Every finding on record at Shawneespring Health Care Center

Based on observation, interview, and policy review, the facility failed to store, prepare and serve food in a manner that prevents the potential spread of food-borne illness to the residents. This had the potential to affect 128 residents who received meals in the facility. Findings include: Observation and interview on 03/02/26 at 9:00 A.M. in the kitchen with Dietary Manager (DM) #380 revealed a total of three crates of milk sitting directly on the floor in the walk-in refrigerator. DM #380 confirmed this observation and stated their milk delivery was received the day prior (03/01/26).Review of the facility policy titled Food Storage dated 01/2019 revealed all foods stored in the walk-in refrigerator and freezer will be stored at least six inches above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning.Observation and interview on 03/04/26 at 10:35 A.M. revealed [NAME] #265 was preparing pureed food and had facial hair measuring approximately one-half inch in length, and was not covering his mustache with a facial hair restraint. Regional Chef #381 and [NAME] #265 confirmed this observation.Observation and interview on 03/04/26 at 12:10 P.M. revealed Food Service Assistant (FSA) #301 was obtaining temperatures of food and serving food and had facial hair including a beard and mustache measuring approximately one-half inch in length, and was not fully covered with a facial hair restraint. FSA #301 and DM #380 confirmed this observation.Review of the facility policy titled Uniform-Dress Code dated 01/2024 revealed hair and beard restraints must be worn by kitchen staff and serving staff.

Based on record review, observation, staff and resident interview, and review of facility policy, the facility failed to obtain a resident's consent prior to searching the resident's personal belongings. This affected one (Resident #66) of four residents reviewed for respect and dignity. The facility census was 128. Findings include: Record review of Resident #66 revealed an admission date of 11/15/25. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation and tobacco use.Observation on 03/02/26 at 11:27 A.M. revealed Maintenance Director #311 entering into Resident #66's room. Unit Manager (UM) #350 and Occupational Therapy Assistant (OTA) #382 were standing near Resident #66's bedside stand inside the bedroom. Maintenance Director #311 then unlocked the drawer on the night stand and UM #350 removed an object from Resident #66's drawer. Resident #66 was not observed to be in the room or vicinity of the room when the resident's locked drawer was unlocked and property removed.Interview on 03/02/26 at 11:27 A.M. with UM #350 confirmed they removed a vape pen from Resident #66's locked nightstand drawer. Interview on 03/04/26 at 2:33 P.M. with Maintenance Director #311 revealed they brought the key to Resident #66's room on 03/02/26 because they were asked to do so. Maintenance Director #311 reported they gave the key to UM #350 who then unlocked Resident #66's locked drawer at which point UM #350 returned the key to Maintenance Director #311. Maintenance Director #311 verified they did not ask Resident #66 for consent to unlock their drawer.Interview on 03/04/26 at 2:41 P.M. with UM #350 confirmed OTA #382 and Maintenance Director #311 were in Resident #66's room on 03/02/26 to remove a vape pen. UM #350 confirmed Resident #66 was not present for the search. UM #350 confirmed she did not ask Resident #66 for consent to search their property. UM #350 reported that they were not sure if OTA #382 had already asked consent to search from Resident #66. UM #350 reported Maintenance Director #311 then unlocked Resident #66's nightstand drawer and UM #350 removed the vape pen from the locked drawer.Interview on 03/04/26 at 2:58 P.M. with OTA #382 revealed they had notified the Director of Therapy of Resident #66 of having a vape pen. OTA #382 reported they verbally notified UM #350 of the resident having a vape pen. OTA #382 confirmed Resident #66 was not in the room when the vape pen was removed from the locked drawer. Interview on 03/04/26 at 3:08 P.M. with Director of Nursing (DON) revealed they were not aware of Resident 66's property being searched on 03/02/26. The DON reported on 03/02/26, the DON walked into her office and found a vape pen sitting on their desk with a post-it note on it. The DON confirmed she had not spoken to Resident #66 about their property being searched and they were still in the process of getting a hold Resident #66's family member who was also the power of attorney for Resident #66 but the family member has not yet returned the facilities calls. The DON confirmed that Ideally, a resident should be present if staff are searching their property.Further interview on 03/04/26 at 4:13 P.M. with OTA #382 confirmed they were not asked by Resident #66 to retrieve anything from his nightstand and OTA #382 did not ask the resident for consent to search their property. Interview on 03/04/26 at 2:36 P.M. with Resident #66 revealed that staff took Resident #66's vape pen from his locked drawer while he was out at therapy on 03/02/26. Resident #66 confirmed that no one asked for his consent to search his property. Resident #66 reported the staff did not ask any staff to retrieve anything from his room for him while he was out at therapy.Review of the facility policy titled Resident Rights- Self Determination- Resident Smoking Policy dated 07/2025 revealed staff members will monitor the room and belongings of each resident who smokes for the presence of smoking materials. This will be accomplished in a manner that does not violate the resident's right to privacy.This deficiency represents non-compliance investigated under Complaint Number 2786143.

