking all night. When LPN #590 went in to assess the resident at approximately 7:15 A.M. the nocturnal tube feeding was disconnected and there was a piece broken off the g-tube. LPN #590 confirmed she asked the supervisor if they could send the resident out to the hospital to have his tube replaced but supervisor told her to wait because she was going to try to figure out a way to repair the tube with replacement parts. LPN #590 confirmed they were not able to repair the tube and she tried to give the resident a bolus feeding at 1:00 P.M. but it didn't work-the tube feeding would not go into the tube. LPN #590 confirmed she did not give the 1:00 P.M. dose of gabapentin. LPN #590 confirmed she placed a plastic glove over Resident #33's g-tube to keep stomach contents from leaking out. LPN #590 confirmed at approximately 6:00 P.M. on 04/03/23 the supervisor informed her the attending physician had given an order for resident to go to the hospital to have his g-tube replaced. Resident #33 was transported to the hospital via 911. Review of the facility policy titled Enteral Feeding Dated 02/28/20 enteral feedings will be provided according to physician's orders to assist the resident in meeting daily nutritional intake requirements. This deficiency represents non-compliance investigated under Complaint Number OH00141716.

Based on record review and staff interview, the facility failed to ensure resident's pain was appropriately managed. This affected one (#106) of three residents reviewed for pain management. The facility census was 105. Findings include: Review of the medical record for Resident #106 revealed an admitted [DATE] with a diagnosis of aftercare following joint replacement surgery, presence of right knee artificial joint, unilateral primary osteoarthritis (OA). Review of the Minimum Data Set (MDS) for Resident #106 dated 12/03/22 revealed the resident was cognitively intact and required extensive assistance with activities of daily living (ADL's). Review of the MDS revealed the resident was coded for almost constant pain which was rated as eight on a scale of one to 10 with 10 being the worst pain. Review of the hospital continuity of care form for Resident #106 dated 11/29/22 revealed resident received oxycodone for pain on 11/29/22 at 10:12 A.M. before leaving the hospital to travel by ambulance to the facility. Resident #106 had a right total knee replacement on 11/28/22. Review of the admission nursing assessment for Resident #106 dated 11/29/22 timed at 11:53 A.M. revealed the resident complained of right knee pain which she rated as eight on a scale of one to 10. Review of the November 2022 admission orders for Resident #106 dated 11/29/22 revealed an order for oxycodone five milligrams (mg) every four hours as needed for pain. Review of the orders revealed there were no other orders for pain medication or non-pharmacological measures to be given for pain. Review of the emergency box controlled substance sheet for Resident #106 dated 11/29/22 revealed a five mg dose of oxycodone was pulled from the emergency supply for Resident #106 at 3:25 P.M. Review of the care plan for Resident #106 dated 11/30/22 revealed the resident was at risk for pain due to joint replacement surgery and generalized discomfort. Resident #106 remains at risk for fluctuations and potential for adverse effects related to medication therapy. Interventions included the following: administer analgesia as ordered, evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, monitor/document for side effects/adverse effects of pain medication, observe for constipation, urinary retention, new onset or increased agitation, restlessness, confusion, hallucinations, sedation, respiratory distress, dysphoria, nausea, vomiting, pruritus, dizziness and falls. Report occurrences to the physician, ask physician to review medication if side effects/adverse effects persist, offer and implement non-drug interventions to help manage pain/discomfort including food/drink, rest, and repositioning; monitor for effectiveness. Review of the November 2022 Medication Administration Record (MAR) for Resident #106 revealed pain scaled completed for resident for dayshift on 11/29/22 was for resident pain of a level eight on a scale of one to 10. Pain level on evening shift for 11/29/22 was a level nine on a scale of one to 10. Resident received oxycodone on 11/29/22 at 3:25 P.M. and 9:51 P.M. Resident #106 had no other pain medications ordered and MAR did not include nonpharmacological interventions for pain. Review of the November 2022 Treatment Administration Record (TAR) for Resident #106 revealed the TAR did not include nonpharmacological interventions for pain. Review of the nurse progress note for Resident #106 dated 11/29/22 timed at 12:49 P.M. revealed the nurse verified the admitting orders with the attending physician with no changes from the hospital continuity of care form. Orders were faxed to pharmacy at this time. There was no documentation in the nurses' notes of nonpharmacological interventions for pain. Interview on 04/05/23 at 8:00 A.M. with Registered Nurse (RN) #500 confirmed she was the admitting nurse when Resident #106 arrived to the facility from the hospital following a right total knee replacement on 11/29/22 at approximately 11:53 A.M. RN #500 confirmed she assessed resident's pain to her right knee immediately upon resident's arrival to the facility, and resident reported her pain was eight on a scale of one to 10. RN #500 confirmed the facility called the doctor to verify resident's admitting orders but did not report the high pain level to the doctor and/or request additional options for pain management. RN #500 confirmed there was a delay in being able to pull oxycodone from the emergency supply because they had to wait until the pharmacy gave the authorization to pull the medication. RN #500 confirmed Resident #106 received oxycodone at 3:25 P.M. but did not receive anything else for pain sooner, including non-pharmacological interventions, because nothing else was ordered. Interview on 04/05/23 at 1:18 P.M. with the Administrator confirmed the facility did not have a pain management policy, and the facility assessed residents for pain on a daily basis and managed pain based on input from the attending physician and based on physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00141072.