Based on observation, resident and staff interviews, and policy review, the facility failed to post the most recent survey of the facility that was readily accessible to residents, and family members and legal representatives of residents. This affected three residents (#14, #86, and #119) and the potential to affect all the residents residing in the facility. The facility census was 128.Findings Include: During the Resident Council Task Meeting interview on 03/04/26 at 2:34 P.M., Residents #14, #86, and #119 revealed they had no knowledge of where the results of the State Inspection were located.During an observation and interview on 03/05/26 at 10:00 A.M., there was no signage at main entrance/receptionist desk as to where to locate the Survey Results binder and there was no Survey Result binder found at the main entrance. Receptionist #368 revealed no knowledge of what the Survey Results binder was or where it was located. Receptionist #368 verified there was no signage as to the location of the Survey results binder.During an observation on 03/05/26 at 10:10 A.M., the Survey Results Binder was located on a counter in the first floor activities room. There was no signage in the first floor activities room as to the location of the Survey Results binder.Review of the facility's handbook titled Resident's Rights and Facility Responsibilities revealed the facility must post in a place readily accessible to residents and family members and legal representatives of residents, the results of the most recent survey of the facility. The facility must also post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Based on medical record review, review of hospital medical records, interview with staff, Medical Director (MD) #90 and Nurse Practitioner (NP) #9, policy review and review of information from the National Library of Medicine, the facility failed to monitor a resident's bowel movements and implement their bowel monitoring policy when the resident did not have a bowel movement for five consecutive days. This resulted in a fecal impaction with a perforated bowel requiring hospitalization. This resulted in Immediate Jeopardy when Resident #10, with a history of constipation, was placed at risk for serious life-threatening harm, negative health outcomes, and/or death when the facility failed to monitor the resident's bowel status by implementing their bowel monitoring policy when the resident did not have a bowel movement for five consecutive days. Resident #10 began experiencing abdominal pain and labored breathing and was transferred to the hospital on [DATE]. Resident #10 was treated for a bowel impaction with a perforated bowel and died at the hospital on [DATE]. This affected one (Resident #10) of three residents reviewed for change of condition. The facility census was 123. On [DATE] at 3:59 P.M. the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #95, Registered Nurse (RN) #96 and RN #97 were notified that Immediate Jeopardy began on [DATE] at 9:00 P.M. when Resident #10 did not have a bowel movement for five consecutive days. Resident #10 complained of abdominal pain with labored breathing. Resident #10 was sent to local emergency room for evaluation and treated for a fecal impaction with a perforated bowel. Resident #10 subsequently died at the hospital on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] by 1:00 P.M. the DON reviewed all current residents with any new progress notes during the past 24 hours to review for residents with a possible change of condition. No concerns were identified. On [DATE] at 2:15 P.M., a Quality Assurance (QA) meeting was held with the Administrator, MD #90, DON, Assistant Director of Nursing (ADON) #89, Corporate Nurse Educator (CNE) #96, RDO #95, and [NAME] President (VP) of Nursing #99 to review findings. The QA committee developed, reviewed, and approved the plan of action. The QA review included but was not limited to Resident Assessment and change of condition including bowel monitoring and notification. No changes were made to the Change of Condition or Bowel Monitoring Policies. Determination was made for plan of action including but not limited to plan to evaluate bowel status for current residents and review of progress notes for 24 hours for potential change of condition. On [DATE] at 2:30 P.M. the DON and ADON #89 were provided with an in-service education by CNE #96 on Change in Condition Policy and conducting assessments including but not limited to abdominal assessment and change in bowel movements. On [DATE] at 2:30 P.M. an audit was initiated by DON and RN Unit Managers (UM) #50 and #76. This audit reviewed each resident that had not had a bowel movement for three days and the residents were assessed, if appropriate providers were contacted and interventions were implemented as needed. Those three residents were Resident #32, #33, and #34 and the bowel monitoring policy was implemented. This audit was completed on [DATE] at 9:30 P.M. Starting on [DATE] at 3:00 P.M. the DON, ADON #89, and Team Lead #60 started an additional in-service education for current licensed nurses. The education included but was not limited to ensuring nurse timely assesses residents for potential change in condition, reviewing clinical dashboard in the electronic medical record, including absence of bowel movements. Any licensed nurse not on-site was provided education via telephone by the DON, ADON #89, and Team Lead #60. All licensed nurses were provided education by [DATE] at 8:10 P.M. Any licensed nurses unavailable for education (four as needed licensed nurses were identified) have not worked since [DATE] and will not work until the education is complete. Licensed nurses were able to verbalize understanding of the educational content. On [DATE] at 4:00 P.M., QA Nurse #96 initiated an audit to ensure appropriate care plan interventions are in place and being implemented as needed. This audit was completed on [DATE] at 12:00 P.M. Beginning on [DATE] to monitor ongoing compliance for potential change of condition, the DON, ADON #89, or UM #50 and #75 will review current residents, including those at risk for constipation, progress notes daily from the past 24 hours to review for residents with possible change of conditions. This will be completed for 30 days. Beginning on [DATE] to monitor ongoing compliance for bowel monitoring, the DON, ADON #89, or UM #50 and #75 will review residents, including the at risk for constipation, without a bowel movement noted for three days to ensure assessment and intervention and physician notification as appropriate. Beginning on [DATE] a Performance Improvement audit worksheet is being completed for 10 residents to ensure residents are assessed for potential changes in condition related to not having a bowel movement in three days. This Performance Improvement audit worksheet is being completed by the DON, ADON #89, or QA Nurse #96 daily for seven days, then three times a week per week for four weeks, weekly for four weeks, and then monthly. Results of the Performance Improvement worksheet will be reported to the QA committee for a determination of the need for further ongoing formal monitoring. A QA meeting was held on [DATE] with the Administrator, MD #90, DON, ADON #89, Regional QA Nurse #96, RDO #95, and VP of Nursing #99 to review education, audit findings, and ongoing schedule for audits. The QA committee reviewed the plan. No concerns were identified. The QA Committee will monitor weekly for four weeks. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #10's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, anemia, constipation, depression, and edema. Resident #10 was sent out to the hospital [DATE] and died on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had moderate cognitive deficits, required supervision to dependent of staff for activities of daily living, and was frequently incontinent of bowels. Review of the care plan dated [DATE] revealed Resident #10 had the potential for constipation related to decreased mobility and side effects of medications. Interventions dated [DATE] included to monitor and record frequency of bowel movements and administer laxatives per doctor's order. Review of Resident #10's physician order dated [DATE] revealed an order for polyethylene glycol (Miralax), a laxative, give 17 grams by mouth one time a day for constipation. Review of the bowel tracking report dated [DATE], revealed Resident #10 had a small bowel movement on [DATE]. Resident #10 had no bowel movements recorded on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the pain levels documented in the electronic medical record revealed on [DATE] at 8:47 P.M., Resident #10 reported a pain score of five on a zero to ten pain scale. Review of a nursing note dated [DATE] at 10:44 P.M. revealed Resident #10 had complaints of abdominal pain with pain upon palpation, coughing up mucus, and labored breathing. Notified on-call MD and received new order to send Resident #10 out to the Emergency Department (ED) for evaluation and treatment due to possible delay of treatment due to Thanksgiving holiday. Resident #10's wife notified and is fine with sending Resident #10 out and will be meeting him at the hospital. Report given to nurse at the ED. Review of SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress note dated [DATE] revealed Licensed Practical Nurse (LPN) #88 documented Resident #10's last bowel movement was on [DATE]. Review of the hospital Computed Tomography Angiography (CTA) dated [DATE] for Resident #10 revealed the resident had a large amount of stool within the rectum with mild wall thickening, large amount of stool also present in the upstream sigmoid colon where there is mild wall thickening and induration of the associated mesentery, and moderate amount of pneumoperitoneum is present, for which the source is suggested in the sigmoid colon. Review of the impression of the CTA revealed moderate amount of pneumoperitoneum consistent with bowel perforation, likely rising from the sigmoid colon. This may be related to a fecal impaction and stercoral colitis. Review of a nursing note dated [DATE] at 5:06 A.M. revealed Resident #10 was admitted to local hospital for urinary tract infection and further evaluation. Review of nursing note at 6:29 A.M. revealed the facility called the hospital for an update on Resident #10 and was advised to call the family. A call was placed to Resident #10's family who stated Resident #10 had passed away. Review of Resident #10's death certificate revealed the resident passed away on [DATE] at 4:53 A.M. Resident #10's cause of death was cardiac respiratory arrest. During an interview on [DATE] at 2:09 P.M., the DON verified Resident #10 had a small bowel movement on [DATE] and the charting documented he had not had a bowel movement for five days, from [DATE] through [DATE]. The DON verified on the third day when a resident does not have a bowel movement, the dashboard in the electronic medical record would alert the nurse. The DON confirmed the electronic medical record should have alerted the nurses that Resident #10 did not have a bowel movement after the third day with no bowel movement. The DON verified there was no action documented indicating the bowel monitoring policy had been implemented after Resident #10 had no bowel movement for multiple consecutive days. During an interview on [DATE] at 11:13 A.M., MD #90 stated that five consecutive days with no bowel movement could cause a fecal impaction, which is 100 percent preventable. MD #90 stated he did not get a call from the facility when Resident #10 was on day three of no bowel movement, however one of his on-call NP's could have received a call. During a phone interview on [DATE] at 12:53 P.M., NP #91 stated she was not informed that Resident #10 had not had a bowel movement after three days. NP #91 stated it is the expectation to be called when it is noticed that a resident has not had a bowel movement in three days so a new order can be given. Review of the facility policy titled, Bowel Monitoring, dated 08/2017, revealed the charge nurse will review the electronic medical record for residents without a bowel movement for three consecutive days. Charge nurses may administer any as needed laxative medication or other interventions such as prune juice, and/or notify clinician. Review of information from the National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/NBK560608/ revealed stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma formation. Fecalomas can lead to focal pressure necrosis and perforation, while colonic distention and increased intraluminal pressure can lead to compromise of the vascular supply and ischemic colitis. Review of information from the National Library of Medicine at https://medlineplus.gov/ency/patientinstructions/000120.htm revealed Constipation is when you do not pass stool as often as you normally do. Your stool may become hard and dry, and it can be difficult to pass. And under the section, When to contact a medical professional, Contact your provider if you have not had a bowel movement in 3 days. This deficiency represents non-compliance investigated under Complaint Number 2700642.

Based on medical record review, review of witness statements, review of facility Self-Reported Incidents (SRI's), staff interviews and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected one (#14) of three residents reviewed for abuse. The facility census was 123. Findings include: Review of the medical record for Resident #14 revealed an admissions date of 10/28/25 with diagnoses including psychosis, hallucinations, Parkinson's disease, and neurocognitive disorder with lewy bodies. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Administrator's written witness statement dated 10/31/25 revealed Administrator spoke with Resident #14 regarding a sexual abuse allegation. Resident #14 stated that someone had grabbed his penis. Further review revealed that Administrator had talked to Resident #14's son, determining that the resident was having hallucinations and decided not to investigate. Review of the facility's SRI's from 10/01/25 to 01/05/25, revealed the facility had not reported any allegations of sexual abuse related to Resident #14. Interview on 01/05/25 at 10:36 A.M. with Social Worker #66 revealed that Resident #14 triggered for a level two Preadmission Screening and Resident Review (PASRR). While the assessor was completing her screening, Resident #14 stated that someone had grabbed his penis. Social Worker #66 verified that Administrator was notified of the allegation of sexual abuse. Interview on 01/05/25 at 10:45 A.M. with Administrator revealed that she was aware that Resident #14 alleged that someone had grabbed his penis. Administrator stated that Resident #14 was experiencing hallucinations at that time and after discussion with the family, it was decided that the allegation was likely a hallucination. Administrator verified that an SRI was not initiated and there was no further investigation. Administrator verified the facility failed to follow their abuse policy once the allegations of sexual abuse were discovered. Interview on 01/05/25 at 2:35 P.M. with Director of Nursing (DON) revealed that Resident #14 was being seen by the an assessor for a level two PASRR when Resident #14 told the assessor that someone had touched his penis. DON verified that the Administrator was notified of the allegation. Review of the facility policy titled, Abuse/Neglect/Misappropriation of Property, dated September 2022, revealed if there is allegation of abuse or serious bodily injury, it should be reported to State Survey Agency immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Number 2661357.

Based on medical record review, review of witness statements, review of facility Self-Reported Incidents (SRI's), staff interviews and policy review, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (#14) of three residents reviewed for abuse. The facility census was 123. Findings include: Review of the medical record for Resident #14 revealed an admissions date of 10/28/25 with diagnoses including psychosis, hallucinations, Parkinson's disease, and neurocognitive disorder with lewy bodies. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Administrator's written witness statement dated 10/31/25 revealed Administrator spoke with Resident #14 regarding a sexual abuse allegation. Resident #14 stated that someone had grabbed his penis. Further review revealed that Administrator had talked to Resident #14's son, determining that the resident was having hallucinations and decided not to investigate. Review of the facility's SRI's from 10/01/25 to 01/05/25, revealed the facility had not reported any allegations of sexual abuse related to Resident #14. Interview on 01/05/25 at 10:36 A.M. with Social Worker #66 revealed that Resident #14 triggered for a level two Preadmission Screening and Resident Review (PASRR). While the assessor was completing her screening, Resident #14 stated that someone had grabbed his penis. Social Worker #66 verified that Administrator was notified of the allegation of sexual abuse. Interview on 01/05/25 at 10:45 A.M. with Administrator revealed that she was aware that Resident #14 alleged that someone had grabbed his penis. Administrator stated that Resident #14 was experiencing hallucinations at that time and after discussion with the family, it was decided that the allegation was likely a hallucination. Administrator verified that an SRI was not initiated and there was no further investigation. Administrator verified the facility failed to follow their abuse policy once the allegations of sexual abuse were discovered. Interview on 01/05/25 at 2:35 P.M. with Director of Nursing (DON) revealed that Resident #14 was being seen by the an assessor for a level two PASRR when Resident #14 told the assessor that someone had touched his penis. DON verified that the Administrator was notified of the allegation. Review of the facility policy titled, Abuse/Neglect/Misappropriation of Property, dated September 2022, revealed if there is allegation of abuse or serious bodily injury, it should be reported to State Survey Agency immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Complaint Number 2661357.