Based on record review, observation, resident representative and staff interview, and review of the facility policy, the facility failed to ensure residents received medications as ordered by the physician. This affected one (#33) of three residents reviewed for medications The facility census was 105. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses including traumatic subarachnoid hemorrhage, diffuse traumatic brain injury, epilepsy, major depressive disorder, and osteomyelitis. Review of the Minimum Data Set (MDS) for Resident #33 dated 02/08/23 revealed the resident was cognitively impaired and required extensive assistance with activities of daily living (ADL's). Review of the care plan for Resident #33 dated 05/11/22 revealed the resident has chronic back pain with right side sciatica, and bilateral lower extremity contracture's. Interventions included the following: administer analgesia (medication) as per orders. Give one half hour before treatments or care, monitor and document the side effects of the medication. Review of the care plan for Resident #33 dated 10/12/22 revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube for enteral feeding related to dysphagia. Resident #33 has had to go to the emergency room to have tube replaced. Resident #33 had a history of pulling and tugging on the tube and jamming the tip of the tube. Interventions included the following: abdominal binder if needed and as tolerated by resident, monitor tube feeding tolerance and document any gastrointestinal issues, provide tube feeding per orders, administer medications as ordered, monitor/document for side effects and effectiveness, provide local care to the g-tube site and monitor for any signs of infection Review of the April 2023 monthly physician orders for Resident #33 revealed an order dated 12/26/22 for the resident to receive gabapentin three times daily at 6:00 A.M., 1:00 P.M. and 6:00 P.M. for low back pain. Review of the April 2023 Medication Administration Record (MAR) for Resident #33 revealed the 1:00 P.M. dose of gabapentin was signed off as administered. Review of the nurse progress note for Resident #33 dated 04/03/23 timed at 5:44 P.M. per Licensed Practical Nurse (LPN) #590 revealed resident's gastrostomy (g-tube) needed to be replaced and staff were not able to give med's or bolus tube feeding without it coming out the other side. Review of the nurse progress note for Resident #33 dated 04/04/23 timed at 6:32 A.M. revealed the resident returned to facility from an emergency room visit for malfunctioning of g-tube. The resident's feeding tube was changed at the hospital and resident's tube was intact and functional. Review of hospital notes for Resident #33 dated 04/04/23 timed at 6:28 P.M. revealed the resident arrived at the hospital via squad and presented with problems with his feeding tube. Resident #33 reported his feeding tube had been leaking since last night and the end cap of the tube was missing. Resident #33 was unsure what happened to the tube. Hospital replaced resident's g-tube and confirmed placement via x-ray, and the resident was returned to the facility on [DATE] at 5:23 A.M. Observation on 04/04/23 at 1:11 P.M. of Resident #33 revealed resident was resting in his room with his representative at the bedside and his feeding tube was in place and intact. The tube was not hooked up to a tube feeding at the time of the observation. Interview on 04/04/23 at 1:11 P.M. with Resident #33 and resident's representative confirmed he wanted his representative to be included in discussions regarding his care. Resident #33 confirmed he had his g-tube replaced at the hospital the night before and the new tube was functioning properly and the nurse did not administer his 1:00 P.M. dose of gabapentin on 04/04/23 because his g-tube wasn't working. Interview on 04/04/23 at 1:12 P.M. with Resident #33's representative confirmed the resident's gastrostomy tube had malfunctioned on 04/03/23 in the early morning hours and she learned of problem with resident's g-tube on 04/03/23 at approximately 6:00 P.M. when she came to visit the resident and the staff was getting ready to send him out to the hospital to have the tube replaced. Resident #33's representative confirmed the nurse told her the resident had not received his afternoon dose of gabapentin because the tube was non-functioning. Resident #33's representative confirmed prior to going to the hospital on 04/03/23 the caps were broken off the tube and it was covered with a plastic glove to keep stomach contacts from leaking out. Interview on 04/05/23 at 9:13 A.M. with LPN #590 confirmed when she arrived at the facility on 04/03/23 at approximately 7:00 A.M. the night shift agency nurse told her Resident #33's g-tube was not functioning properly and his tube had been leaking all night. When LPN #590 went in to assess the resident at approximately 7:15 A.M. the nocturnal tube feeding was disconnected and there was a piece broken off the g-tube. LPN #590 confirmed she asked the supervisor if they could send the resident out to the hospital to have his tube replaced but supervisor told her to wait because she was going to try to figure out a way to repair the tube with replacement parts. LPN #590 confirmed they were not able to repair the tube and she tried to give resident a bolus feeding at 1:00 P.M. but it didn't work-the tube feeding would not go into the tube. LPN #590 confirmed she did not give the 1:00 P.M. dose of gabapentin. LPN #590 confirmed she placed a plastic glove over Resident #33's g-tube to keep stomach contents from leaking out. LPN #590 confirmed at approximately 6:00 P.M. on 04/03/23 the supervisor informed her the attending physician had given an order for resident to go to the hospital to have his g-tube replaced. Resident #33 was transported to the hospital via 911. Review of the facility policy titled Medication Administration dated 02/05/20 revealed licensed nurses would administer med's in a safe and effective manner and as ordered. This deficiency represents non-compliance investigated under Complaint Numbers OH00141716, OH00141229 and OH00141072.

Based on record review, staff interview, review of the facility policy, and review of an online medication resource, the facility failed to ensure appropriate monitoring in conjunction with administration of the anticoagulant, Coumadin. This affected one (#36) of three residents reviewed for Coumadin administration. The facility census was 105. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 dated 03/06/23 revealed resident was on anticoagulant therapy related to history of cerebrovascular accident (CVA). Interventions included the following: antidote is Vitamin K, have on hand for emergencies, daily skin inspection, report abnormalities to the nurse, labs as ordered, report abnormal lab results to the physician, monitor/document/report to physician as needed signs and symptoms of anticoagulant complications: blood tinged or [NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the April 2023 monthly physician orders for Resident #36 revealed an order dated 11/29/22 for the resident to take Coumadin seven milligrams (mg) at bedtime daily due to presence of automatic implantable cardiac defibrillator and an order dated 11/13/22 for a Prothrombin Time/International Normalized Ratio (PT/INR) every two weeks on Mondays. Review of the PT/INR lab results for Resident #36 revealed lab dated 02/20/23 results were PT=23.8, INR=2.1. Lab results dated 03/30/23 were PT=25.4, INR=2.3. Lab results dated 04/03/23 were PT=35, INR=3.2. There were no PT/INR results for Monday, 03/06/23. Review of the nurse progress note for Resident #36 dated 04/05/23 timed at 3:15 P.M. per Licensed Practical Nurse (LPN) #800 revealed nurse faxed the high INR results for 04/03/23 to Nurse Practitioner (NP) #885 in the evening on 04/03/23. Review of the fax cover sheets for communication of high INR results for Resident #36 revealed lab results were faxed on 04/03/23 at 5:18 P.M., 6:04 P.M., and 8:00 P.M. Review of the April 2023 Medication Administration Record (MAR) for Resident #26 revealed resident received seven mg of Coumadin on 04/04/23 at bedtime and the most recent INR result at the time of administration was recorded in the MAR as 2.3. Review of nurse progress note for Resident #36 dated 04/05/23 timed at 2:16 P.M. per Corporate Nurse (CN) #880 revealed resident's attending physician was notified of the high INR results for resident dated 04/03/23 which had not been addressed. Physician gave an order for a stat PT/INR and to hold Coumadin until results are received. Physician also noted if nurses are unable to reach the nurse practitioner (NP) they should call the attending physician or the facility medical director. Review of nurse progress note for Resident #36 dated 04/05/23 timed at 6:25 P.M. revealed the nurse was contacted by lab that blood that was drawn today for PT/INR was hemolyzed. Nurse contacted NP #885 and she gave an order to redraw blood in the morning on 04/06/23. Review of the nurse progress note for Resident #36 dated 04/06/23 timed at 9:37 A.M. revealed lab had not come out yet to draw blood for PT/INR for resident. Interview on 04/05/23 at 12:35 P.M. with CN #880 confirmed Resident #36 should have had a PT/INR drawn on 03/06/23 per physician's routine order but this did not occur due to an oversight/error. CN #880 confirmed PT/INR drawn on 04/03/23 for Resident #36 was high with an INR at 3.2. CN #880 confirmed there was no documentation of physician notification of the abnormal lab results. CN #880 confirmed Resident #36's April 2023 MAR indicates Coumadin was administered at 9:00 P.M. on 04/04/23 and the INR recorded at the time of administration was 2.3 which was the INR result from 03/20/23, not 04/03/23. Interview on 04/05/23 at 1:16 P.M. with CN #880 confirmed she notified the attending physician of Resident #36's high INR result on 04/03/23. CN #880 confirmed she notified the physician that agency LPN #890 administered seven mg of Coumadin to resident at 9:00 P.M. on 04/03/23. Physician gave order for the resident to have a stat PT/INR drawn and to hold Coumadin until results were received. Physician said if NP did not respond, staff should call him or the facility Medical Director. CN #880 confirmed she spoke with the nurse supervisor on 04/03/23, LPN #800 who confirmed she had faxed the high PT/INR results to NP #885 three times on 04/03/23 but did not receive a response. Interview on 04/06/23 at 12:43 P.M. with LPN #800 confirmed she faxed the high PT/INR results to NP #885 three times on 04/03/23 between 5:00 P.M. and 8:00 P.M. but she did not get a response. LPN #800 confirmed she did not document the high INR in Resident #36's record until 04/05/23. LPN #800 confirmed she verbally told the agency nurse to wait to give the Coumadin until they heard back from the doctor, but she did not document any of this. Review of the facility policy titled Coumadin Administration dated 01/26/21 revealed Coumadin will be administered by licensed nurses and laboratory monitoring will be completed and dosage adjustments will be made according to physician's order. Review of online resource Medscape at https://reference.medscape.com/drug/coumadin-jantoven-warfarin-342182#5 revealed Coumadin had a black box warning, because the medication could cause major or fatal bleeding particularly with a higher dose resulting in a higher INR. Risk factors for bleeding include high intensity of anticoagulation (INR greater than four), age [AGE] years or older, highly variable INR's, history of gastrointestinal bleeding, hypertension, cerebrovascular disease, serious heart disease, anemia, malignancy, trauma, renal insufficiency, concomitant drugs, and long duration of Coumadin therapy. Regular monitoring of INR should be performed on all treated patients, and those at high risk of bleeding may benefit from more frequent INR monitoring. Careful dose adjustment to desired INR's should be made. Patients should be instructed about prevention measures to minimize the risk of bleeding and to immediately report any signs or symptoms of bleeding to their physician. This deficiency represents non-compliance investigated under Complaint Number OH00141072.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were not left unattended. This affected two (#36 and #38) of four residents observed for medication administration. The census was 105. Findings include: 1. Review of the medical record for Resident #38 revealed an admitted [DATE] with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #38 dated 03/13/23 revealed resident was cognitively intact and required extensive assistance of one staff with activities of daily living (ADL's). Review of the April 2023 monthly physician orders for Resident #38 revealed an order dated 02/27/23 for resident to receive Miralax 17 grams mixed in water once daily. Observation of medication administration on 04/04/23 at 8:30 A.M. in the dining room revealed Licensed Practical Nurse (LPN) #875 administered resident's oral tablet medications in a plastic cup and gave resident a cup of water mixed with the dose of Miralax to wash down the tablets. Resident #38 swallowed the tablets and still had approximately half a cup of water and Miralax remaining. LPN #875 left the dining room leaving the medication unattended and went back to the medication cart which was in the hallway. LPN #875 did not stay to ensure the entire resident consumed the entire dose of Miralax. 2. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including cerebral infarction and vascular dementia. Review of the MDS for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with ADL's. Review of the April 2023 monthly physician orders for Resident #38 revealed an order dated 12/26/22 for resident to receive Miralax 17 grams mixed in water once daily. Observation of medication administration on 04/04/23 at 8:34 A.M. inside Resident #36's room revealed LPN #875 administered resident's oral tablet medications in a plastic cup and gave resident a cup of water mixed with the dose of Miralax to wash down the tablets. Resident #36 swallowed the tablets and still had approximately half a cup of water and Miralax remaining. LPN #875 left the resident's room leaving the medication unattended and went back to the medication cart. LPN #875 did not stay to ensure the entire resident consumed the entire dose of Miralax. Interview on 04/04/23 at 8:40 A.M. of LPN #875 confirmed Residents #36 and #38 did not have orders to self-administer Miralax. LPN #875 confirmed she did not observe Residents #36 and #38 to ensure the entire dose of Miralax was consumed. Interview on 04/04/23 at 2:32 P.M. with the Director of Nursing (DON) confirmed nurses should not leave medications unattended and should stay with the resident to ensure the entire dose of medication is consumed. Review of the facility policy titled Medication Storage dated 02/25/20 revealed medications are stored safely, securely, and properly. Review of the facility policy titled Medication Administration dated 02/05/20 revealed nurses should administer med's in a safe and effective manner, and the medication cart is locked at all times unless in use and under the direct observation of the medication nurse. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview and review of the facility policy, the facility failed to ensure lab tests were obtained as ordered. This affected one (#36) of three residents reviewed for laboratory testing. The facility census was 105. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 dated 03/06/23 revealed resident was on anticoagulant therapy related to history of cerebrovascular accident (CVA). Interventions included the following: antidote is Vitamin K, have on hand for emergencies, daily skin inspection, report abnormalities to the nurse, labs as ordered, report abnormal lab results to the physician, monitor/document/report to physician as needed signs and symptoms of anticoagulant complications: blood tinged or [NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the April 2023 monthly physician orders for Resident #36 revealed an order dated 11/29/22 for resident to take Coumadin seven milligrams (mg) at bedtime daily due to presence of automatic implantable cardiac defibrillator and an order dated 11/13/22 for a Prothrombin Time/International Normalized Ratio (PT/INR) every two weeks on Mondays. Review of the PT/INR lab results for Resident #36 revealed lab dated 02/20/23 results were PT=23.8, INR=2.1. Lab results dated 03/30/23 were PT=25.4, INR=2.3. Lab results dated 04/03/23 were PT=35, INR=3.2. There were no PT/INR results for Monday, 03/06/23. Interview on 04/05/23 at 12:35 P.M. with Corporate Nurse (CN) #880 confirmed Resident #36 should have had a PT/INR drawn on 03/06/23 per physician's routine order but this did not occur due to an oversight/error. Review of the facility policy titled Coumadin Administration dated 01/26/21 revealed Coumadin will be administered by licensed nurses and laboratory monitoring will be completed and dosage adjustments will be made according to physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00141072.