Based on observation and interviews, the facility failed to provide appropriate incontinence care. This affected one (Resident #104) of four residents reviewed for incontinence care. The facility census was 125. Findings include: Review of the medical record for Resident #104 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), Alzheimer's disease, major depressive disorder, anxiety disorder, and interstitial pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #104 dated 09/25/23 revealed the resident was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood, required extensive assistance of two staff with toileting, and was always incontinent of bowel and bladder. Review of the care plan for Resident #104 dated 11/27/23 revealed the resident had bladder incontinence related to Alzheimer's disease, confusion, impaired mobility, and side effects of medications. Interventions included the following: use disposable briefs, staff to clean peri-area with each incontinence episode, staff to monitor labs as ordered, staff to monitor and document for signs and symptoms of urinary traction infection including pain, burning, blood-tinged urine, no output, increased pulse, increased temperature, and change in mental status, staff to apply protective barrier cream after each incontinence episode. Observation on 11/27/23 at 9:21 A.M. of incontinence care for Resident #104 per State tested Nursing Assistants (STNAs) #11 and #12 revealed resident was noted to be wearing two incontinence briefs one on top of the other and there was a strong urine odor in the room. STNAs #11 and #12 removed the two briefs which were both thoroughly saturated with urine and provided perineal care to Resident #104. Interview on 11/27/23 at 9:21 A.M. with STNA #11 confirmed Resident #104 was found to be wearing two briefs which were both saturated with urine. Interviews on 11/27/23 at 10:48 A.M. with the Director of Nursing (DON) and at 11:29 A.M. with the Administrator confirmed staff should not apply two incontinence briefs one on top of the other to Resident #104 as this was not part of the resident's incontinence care plan. This deficiency represents non-compliance investigated under Complaint Number OH00147833.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure residents received timely incontinence care. This affected two residents (#38 and #73) of four residents reviewed for incontinence care. The facility census was 105. Findings include: 1. Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included type II diabetes, morbid obesity, diastolic heart failure, and hemiparesis/hemiplegia following cerebral infarction affecting left non-dominant side. Review of the Minimum Data Set (MDS) assessment initiated 04/02/23 revealed the resident had moderately impaired cognition. Resident #38's ADL assessment was incomplete. The resident required two-person staff assistance with care but had not been assessed for the extent of care needed. Review of the care plan dated 03/28/23 revealed Resident #38 had bladder incontinence related to impaired mobility, physical limitations, and hemiparesis/hemiplegia. Interventions included disposable briefs, peri-care with each incontinence episode, laboratory studies as ordered, monitor/report signs of urinary tract infection (UTI), and provide protective barrier after incontinent episodes. Review of the task documentation dated 04/02/23 revealed Resident #38 received total one-staff assistance with toilet use and bowel and bladder elimination twice for the entire day, once at 12:30 A.M. and once at 10:13 A.M. There was no documentation for evening or night shift assistance with toilet use or bowel/bladder elimination on 04/02/23. 2. Review of the medical record for Resident #73 revealed an admitted [DATE]. Diagnoses included stage II chronic kidney disease, anxiety disorder, flaccid neuropathic bladder, and chronic pain syndrome. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #73 required one to two person physical assistance, extensive assistance for bed mobility, transfers, dressing, and toilet use, limited assistance with personal hygiene, supervision with eating, and locomotion had not occurred. Resident #73 had an indwelling catheter, was occasionally incontinent of bowel, and was not on a toileting program. Review of the care plan revealed Resident #73 had bowel incontinence related to immobility and impaired cognition. Interventions included evaluate for complaints of abdominal distention/discomfort, assist to bathroom/with bedpan as needed, keep call light within reach, monitor bowel elimination offer privacy with toilet use, and offer peri care after each incontinent episode. Additionally, Resident #73 had a behavior problem related to anxiety and refused to be changed/refused peri care. Interventions included administer medications as ordered, anticipate resident needs, provide opportunities for positive interactions, elicit family input for successful interventions, and encourage participation in self-care. Review of the task documentation dated 04/02/23 revealed Resident #73 received total one staff assistance with toilet use and bowel and bladder elimination twice for the entire day, once at 12:40 A.M. and once at 10:08 A.M. There was no documentation for evening or night shift assistance with toilet use or bowel/bladder elimination on 04/02/23. During an observation and interview on 04/03/23 at 9:44 A.M. Nurse Aide Trainee (NAT) #136 entered Resident #38's room and answered the call light. At 9:46 A.M. after NAT #136 left the room, Resident #38 stated he had just told NAT #136 that he needed to be changed, and she said she would let his aide know. Observation from 9:46 A.M. to 10:35 A.M. revealed no staff returned to Resident #38's room. At 10:35 A.M. State tested Nurse Aide (STNA) #200 entered Resident #38's room and asked if the resident wanted to get up. Resident #38 told STNA #200 that he had not been changed all night and he just wanted to be changed and left in bed. STNA #200 provided incontinence care with no concerns noted. During an interview on 04/02/23 at 10:35 A.M. and 10:48 A.M. STNA #200 stated she arrived late to work around 8:00 A.M. and verified 9:46 A.M. was the first time she had seen or offered care to Resident #38 that day. STNA #200 verified incontinence rounds were to be completed every two hours at minimum. Observation and interview on 04/03/23 from 10:54 A.M. to 11:15 A.M. STNA #200 entered Resident #73's room and told her she would get her up for therapy and STNA #200 left the room. Resident #73 was laying in bed wearing a shirt, had a blanket covering her lower extremities, and had bowel movement (BM) smeared on her fitted sheet by her right hip. There was an odor of BM in the room. At 10:58 A.M. STNA #200 entered the room with a stack of linens and began incontinence care. STNA #200 washed hands and changed gloves multiple times and pressed the call light and asked staff to bring additional washcloths to clean the BM that, once the blanket was removed from the resident's legs, was observed leaking out of the sides of the resident's brief. NAT #111 and STNA #103 stayed to assist STNA #200 to clean the resident and changed the sheets on the bed. STNA #200 verified 10:58 A.M. was the first round she had completed for Resident #73 since she had arrived at work. During interviews on 04/03/23 from 1:05 P.M. to 1:41 P.M., Licensed Practical Nurse (LPN) #190, and NAT's #136 and #155 each stated they had not performed incontinence care on any resident on the hall where Resident #38 and #73 lived. STNA #129 stated she was able to dress Resident #31 before breakfast on 04/03/23 but had not checked or changed any other resident on the hall. Staff stated incontinence care rounds should be completed every two hours at minimum and as needed. Review of the policy titled Peri Care revised 06/2021 revealed peri care was performed after each occurrence for bowel and/or bladder incontinence to prevent urinary tract infections and staff reported unusual findings to the nurse. This deficiency represents non-compliance investigated under Complaint Number OH00141095.