Based on record review, staff interview and review of the facility policy, the facility failed to ensure residents' medical record included significant clinical information regarding changes in condition. This affected one (#36) of three residents reviewed for medical records. The facility identified three residents with orders for Coumadin. The facility census was 105. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including cerebral infarction and vascular dementia. Review of the Minimum Data Set (MDS) for Resident #36 dated 02/19/23 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADL's). Review of the care plan for Resident #36 dated 03/06/23 revealed resident was on anticoagulant therapy related to history of cerebrovascular accident (CVA). Interventions included the following: antidote is Vitamin K, have on hand for emergencies, daily skin inspection, report abnormalities to the nurse, labs as ordered, report abnormal lab results to the physician, monitor/document/report to physician as needed signs and symptoms of anticoagulant complications: blood tinged or [NAME] blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the April 2023 monthly physician orders for Resident #36 revealed an order dated 11/29/22 for resident to take Coumadin seven milligrams (mg) at bedtime daily due to presence of automatic implantable cardiac defibrillator and an order dated 11/13/22 for a Prothrombin Time/International Normalized Ratio (PT/INR) every two weeks on Mondays. Review of the PT/INR lab results for Resident #36 revealed lab dated 02/20/23 results were PT=23.8, INR=2.1. Lab results dated 03/30/23 were PT=25.4, INR=2.3. Lab results dated 04/03/23 were PT=35, INR=3.2. There were no PT/INR results for Monday, 03/06/23. Review of the April 2023 Medication Administration Record (MAR) for Resident #26 revealed resident received seven mg of Coumadin on 04/04/23 at bedtime and the most recent INR result at the time of administration was recorded in the MAR as 2.3. Review of nurse progress note for Resident #36 dated 04/05/23 timed at 2:16 P.M. per Corporate Nurse (CN) #880 revealed resident's attending physician was notified of the high INR results for resident dated 04/03/23 which had not been addressed. Physician gave an order for a stat PT/INR and to hold Coumadin until results are received. Physician also noted if nurses are unable to reach the nurse practitioner (NP) they should call the attending physician or the facility medical director. Interview on 04/05/23 at 12:35 P.M. with CN #880 confirmed PT/INR drawn on 04/03/23 for Resident #36 was high with an INR at 3.2. CN #880 confirmed there was no documentation of physician notification of the abnormal lab results. CN #880 confirmed Resident #36's April 2023 MAR indicates Coumadin was administered at 9:00 P.M. on 04/04/23 and the INR recorded at the time of administration was 2.3 which was the INR result from 03/20/23, not 04/03/23. Interview on 04/05/23 at 1:16 P.M. with CN #880 confirmed she notified the attending physician of Resident #36's high INR result on 04/03/23. CN #880 confirmed she notified the physician that agency LPN #890 administered seven mg of Coumadin to resident at 9:00 P.M. on 04/03/23. Physician gave order for resident to have a stat PT/INR drawn and to hold Coumadin until results were received. Physician said if NP did not respond, staff should call him or the facility Medical Director. CN #880 confirmed she spoke with the nurse supervisor for 04/03/23, LPN #800 who confirmed she had faxed the high PT/INR results to NP #885 three times on 04/03/23 but did not receive a response. CN #880 confirmed Resident #36's medical record did not include documentation of NP notification of the abnormal lab results dated 04/03/23. Interview on 04/06/23 at 12:43 P.M. with LPN #800 confirmed she faxed the high PT/INR results to NP #885 three times on 04/03/23 between 5:00 P.M. and 8:00 P.M. but she did not get a response. LPN #800 confirmed she did not document the high INR in Resident #36's record until 04/05/23. LPN #800 confirmed she verbally told the agency nurse to wait to give the Coumadin until they heard back from the doctor, but she did not document any of this in the medical record on 04/03/23. Review of the facility policy titled Change of Resident Condition, Physician and Family Notification dated 01/2021 revealed the nurse would document in the resident's medical record information relative to the changes in the resident including assessment and notification of changes. This deficiency represents non-compliance investigated under Complaint Numbers OH00141072 and OH00140514.

Based on record review, observation, and staff interview, the facility failed to provide nail care and hygiene for a dependent resident. This affected one (#85) out of three residents reviewed for bathing/hygiene. The census was 92. Findings include: Review of the medical record for Resident #85 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #85 dated 12/07/18 revealed resident had an activities of daily living (ADL) self-care performance deficit related to dementia, [CONDITION(S)], polyarthritis, depression, and cognitive deficits. Resident #85 was unable to care for herself and was dependent on facility staff for all of her daily needs. Interventions included the following: provide one-person physical assistance with personal hygiene, check nail length and clean and trim as necessary, report any changes to the nurse. Review of the Minimum Data Set (MDS) for Resident #85 dated 01/18/22 revealed the resident was cognitively impaired, was coded negative for the presence of behavioral symptoms including refusal of care and required extensive assistance of one staff with personal hygiene. Review of the Kardex for Resident #85 printed on 04/21/22 revealed staff should keep resident's nails short. Review of the nurse progress notes for Resident #85 for 03/01/22 through 04/21/22 revealed the notes contained no documentation regarding refusal of nail care. Observation on 04/21/22 at 10:00 A.M. with State tested Nursing Assistant (STNA) #625 revealed Resident #85's fingernails were long (extending approximately one quarter inch past the end of the fingers). There was debris under the nails and the right hand had chipped green fingernail polish on all five digits. Interview on 04/21/22 at 10:01 A.M. with STNA #625 confirmed Resident #85's nails were long and needed to be trimmed. STNA #625 also confirmed resident's nails needed to be cleaned. Interview on 04/21/22 at 10:16 A.M. with Licensed Practical Nurse (LPN) #520 confirmed Resident #85's fingernails were too long and needed to be trimmed and cleaned. LPN #520 confirmed residents should have nail care on her bath days and as needed. LPN #520 could not confirm the last time nail care had been provided for Resident #85. Interview on 04/21/22 at 3:24 P.M. with the Administrator confirmed the facility did not have a written policy regarding nail care but confirmed the facility followed professional standards of care. This deficiency substantiates Complaint Number OH 807.