Based on interviews, record review, review of facility policy and review of online resources from the Centers for Disease Control (CDC), the facility failed to monitor and ensure residents were up to date on pneumonia vaccinations and facility failed to ensure their pneumonia policy was updated annually. This affected four of five residents (#4, #69, #84, and #87) reviewed for immunizations. Facility census was 106. Findings include: 1. Review of medical records for Resident #69 revealed an admitted [DATE] with congestive heart failure (CHF). Review of the MDS assessment dated [DATE], revealed resident had severe cognitive impairment. Review of the immunizations for Resident #69, revealed resident received the Pneumococcal Polysaccharide Vaccine (PPSV23) on 04/27/00 and was due for another pneumonia vaccination at time of admission to the facility. Medical records revealed no declination/consent form being present in resident's hard chart. Review of Influenza-flu and Pneumococcal-Pneumonia vaccination Consents dated 09/29/22, revealed Resident #69 was offered Pneumococcal Conjugate Vaccine (PCV 13), Valent Pneumococcal Conjugate Vaccines (PCV15 and PCV20), and PPSV23 Pneumonia vaccinations, which were declined by residents representative. Resident #69's representative consented to the influenza and the influenza consent was marked I wish to receive. Notes indicated the pneumonia vaccination was not offered on this consent. The consents were signed and dated in two different handwritings. 2. Review of records for Resident #84 revealed an admitted [DATE] with diagnosis of COPD. Review MDS assessment dated [DATE], revealed resident had severe cognitive impairment. Review of the immunization records for Resident #84, revealed no pneumonia vaccine information was available. Notes indicated Resident #84 was due for a pneumonia vaccination upon admission to the facility. Further review of medical records revealed no declination/consent form was present in resident's hard chart. 3. Review of records for Resident #87, revealed an admitted [DATE] with chronic renal failure. Review of MDS assessment dated [DATE], revealed Resident #87 had moderate cognitive impairment. Review of the immunizations for Resident #87, revealed resident received the PCV13 vaccination on 01/02/14 and was due for PPSV23 or PCV20 at time of admission to the facility. Further review of the medical chart revealed no declination/consent form was present in resident's hard chart. Review of Influenza-flu and Pneumococcal-Pneumonia Vaccination Consents dated 07/16/22, revealed Resident #87 was offered PCV13, PCV15, PCV20, and PPSV23 pneumonia vaccinations, which were declined and the influenza consent was marked not applicable. Review of Influenza-Flu vaccination Consents dated 09/29/22, revealed Resident #87 consented to the influenza vaccination and the pneumonia vaccination was not offered on this consent form. 39967 4. Review of the Resident #04's medical chart revealed Resident #04 was admitted to the facility on [DATE] with diagnoses including COPD, CHF, acute kidney failure, atrial fibrillation, non-traumatic hematoma of soft tissue, severe persistent asthma hematoma of soft tissue, severe persistent asthma with exacerbation, Crohn's disease of both small and large intestine without complications, dysphagia, unspecified convulsions, aphasia, major depressive disorder, hyperlipidemia, hypertensive heart disease with heart failure, anemia and hypothyroidism. Review of Resident #04's quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact and Resident #04 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #04 required supervision with eating. Review of Resident #04's undated Influenza and Pneumococcal Vaccination Consent form revealed Resident #04 was allergic to shot and the box was checked stating I do not wish to have either pneumococcal vaccine administered to the aforementioned resident, and I have received the vaccinate information sheet. Resident #04 did not sign the consent. Survey team requested the Pneumonia line list, consent/declinations for sampled residents, and pneumonia policy on 01/25/22 at 4:00 P.M., again on 01/26/22 at 11:54 A.M., 12:57 P.M., and 1:30 P.M. Consents as described above were provided, however, no line list was provided. Interview on 01/26/23 at 11:41 A.M. with Assistant Director of Nursing (ADON) #10 verified Resident #04's undated influenza and pneumococcal vaccination consent form was not signed. Interview on 01/26/23 at 11:54 A.M. with Registered Nurses (RN) (#10 and #112), stated that there was a vaccination log for residents. RNs (#10 and #112) were uncertain as to when the updated pneumonia vaccinations were audited or offered to residents on an annual basis to ensure compliance. Interview with Resident #04 on 01/26/23 at 1:24 P.M., revealed Resident #04 did not want the pneumococcal vaccine due to him having an allergic reaction to it. Resident #04 stated that he was educated on the different pneumococcal vaccines and understood the risk and benefits but did not want the vaccine. Interview on 01/26/23 at 2:24 P.M. Director of Nursing (DON) verified Pneumonia Policy, undated and without review dates listed, was the most recent policy the facility had in place. DON verified that consents were as described, with older consent forms including the PCV13, PCV15, PCV20, AND PPSV23 vaccinations, but the consent dated 10/20/22 did not include PCV15 or PCV20. Review of online resources from CDC (https://www.cdc.gov/media/releases/2022/s1020-immunization-vote.html) revealed on 10/20/22, the Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) recommended updated immunization schedules and program guidance to be published in early 2023, which included updated pneumonia vaccinations for individuals over the age of 65. Review of online resources from CDC (https://www.cdc.gov/vaccines/acip/recommendations.html), the recommended pneumonia vaccinations for individuals over the age of 65 were: Shared clinical decision-making is recommended regarding administration of PCV20 for adults aged older than [AGE] years who completed their vaccine series with both PCV13 and PPSV23. If a decision to administer PCV20 is made, a dose of PCV20 is recommended at least 5 years after the last pneumococcal vaccine dose. Review of online resources from CDC (https://www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm) revealed that for individuals over the age of 65 were recommended to receive one dose of PCV20 or one dose of PCV15 followed by a dose of PPSV23 one year later. These recommendations were approved for use beginning 10/24/22. Review of the pneumococcal vaccine policy dated October 2022, revealed each resident or resident's representative receives education regarding the benefit and potential side effects of the immunization. Each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. The resident or the resident representative has the opportunity to refuse the immunization. The medical record includes documentation that at minimum indicates that the resident or resident representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization and the resident either received the pneumococcal immunization or if the resident did not receive the pneumococcal immunization due to medical contraindication or refusal. If the resident has not received previous immunization, the consent and denial form will be signed, and the physician order will be obtained.

Based on observations, record review, staff interview, and review of faciliyt policy, the facility failed to ensure food items were maintained in a sanitary manner. This affected all residents except Resident #75 and Resident #251 that were no food by mouth. The facility census was 106. Findings include: Observation of the kitchen on 01/23/23 at 8:12 A.M., revealed there to be food debris on the edge of the fryer and in the oil of the fryer that were brown in color. Observation of the reach in refrigerator in the kitchen, revealed there to be an open and undated bag of provolone cheese, an open and undated plastic tub of vegetable base, an open and undated plastic tub of beef base on the first shelf, a half-full plastic cup of iced coffee with a straw in it that was not labeled, dated or covered, two full plastic cups of ice coffees that were not labeled, dated or covered, an opened and updated bottle of soda on the second shelf and a opened package of diced bacon that was not labeled or dated and a plastic container kitchen of boiled eggs that were not labeled or dated. Continued observation of the bread rack, revealed two loaves of wheat bread with an expiration date of 01/18/23, two loaves of white bread with an expiration date of 01/20/23, nine packs of white buns with an expiration date of 01/18/23, five packs of white buns with an expiration date of 01/12/23, and one open pack of white buns with an expiration date of 01/18/23. Interview with Food Service Assistant (FSA) #801 on 01/23/23 at 8:12 A.M. verified there to be food debris on the edge of the fryer and in the oil of the fryer that were brown in color. FSA #801 confirmed the fryer was not used on 01/23/23. FSA #801 verified there to be an open and undated bag of provolone cheese, an open and undated plastic tub of vegetable base, an open and undated plastic tub of beef base on the first shelf, a half full plastic cup of iced coffee with a straw in it that was not labeled, dated or covered, two full plastic cups of ice coffees that were not labeled, dated or covered, a opened and updated bottle of soda on the second shelf and a opened package of diced bacon that was not labeled or dated and a plastic container of boiled eggs that were not labeled or dated in the reach in refrigerator. FSA #801 also verified there to be two loaves of wheat bread with an expiration date of 01/18/23, two loaves of white bread with an expiration dated if 01/20/23, nine packs of white buns with an expiration date of 01/18/23, five packs of white buns with an expiration date of 01/12/23, and one open pack of white buns with an expiration date of 01/18/23 on the bread rack. Review of the facility's undated list of residents that were no food by mouth revealed resident (#75 and #251) did not receive any food by mouth. Review of the facility's food storage policy dated January 2019 revealed food storage areas will be maintained in a clean, safe, and sanitary manner. All leftovers will be labeled, dated, and covered.

Based on record review, observations, staff interviews, review of facility policy, and review of Centers for Disease Control (CDC) recommendations, the facility failed to ensure glucometers were cleaned after usage. This affected 19 residents (#54, #15, #31, #55, #47, #10, #57, #37, #11, #20, #46, #83, #73, #74, #45, #86, #61, #25, and #13) who received medications from the 2400 hall medication cart. The facility also failed to ensure staff's personal belongings were not stored in the medication carts. This affected 17 residents (#70, #62, #252, #39, #75, #27, #22, #30, #81, #68, #77, #26, #5, #3, #201, #82, and #88) who received medications from the 1200 hall medication cart. Facility Census was 106. Findings Included: Review of record for Resident #86 revealed the resident was admitted on [DATE]. Diagnosis included, but not limited to, diabetes, urinary tract infection, major depressive disorder, anxiety disorder, acute kidney failure, chronic systolic heart failure, and dementia. Review of quarterly Minimum Data Set (MDS) assessment on 11/15/22, revealed Resident #86 had a Brief Interview of Mental Status (BIMS) of 02 which indicated the resident was severely cognitively impaired. Observation of medication administration on 01/25/23 at 7:51 A.M. with Licensed Practical Nurse (LPN) #33 for the 2400 hall, revealed LPN #33 removed a glucometer from the 2400 hall medication cart, entered Resident #86's room and checked Resident #86's blood glucose. Continued observation, revealed LPN #33 completed the blood glucose check, returned to the cart with the glucometer, and placed the contaminated glucometer in the cart without cleaning. Observation revealed there were no cleaning wipes available in the cart to utilize. Interview on 01/25/23 at 8:55 A.M. with LPN #33 verified he placed the contaminated glucometer in the 2400 hall medication cart without cleaning it. Observation of the 1200 Hall medication cart on 01/25/23 at 10:03 A.M. with LPN #98, Assistant Director of Nursing (ADON) #10, and Centers for Medicare and Medicaid Services (CMS) surveyor, revealed a black sweater lying on top of resident's medications and medical supplies and a coffee mug belonging to LPN #98 in the bottom right drawer. Interview at the same time with LPN #98 and ADON #10 verified LPN #98's personal items being stored in the medication cart along with resident's medications and medical supplies. Continued observation, revealed LPN #98 removed the coffee mug and drank from it. Interview on 01/25/23 at 10:16 A.M. with ADON #10, stated the facility did not allow drinks or personal items to be stored in the medication carts and personal items should not be stored in the medication carts. Review of Infection Prevention and Control Program revised on 10/2022, revealed that the facility will maintain, and infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Review of CDC Infection Prevention, (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html), during glucose monitoring and insulin administration revealed whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared.