Based on record review, observation, and staff interview, the facility failed to apply resident hand splints for contracture management as ordered by the physician. This affected one (#85) out of three residents reviewed for contracture's. The census was 92. Findings include: Review of the medical record for Resident #85 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan for Resident #85 dated 12/07/18 revealed resident had an activities of daily living (ADL) self-care performance deficit related to dementia, [CONDITION(S)], polyarthritis, depression, and cognitive deficits. Resident was unable to care for herself and was dependent on facility staff for all of her daily needs. Interventions included staff to provide one-person physical assistance with personal hygiene. Care plan was silent regarding us of hand splint. Review of the Minimum Data Set (MDS) for Resident #85 dated 01/18/22 revealed the resident was cognitively impaired, was coded negative for the presence of behavioral symptoms including refusal of care and required extensive assistance of one staff with personal hygiene. Review of the Kardex for Resident #85 printed on 04/21/22 revealed resident was to wear palm protector (splint) on right hand for up to eight hours for contracture management. Review of the occupational therapy (OT) evaluation for Resident #85 dated 05/14/21 revealed the resident was being seen by OT due to with a goal to prevent further contracture to her right hand. Goal of treatment included resident would tolerate right resting hand splint per designated wear schedule (to be determined) and staff would demonstrate competency with application in order to prevent further contracture and enhance optimal positioning. Review of OT discharge summary for Resident #85 dated 06/10/21 revealed therapist's discharge recommendations were to continue right hand resting splint per established schedule daily for contracture prevention, Therapist provided staff education for proper splint application and reinforced wear schedule for contracture prevention/management. Resident #85 continued to tolerate the splint for eight hours per day. Review of the monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress notes for Resident #85 for 03/01/22 through 04/21/22 revealed the notes contained no documentation regarding application or refusal of the hand splint. Observation on 04/21/22 at 10:00 A.M. with State tested Nursing Assistant (STNA) #625 revealed Resident #85's right hand was contracted. Resident #85 was not wearing a hand splint. There was a sign over resident's bed which read as follows: Splint ON during day, OFF at night. Further observation revealed Resident #85's splint was in her middle dresser drawer underneath some clothing. STNA #625 applied the splint after discussion with the surveyor and resident tolerated application of the splint well. Interview on 04/21/22 at 10:01 A.M. with STNA #625 confirmed Resident #85 was not wearing a splint, and she thought resident was supposed to be wearing a splint. Interview on 04/21/22 at 10:16 A.M. with Licensed Practical Nurse (LPN) #520 confirmed Resident #85's was supposed to be wearing a right-hand splint per therapy recommendations and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #520 confirmed staff were not documenting application of the splint in the resident's progress notes or MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/21/22 at 3:24 P.M. with the Administrator confirmed the facility did not have a written policy regarding splints but confirmed the facility followed professional standards of care and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, and review of facility documents, the facility failed to post the daily nurse staffing information for the date of the survey. This had the potential to affect all 92 residents residing in the facility. The census was 92. Findings include: Observation on 04/21/22 at 8:29 A.M. with the Director of Nursing (DON) revealed the daily nurse staffing information was posted outside the office of Scheduler #570 and the information was for 04/19/22. Further observation there were staffing sheets for 04/18/22 and 04/17/22 behind the posting for 04/19/22 in the plastic display holder. There was no sheet with the staffing information for 04/20/22 or 04/21/22. Scheduler #570 was not in his office. Interview on 04/21/22 at 8:30 A.M. with the DON confirmed Scheduler #570 posted the daily staffing information for the facility and confirmed the posted staffing information was for 04/19/22 not for the current date of 04/21/22. Interview on 04/21/22 at 9:30 A.M. with Scheduler #570 confirmed he had prepared the daily staffing posting sheets for 04/20/22 and 04/21/22 but he had not posted them at the beginning of the day on 04/20/22 and 04/21/22. Review of daily staffing posting sheets dated 04/20/22 and 04/21/22 revealed the sheet was completed for a census of 92 residents and listed the total number of hours for licensed nurses and aides for the day. Interview on 04/21/22 at 3:24 P.M. with the Administrator confirmed the facility did not have a written policy regarding the daily staffing posting but did confirm the nurse staffing information should be posted daily. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview and policy, the facility failed to immediately notify family representatives of a deterioration in a resident's health status. This affected one (#87) of three residents reviewed for change in condition. The facility census was 70. Findings include: Review of medical record for Resident #87 revealed an admission on 08/13/18. Resident #87 was discharged on [DATE] to in patient hospice care where she passed away on 11/26/21. [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment for Resident #87 dated 11/05/20 revealed the resident had severe cognitive impairment. Resident #87 required extensive assist from two staff members for bed mobility, transfers, and toileting. Resident #87 required extensive assist from one staff member for eating. Review of MDS assessment for Resident #87 dated 11/24/20 revealed the resident was receiving hospice services during the look back period. Resident #87 was assessed as being in a persistent vegetative state and was totally dependent for bed mobility, transfers, toileting and eating. Review of the plan of care for Resident #87 dated 12/01/20 revealed the resident was on antibiotic therapy for recurrent nephrolithiasis on 10/23/20 and left basilar pneumonia and effusion on 11/21/20. Interventions included medication as ordered, monitor for signs and symptoms of adverse side effects from antibiotics, droplet isolation, and report pertinent laboratory results. Review of plan of care for Resident #87 dated 12/01/20 revealed intravenous administration of antibiotics and fluids by using peripherally inserted central catheter (PICC) to right upper extremity. Interventions include administer antibiotic as ordered, change dressing to PICC line each week and flush PICC line before and after each dose of antibiotic. Review of plan of care for Resident #87 dated 12/01/20 revealed the resident has left basilar pneumonia and effusion and was to have nothing by mouth (NPO) until 11/24/20 until seen by physician. Interventions include elevate the head of her bed for comfort and lung expansion and encourage good fluid intakes as well as good nutrition and adequate rest, give medications as ordered, monitor vital signs as ordered, monitor, document and report to physician recurrent fever and monitor for mental changes. Review of nurses' note dated 11/19/20 at 7:32 P.M. for Resident #87 revealed the resident was lethargic, sleeping most of the time. Resident #87 refused her breakfast lunch and dinner. Resident #87 consumed 240 milliliters (ml) of her juice (total), 60 ml of her supplement. Tried several times even with the help of therapy staff. Resident #87 continue to close her mouth. Mouth care done. Respirations are easy/even and color is natural. Skin is warm/dry. Resident's vital signs: 146/92 blood pressure (BP), 64 pulse (P), 18 respirations (R) and temperature 97.7 degrees Fahrenheit (F) , 94 percent (%) oxygen saturation rate (O2 stat) without administration of oxygen. Will continue to monitor. Review of nurses' note dated 11/20/20 at 12:21 A.M. for Resident #87 revealed the resident continues to be lethargic, refused bedtime medications. Resident #87 is responsive to touch and voice command with eye opening at times. Resident #87's body is warm and pink. No signs of pain or distress noted this time. BP 139/90, P 101, temperature 97.6 degrees F, R 16, 02 sat 91%. Supervisor notified and stated will fax the physician. Review of nurses' note dated 11/20/20 at 7:31 A.M. for Resident #87 revealed the resident has been monitored throughout the night. BP 121/86, 02 sat 90%, P 107, temperature 100.3 degrees F. Resident #87 refused [MEDICATION NAME] (pain management) attempted on three occasions. Supervisor was notified. Review of nurse's note dated 11/20/20 at 10:17 A.M. for Resident #87 revealed orders for stat (as soon as possible) for complete blood count and comprehensive metabolic profile. Additionally, ordered urinalysis and culture and sensitivity by straight catheter. Review of nurse's note dated 11/20/20 at 7:01 P.M. revealed Resident #87 was afebrile, resident has been drowsy and sleeping all day, would not wake up to take medicine, urine analysis has been collected per primary care physician, resident showing no symptoms of [MEDICAL CONDITION], lung sounds clear, bowel sounds active in all four quadrants. Review of nurse's noted 11/20/20 at 11:59 P.M. revealed Resident #87 had an elevated/abnormal laboratory results of glucose level of 181, normal range is 65 -125; blood uric nitrogen (BUN) of 72, normal range is 7-25; creatinine 1.80, normal range is 0.6- 1.3; sodium 160, normal range is 135-145; and chloride 120, with normal range is 96-110. All laboratory results were reported to the physician. Review of nurse's note dated 11/20/20 at 1:19 P.M. revealed Resident #87 continued to be lethargic, did not open her mouth for any medications or anything offered but responsive to touch, open eyes at times, body is warm, no sign of pain or distress. BP 143/107, P 98, temperature 98.3 degrees F, 02 sat 94%. Will continue to monitor for any changes. Review of nurse's note dated 11/21/20 at 4:58 A.M. revealed Resident #87 received new orders to obtain peripheral intravenous (IV) access and run [MEDICATION NAME] five at 50 milliliters (ml) for a total of one liter. Obtain basic metabolic panel (BMP) after one liter completed. Review of physicians' orders dated 11/21/21 at 5:15 A.M. revealed orders for obtain peripheral IV access and administer [MEDICATION NAME] solution 50 ml every hour IV one time for dehydration for two days. After one liter completed obtain BMP. Review of physicians' orders dated 11/21/21 at 7:00 A.M. revealed orders for complete blood count (CBC) and BMP on 11/23/20 and 11/25/20 and obtain chest x-[MEDICAL CONDITION] (x-ray). Review of nurse's note dated 11/21/20 at 8:58 A.M. for Resident #87 revealed vascular access placed for IV line for fluids per order. Review of nurse's note dated 11/21/20 at 10:18 A.M. for Resident #87 revealed orders for [MEDICATION NAME] (sugar water solution) D5W half normal saline (NS) run at 75 ml per hour for four days. Repeat BMP and CBC on Monday and Wednesday due to [MEDICAL CONDITION] (too much sodium in the blood) and leukocytosis (high level of white blood cells), start [MEDICATION NAME] (antibiotic) one gram IV now and then daily time four days, obtain chest x-ray and fax final urinalysis when completed and stay NPO (nothing by mouth) until Monday when physician will come to see her. Review of physicians' orders dated 11/21/21 at 12:00 P.M. revealed orders for [MEDICATION NAME] solution reconstituted one gram (antibiotic). Use one gram IV one time a day for [MEDICAL CONDITION] (high sodium) for four days, nothing by mouth (NPO) until seen by physician on Monday, 11/23/20. Review of nurse's note dated 11/22/20 at 3:32 P.M. revealed Resident #87's peripheral IV line infiltrated (displaced catheter). Vascular access company called and notified that new line will be placed but a midline not a peripheral IV will be started. Review of nurses' note dated 11/22/20 at 8:04 P.M. revealed physician was notified of chest x-ray results (pneumonia) and no new orders were given. Review of nurses' note dated 11/23/20 at 11:04 A.M. revealed Resident #87's power of attorney (POA) was notified of the residents change in condition, IV fluids and antibiotic. POA was agreeable to hospice consult. Further review of physician's orders [REDACTED].#87 to Hospice Agency #2, oxygen at two liters per minute via nasal cannula due to comfort, [MEDICATION NAME] suppository 650 milligrams (mg) one suppository rectally every four hours as needed for fever, [MEDICATION NAME] suppository 10 mg one suppository rectally every 24 hours as needed for constipation, [MEDICATION NAME] sulfate solution give two drops sublingually every two hours for increased secretions. Review of physician orders [REDACTED]. Additionally, an order dated 11/24/21 for Resident #87 revealed a discharge order for Resident #87 to be admitted to hospice in patient unit. Interview on 02/23/21 at 3:01 P.M. with Director of Nursing (DON) verified Resident #87's progress notes did not contain any documentation regarding change of condition notification to family or family representative as it should have with multiple physicians' orders and IV initiation. The DON further verified Resident #87's family representative was not given the opportunity to give consent to IV placement or treatment. Interview on 02/230/21 at 3:13 P.M. with Licensed Practical Nurse (LPN) #5 stated she did notify the family on 11/22/20 of Resident #87's change in condition but did not documentation the notification. LPN #5 further stated she was unable to recall who she notified of the change in condition. Review of facility policy titled Change of Condition undated revealed the facility did not implemented the policy. Number one indicated the nurse will notify the resident's responsible party when there is a need to alter the residents medical treatment. This deficiency substantiates Complaint Number OH 557.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of the facility's video surveillance timeline, review of hospital records, review of a Complaint Form submitted to the State Board of Nursing, staff interviews, review of facility neurological checks post fall (72 hour monitoring), and review of facility policy, the facility failed to ensure a resident who sustained a fall with a visible injury to the left side of the forehead, was monitored for a change in health status. This resulted in Immediate Jeopardy and serious life-threatening harm when a resident was not monitored, did not have neurological assessments completed following the initial assessment after a fall, and was found more than five hours later unresponsive in bed with coffee ground emesis (vomit) which tested positive for blood. The resident was then transferred to the hospital, diagnosed with [REDACTED]. This affected one (#07) of nine residents reviewed for falls. The facility census was 96. On 06/03/19 at 2:31 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Registered Nurse Director of Clinical Services (RNDCS) #75, and Chief Operating Officer (COO) #99 were notified Immediate Jeopardy began on 05/20/19 at 12:36 A.M. when Licensed Practical Nurse (LPN) #16 left the residents room, after an initial assessment, and did not return to complete neurological assessments or monitor the resident until after being informed Resident #07 was unresponsive and had vomited by State tested Nursing Assistant (STNA) #36 at 6:10 A.M. The resident was then transferred to the hospital, diagnosed with [REDACTED]. The Immediate