Based on record review and staff interview, the facility failed to ensure resident's anticoagulant medications were accurately coded on the Minimum Data Set (MDS). This affected one resident (#81) out of 22 residents reviewed for accuracy of MDS assessments. The facility census was 106. Findings include: Review of the Resident #81's chart revealed resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis, history of other venous thrombosis and embolism unspecified lump in unspecified breast, disorder of kidney and ureter, chronic obstructive pulmonary disease (COPD), anxiety disorder, personal history of Coronavirus (COVID-19), weakness, and hypothyroidism. Review of Resident #81's quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact and Resident #81 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #81 required supervision with eating. Further review of Resident #81's MDS revealed Resident #81 did not receive any anticoagulants during the MDS review period. Review of Resident #81's care plan reference to bleeding dated 02/01/22, revealed Resident #81 had a risk of bleeding due to the use of Eliquis (anticoagulant). Interventions included administer medications as ordered, gentle oral hygiene, monitor for signs and symptoms of bleeding and obtain and monitor laboratory (labs) results and diagnostic tests as ordered. Review of Resident #81's physician orders dated 02/28/22, revealed Resident #81 was prescribed Eliquis tablet 2.5 milligrams (mgs) give one tablet by mouth two times a day related to personal history of other venous thrombosis and embolism. Resident #81's Eliquis did not have a stop date. Interview with Corporate Nurse #800 on 01/25/23 at 10:18 A.M., verified Resident #81's Eliquis was not accurately coded as an anticoagulant on the MDS. Review of email correspondence from the Administrator on 01/26/23 at 10:24 A.M., revealed the facility did not have a policy on accurately coding the MDS.

Based on observations, record reviews and staff interviews, the facility failed to develop a care plan for a resident's hearing loss and the facility failed to implement a resident's falls care plan. This affected two residents (#26 and #81) out of the 22 residents reviewed for care planning. The facility census was 106. Findings include: 1. Review of the Resident #81's chart revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis, history of other venous thrombosis and embolism, unspecified lump in unspecified breast, disorder of kidney and ureter, chronic obstructive pulmonary disease (COPD), anxiety disorder, insomnia, disorder of bone density and structure, tobacco use, repeated falls, personal history of Coronavirus (COVID-19), weakness, restless leg syndrome, irritable bowel syndrome without diarrhea, and hypothyroidism. Review of Resident #81's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be cognitively intact and Resident #81 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #81 required supervision with eating. Further review of Resident #81's MDS revealed Resident #81 had one fall with major injury. Review of Resident #81's fall risk assessment dated [DATE], revealed Resident had one to two falls in the past 90 days and Resident #81 was at increased risk for falls. Review of Resident #81's fall care plan revised on 01/05/23, revealed Resident #81 was at risk for falls. Interventions included bright tape to wheelchair breaks. Observation of Resident #81 on 01/25/23 at 11:21 A.M., revealed Resident #81 to be sitting in her wheelchair in the activity room. Resident #81 did not have any bright colored tape to her wheelchair breaks and her wheelchair breaks were not engaged. Interview with Registered Nurse Unit Manager (RN) #120 on 01/25/23 at 11:21 A.M., verified Resident #81's care plan stated she was to have bright tape on her wheelchair breaks. RN Unit Manager #120 also verified Resident #81 did not have any bright tape to her wheelchair breaks while she was sitting in her wheelchair in the activity room. 2. Review of the Resident #26's chart revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD, hearing loss, acute and chronic respiratory failure with hypoxia, altered mental status, dry eye syndrome of unspecified lacrimal gland, insomnia, primary osteoarthritis, presence of right artificial knee, other psychoactive substance abuse, family history of other psychoactive substance abuse and dependence, unspecified mood disorder, major depressive disorder, primary osteoarthritis, generalized anxiety disorder, hypothyroidism, gastro esophageal reflux disease without esophagitis. Review of Resident #26's quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact and Resident #26 required limited bed mobility, dressing, toileting, and personal hygiene. Resident #26 required supervision with eating and transfers. Resident #26 had adequate hearing with no devices. Review of Resident #26's audiology visit dated 09/16/22, revealed Resident #26's hearing tests were performed. Resident #26 reported having hearing aids in the past but lost them about five years ago when she moved to the nursing home. The hearing evaluation revealed a bilateral mild to moderate hearing loss. Review of Resident #26's care plan dated 01/25/23, revealed Resident #26 did not have a care plan for hearing loss. Interview with Corporate Nurse #800 on 01/25/23 at 10:18 A.M., verified Resident #26's hearing loss documented in the 09/16/22 audiology visit was not addressed in the care plan. Review of the facility's care planning policy dated October 2022, revealed the facility will provide resident centered care aiming to provide individualized comprehensive care plans for each resident. A care plan will be developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level.

Based on record review, observations, staff interviews, review of online resources from Medline Product review, review of online resources from Medscape, and review of the Material Safety Data Sheets (MSDS), the facility failed to ensure medications were stored and prepared for administration in accordance with acceptable professional nursing standards of practice. This affected one resident (#353) of the three residents reviewed during medication administration. The facility census was 106. Findings Included: Review of record of Resident #353, revealed an admitted on 01/24/23. Diagnosis included, but not limited to, pneumonia, chronic obstructive pulmonary disease (COPD), hypertensive heart disease, dementia, Alzheimer's disease, malignant neoplasm of breast, and allergic Rhinitis. A comprehensive Minimum Data Set (MDS) assessment had not been completed. Review of Plan of Care dated on 01/24/23, revealed Resident #353 was at risk for altered cardiopulmonary status related to COPD, shortness of breath when lying flat, and interstitial pulmonary disease. Interventions included administer medications as ordered and assist with activity of daily living as needed. Review of the physician's orders for Resident #353 dated on 01/24/23, revealed resident was ordered to received Fluticasone-Salmeterol (bronchodilator/steroid) 232-14 micrograms aerosol powder via one puff by mouth every morning and at bedtime for chronic pulmonary disease. Physician's orders dated 01/24/23, revealed resident was ordered to receive Azelastine HCL (antihistamine) 0.1 percent solution via two sprays in both nostrils every morning and at bedtime for chronic pulmonary disease. During observation of medication administration on 01/25/23 at 8:40 A.M. with Registered Nurse (RN) #132, revealed RN #132 administered medications to Resident #353 which included Fluticasone-Salmeterol inhaler and Azelastine nasal spray. Observation immediately afterwards, revealed RN #132 returned the medication cart, removed a container of Micro-Kill disinfectant wipes, and cleaned the Fluticasone-Salmeterol inhaler and a Azelastine container of nose spray including the applicator tips of the containers. Interview