Jeopardy was removed, and the deficient practice corrected on 05/29/19 when the facility implemented the following corrective actions: · On 05/20/19 at 6:45 A.M., Emergency Medical Services (EMS) arrived and transported Resident #07 to the local hospital. · On 05/20/19 at 8:15 A.M., the DON notified the Administrator about Resident #07's fall with injury. · On 05/20/19 at 9:30 A.M., the DON began a fall investigation. · On 05/20/19 at 9:45 A.M., the DON called LPN #16 and a left a message for LPN #16 to return the call regarding an urgent matter. The facility was unable to locate neurological assessments for Resident #07, and LPN #16 was responsible for the completion of the neurological assessments. · On 05/20/19 at 11:06 A.M., the Administrator contacted and informed RNDCS #75 about the fall incident. · On 05/20/19 at 11:45 A.M., RNDCS #75 arrived at the facility. · On 05/20/19 from 1:15 P.M. to 2:45 P.M., the Administrator and the DON watched the facility video surveillance. · On 05/20/19 at 2:37 P.M., the DON called and left a message for STNA #36 to come to the facility to be interviewed about the fall. · On 05/20/19 at 2:43 P.M., the Administrator and the DON contacted LPN #16 by telephone. LPN #16 reported neurological assessments were completed all night on Resident #07 and were left on a clipboard on the nursing desk. LPN #16 agreed to meet with management at 5:00 P.M. to discuss the incident due to conflicts between LPNs statement and the video surveillance. · On 05/20/19 beginning at 3:00 P.M., RNDCS #75 reviewed all five residents (#11, #12, #13, #14, #15) who sustained falls between 05/13/19 to 05/20/19 to ensure residents were monitored for a change in health condition with no problems identified. · On 05/20/19 beginning at 3:00 P.M., licensed nurses present in the facility received additional in-service education by the DON, Quality Assurance Registered Nurse (QARN) #67, LPN Supervisor #78, and Registered Nurse Supervisors (RNSs) #80, #81, #82, #83, to include fall protocol, head trauma, change in health status, and neurological checks. Procedure was changed for nursing supervisor or quality assurance nurse to be responsible for completing the initial four hours of neurological checks on residents. Any licensed nurse who had not been at work, on leave, or on vacation, was required to complete education and training prior to working. All licensed nurses had received education and training as of 05/29/19. Any newly hired nurses would receive this education prior to working in the facility. · On 05/20/19 beginning at 3:00 P.M., STNAs present in the facility received additional in-service education by the DON, QARN #67, LPN Supervisor #78, and RNSs #80, #81, #82, and #83, to include fall protocol and change in health status. Any STNA who had not been at work, on leave, or on vacation was required to complete education and training prior to working. All STNAs had received education and training as of 05/23/19. Any newly hired STNA would receive this education prior to working in the facility. · On 05/20/19 at 3:00 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Medical Director (MD) #105, the DON, RNDCS #75, QARN #67, and COO #99 to develop a performance improvement plan regarding completion of neurological checks, change in condition, and adherence to fall protocol. · On 05/20/19 at 5:20 P.M., LPN #16 had not arrived at the facility. The Administrator and the DON informed the nurse supervisor, that LPN #16 was no longer permitted to work in the facility. · On 05/21/19 at 8:00 A.M., Quality Assurance audit tools were developed by RNDCS #75 to monitor completion of neurological checks and staff knowledge of fall and neurological check protocol. · On 05/21/19 at 9:00 A.M., audits were initiated for the completion of neurological checks and fall protocol. A review of all falls, including completion of neurological checks, would be completed daily Monday through Friday during interdisciplinary team (IDT) meeting, ongoing for three months with findings reviewed during monthly QAPI meeting. Additional audit timelines will be implemented based upon recommendations of the QAPI committee. · On 05/21/19 at 9:00 A.M., audits were initiated on staff knowledge of fall procedures and included an audit of 12 nursing staff weekly for three months, with findings reviewed during monthly QAPI meeting. Additional audit timelines will be implemented based upon recommendations of the QAPI committee. · On 05/21/19 at 9:00 A.M., the DON initiated a Complaint Form for submission to the State Board of Nursing. · Interviews on 05/31/19 between 1:45 P.M. and 2:39 P.M. with two LPNs (#201 and #202) and two STNAs (#41 and #42) revealed they were knowledgeable about fall protocol, neurological checks, and recognizing a change in health status. · On 06/03/19, review of the facility chart audits for falls and neurological checks assessment completion revealed ongoing daily audits of every fall with no problems identified. · On 06/03/19, review of the facility audits on staff knowledge of fall procedures revealed 24 nursing staff members had been reviewed with no problems identified. · Interviews on 06/03/19 between 3:23 P.M. and 3:40 P.M. with RN #212, LPN #78, and three STNAs (#43, #44, and #45) revealed they were knowledgeable about fall protocol, neurological checks, and recognizing a change in health status. · Review of medical records for eight residents (#02, #03, #04, #05, #06, #08, #09 and #10) who sustained falls revealed no identified concerns. Findings include: Review of a closed medical record revealed Resident #07 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had severely impaired cognitive skills for daily decision making, was totally dependent upon staff for toileting, and required extensive assistance with bed mobility, transfers, eating, and personal hygiene. A wheelchair was utilized for mobility. Review of physician orders [REDACTED].#07 was prescribed Aspirin, 81 milligrams (mg) by mouth daily and [MEDICATION NAME] (a blood thinning medication), 75 mg by mouth daily for cerebral infarction. Review of care plan initiated 04/12/19 revealed Resident #07 was on anticoagulant therapy post [MEDICAL CONDITION]. Interventions included to monitor, document, and report to medical doctor as needed any signs and symptoms of anticoagulant complications including vomiting, bruising, sudden changes in mental status, and significant or sudden changes in vital signs. Resident #07 was also at risk for falls related to a history of falls, gait/balance problems, and incontinence. Interventions included to follow facility fall protocol if an incident occurred. Review of a nursing occurrence progress note dated 05/20/19 at 3:26 A.M. revealed Resident #07 was observed on the floor on 05/20/19 at 1:00 A.M. STNA #36 informed the LPN #16 Resident #07 was on the floor, in the hall, positioned on her back. Resident #07 had a large knot to the left forehead and two abrasions to her left knee. Vital signs were stable. Ice was placed on the forehead, but the resident refused to keep the ice in place. The left knee was cleansed with normal saline and triple antibiotic ointment was applied. The family, physician, and shift supervisor were notified. The medical record did not contain any further assessments to monitor for a change in health status after the fall. Review of the nursing progress note dated 05/20/19 at 6:27 A.M. revealed STNA #36 informed LPN #16 that Resident #07 was not responding to stimuli and had emesis in the bed. Resident #07 was assessed and had a small flinch like response to sternal rub but would not awaken. Coffee ground emesis was noted in the bed, and the emesis tested positive for blood. The physician was notified, and the resident was transported to the hospital. Review of the hospital history and physical dated 05/20/19 at 7:28 A.M. revealed Resident #07, on Aspirin and [MEDICATION NAME], arrived at the hospital at 7:15 A.M., six hours post fall. Blood pressure and pulse were elevated. The resident had a hematoma to the left forehead and abrasions to the left knee. Admission [DIAGNOSES REDACTED]. Resident #07 was intubated to protect the airway and admitted to the ICU. Review of the Computed [NAME]ography (CT) scan, an x-ray of the head, dated 05/20/19 revealed a large left hemispheric subdural hematoma with associated mass effect on the left lateral ventricle and 12 millimeter (mm) left midline shift (indicative of increased intracranial pressure). Interview on 05/31/19 at 4:24 P.M. with QARN #67 and RNDCS #75 reported neurological checks were not completed on Resident #07 after the fall on 05/20/19. LPN #16 was contacted and reported the neurological checks had been completed but the facility was never able to locate the neurological check post fall 72-hour monitoring form. LPN #16 was scheduled to report to the facility to locate the form but never returned to the facility and was terminated from employment. Interview on 05/31/19 at 4:29 P.M. with the Administrator revealed STNA #36 did not cooperate with the investigation into Resident #07's fall and was terminated from employment. Per the Administrator, video surveillance was reviewed and LPN #16 did not enter Resident #07's room as often as reported. LPN #16 failed to return to the facility for the investigation so she was terminated from employment, and she was reported to the State Board of Nursing for failure to assess, complete neurological checks, or vital signs on a resident per facility policy. Interview on 05/31/19 at 6:05 P.M. with STNA #36 revealed during shift change report on 05/19/19 at 11:00 P.M. it was reported Resident #07 didn't want to go to bed and was up in a wheelchair in the common area. STNA #36 reported Resident #07 was toileted and assisted to bed between 11:30 P.M. on 05/19/19 and 12:00 A.M. on 05/20/19. Approximately an hour later, upon responding to another resident's call light, Resident #07 was observed on the floor in the hall across from her bedroom. STNA #36 reported she turned off the call light, called the nurse who was not on the floor, and stayed with the resident until the resident was assessed and placed back in bed. STNA #36 reported she did not observe the nurse enter Resident #07's room, after the initial assessment, to complete every 15-minute checks and reported she checked on the resident every 1.5 to two hours during the night. STNA #36 would turn on the light and observe for movement. Around 6:00 A.M., incontinence care was provided to Resident #07 and STNA #36 observed vomit in the resident's bed. STNA #36 reported Resident #07 was breathing but unresponsive during care so the nurse was notified immediately following care. STNA #36 reported the facility terminated her employment because the video surveillance indicated she didn't respond to the resident for five minutes after being observed on the floor. Interview on 05/31/19 at 6:24 P.M. with STNA #35 revealed upon arrival to work for night shift on 05/19/19 it was reported Resident #07 remained up and didn't want to go to bed. Per STNA #35, another caregiver, STNA #36, assisted Resident #07 to bed a short time later. During the shift on 05/20/19, STNA #36 went to answer a call light and observed Resident #07 on the floor in the hall across from the resident's bedroom. The resident was assessed by the nurse, had a bump on the forehead, abrasions to the knees, and was assisted back to bed. Resident #07 was awake and alert but didn't communicate which was normal for the resident. Interview on 06/03/19 at 10:08 A.M. with the Administrator, the DON, and RNDCS #75 revealed when the video surveillance recording was reviewed it revealed Resident #07 fell at 12:09 A.M. STNA #36 called the nurse, entered another residents room to answer a call light, and returned to Resident #07 five minutes later. LPN #16 along with the nursing supervisor, RN #81, assessed the resident, obtained an ice pack, placed the resident back in bed, and all staff exited the resident's room at 12:40 P.M. A licensed nurse did not enter the resident's room again until after 6:00 A.M. STNA #36 entered Resident #07's room around 1:00 A.M., 3:00 A.M., and 6:00 A.M. LPN #16 was expected to monitor Resident #07's health status and complete neurological checks per protocol which was not done. Resident #07 was transferred to the hospital and admitted to the ICU on a ventilator (a breathing machine) with a [DIAGNOSES REDACTED]. Review of the facility video surveillance timeline revealed Resident #07 fell on [DATE] at 12:09 A.M. At 12:13 A.M., STNA #36 walked by Resident #07 and went into another room. At 12:18 A.M., STNA #36 went to Resident #07 and the resident sat up on her own. At 12:23 A.M., LPN #16 responded to the resident. At 12:25 A.M., STNA #35 and the nursing supervisor (RN #81) responded to the resident. At 12:26 A.M., Resident #07 was assessed, including a neurological check. At 12:28 A.M., Resident #07 was assisted to her feet, placed in a wheelchair, and taken to her room. At 12:34 A.M., the nurse supervisor RN #81 obtained an ice pack for the resident. All staff exited Resident #07's room at 12:36 A.M. STNA #36 entered Resident #07's room at 1:23 A.M. and exited at 1:26 A.M. STNA #36 was in and out of the resident's room at 3:10 A.M. At 6:05 A.M., the STNA #36 entered Resident #07's room, and exited at 6:09 A.M. waving her arms for the nurse, and re-entered the resident's room with LPN #16 at 6:10 A.M. EMS arrived at the facility on 05/20/19 at 6:45 A.M. Review of the Complaint Form submitted on 05/24/19 to the State Board of Nursing revealed on 05/20/19 a resident was found on the floor from a fall with a large hematoma on the head. Nursing supervisor on unit within minutes of fall and assisted with assessment, first neurological checks, range of motion, and assisting resident back to room and bed. LPN #16 failed to assess, complete neurological checks, or vital signs on the resident per policy, and did not enter the resident's room after her exit at 12:36 A.M. until 6:10 A.M. when an STNA rushed to inform her the resident was unresponsive. Review of the facility's undated Head Trauma/Neurological Checks Policy revealed to ascertain the extent of a head injury and intervene as appropriate when symptoms occur. The procedure included to check level of consciousness; assess resident's level of consciousness/orientation; listen for any change in speech; ask about pain, dizziness, vision problems, hearing, ringing in the ears, numbness in extremities, and/or nausea; check pupils to see if both pupils are equal in size and react equally to light; check for extremity strength, have resident squeeze your hands, was pressure equal or at resident's usual level; continue to do neurological checks (check pupils to see if they are equal and react to light, level of consciousness, and extremity strength): Every 15 minutes until ambulance arrives or times four cycles (one hour); then every 30 minutes for one hour; then every hours for two hours; then every four hours for five cycles (20 hours). Call the physician if you notice any symptom that is getting worse, such as headaches, nausea or sleepiness; changes in behavior, such as irritability or confusion, and vomiting. Document neurological checks on the neurological check sheet. Initial assessment with neurological check will be documented in the nurses' notes, subsequent neurological checks may be documented on the neurological checklist with supplemental notes in the nurses' notes as appropriate. Review of the facility neurological checks post fall 72 hour monitoring included columns for date, time, level of consciousness, blood pressure, pulse, respirations, pupil reaction, hand grasps, range of motion, pain response, and initials. The facility was unable to provide evidence that the neurological checks were done in accordance with facility policy. This deficiency substantiates Complaint Number OH 599