on 01/25/23 at 8:55 A.M. with RN #132, revealed she cleaned all resident's inhalers and nasal sprays with the same Micro-Kill wipes. RN #132 verified she cleaned Resident #353's inhaler and nasal spray and stated she was not aware the inhalers and nasal sprays containers could not be cleaned with the Micro-Kill wipes. Interview on 01/25/23 at 9:57 A.M. with RN #120, stated she would not use the Micro-Kill wipes on a resident's nasal spray or an inhaler. Interview on 01/25/23 at 11:15 A.M. with the Director of Nursing (DON) when questioned about the staff using the Micro Kill wipes, she stated she could not comment, however, stated there was a facility policy in place that staff should follow. DON stated she did not see a concern about staff using the Micro-Kill cleaning wipes on the medication containers. DON stated that she did not have the MSDS sheets for the Micro-Kill in the facility and she would have to get the MSDS sheets faxed to her. Review of online resources from Medline, titled Micro-Kill plus disinfecting /deodorizing Cleaning Wipes with Alcohol (https://www.medline.com/product/Micro-Kill-Disinfecting/Deodorizing-Cleaning-Wipes-with-Alcohol/Disinfectants-Wipes/Z05-PF00603?question=micro%20kill%20wipes), undated, revealed the wipes were intended for use on hard, nonporous surface only and they were listed as hazardous. Review of undated document titled Material Safety Data Sheet (MSDS) for Micro-Kill disinfectant wipes, indicated to avoid contact with eyes, avoid prolonged exposure, provide adequate ventilation and wear appropriate personal protective equipment (PPE) when handling. Prolonged inhalation may be harmful, exposure causes skin irritation, exposed individuals may experience tearing, redness, and discomfort. Review of undated document titled Medline - Product Right-to-Know Ingredient List for product name for Micro-Kill disinfectant wipes revealed the wipes were IRIS Neurotoxicant designated list revealed the chemicals for which a reference dose or reference concentration has been developed based on neurotoxicity in the United States Environmental Protection Agency (EPA) integrated risk information system and the chemicals identified in the wipes were identified as carcinogenic to humans or likely to be carcinogenic to humans. Review of online resources from Medscape titled Salmeterol/fluticasone inhaler (https://reference.medscape.com/drug/advair-diskus-salmeterol-fluticasone-inhaled-343448), undated, revealed to clean the actuator or mouthpiece at least once a week by gently wiping the small circular opening where the medicine is sprayed out with a clean cotton swab dampened with water. Then wipe the inside of the mouthpiece with a clean tissue dampened with water and let it air dry overnight. Review of online resources from Medscape titled azelastine (https://reference.medscape.com/drug/astelin-nasal-spray-astepro-azelastine-343414), undated, revealed to clean container once a week, by removing the dust cap, gently pull upward on the spray pump to lift away from the bottle, wash dust cap and spray pump in warm tap water and allow to dry completely.

Based on observations, record review, staff interview and review of facility policy, the facility failed to ensure resident's fall interventions were in place. This affected two residents (#81 and #86) out of six residents reviewed for falls. The facility census was 106. Findings include: 1. Review of the Resident #81's chart revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including, but not limited to, spinal stenosis, unspecified lump in unspecified breast, disorder of kidney and ureter, anxiety disorder, insomnia, disorder of bone density and structure, repeated falls, personal history of Coronavirus (COVID-19), weakness, restless leg syndrome, irritable bowel syndrome without diarrhea, and hypothyroidism. Review of Resident #81's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be cognitively intact and resident required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #81 required supervision with eating and resident had one fall with major injury. Review of Resident #81's fall risk assessment dated [DATE], revealed Resident #81 had one to two falls in the past 90 days and Resident #81 was at increased risk for falls. Review of Resident #81's fall care plan revised on 01/05/23 revealed Resident #81 was at risk for falls. Interventions included bright tape to wheelchair breaks. Observation of Resident #81 on 01/25/23 at 11:21 A.M., revealed Resident #81 to be sitting in her wheelchair in the activity room. Resident #81 did not have any bright colored tape to her wheelchair breaks and her wheelchair breaks were not engaged. Interview with Registered Nurse Unit Manager (RN) #120 on 01/25/23 at 11:21 A.M., verified Resident #81's care plan stated she was to have bright tape on her wheelchair breaks. RN Unit Manager #120 also verified Resident #81 did not have any bright tape to her wheelchair breaks while she was sitting in her wheelchair in the activity room. 44080 2. Review of Resident #86's medical chart revealed resident was admitted on [DATE]. Diagnosis included, but not limited to, diabetes type two, urinary tract infection, major depressive disorder, anxiety disorder, acute kidney failure, chronic systolic heart failure, and dementia severity without behavioral disturbances. Review of MDS quarterly assessment dated [DATE], revealed Resident #86 had a Brief Interview of Mental Status (BIMS) of two which indicated that the resident had severely impaired cognition. Resident #86 required extensive two-person physical assistance for bed mobility, transfers, bathing, and toilet use. Resident was extensive one-person physical assistance for personal hygiene, and dressing. MDS indicated resident propelled himself in a wheelchair in the facility. MDS indicated resident had two or more falls with no major injuries. Review of plan of care dated on 01/19/23, revealed Resident #86 was at risk for falls related to heart failure with Ejection Fraction (EF) estimated 30 percent (normal 50 to 75 percent), type two diabetes, protein calorie malnutrition, depression, anemia, syncope, and collapse. Resident had history of falls with thoracic (T) 12 fracture. Interventions included ensure bedding was straight and clean, initiate resident about rising and sitting slowly, assist with transfers, keep floors free from spills and clutter, encourage resident to use call light while in room, monitor blood pressure with any complaint of dizziness, notify physician of any falls, obtain and monitor laboratory (lab) results, offer and encourage rest periods, update family on any items needed, use assistive devices to transfer or ambulate resident, proper footwear in place to allow stability when standing, anti-rollbacks to wheelchair, nonskid socks at all times, offer urinal, bright tape to bathroom call light, non-skid rug to floor along bed, non-skid floor mat in bathroom, and bed in lowest position. Review of Fall Risk Scale dated on 11/25/22, revealed that Resident #86 had increased risk for falls with a score of 15.0. Resident was confined to chair for mobility. Observation on 01/25/23 at 7:40 A.M., revealed Resident #86 was seated in a wheelchair with black socks in place. Further observation revealed the socks were not a nonskid type socks. Interview on 01/25/23 at 7:50 A.M. with Licensed Practical Nurse (LPN) #33 verified Resident #86 did not have nonskid socks on or shoes in place. LPN #33 stated he was not sure if the resident was a major fall risk. Continued observation, revealed LPN #33 checked Resident #86's blood glucose and wheeled the resident back to the dining room for breakfast. Continued observations on 01/25/23 at 11:00 A.M., revealed Resident #86 was self-propelling himself in his wheelchair with the same black socks in place. Review of the fall and accident management policy dated June 2019, revealed the facility would identify patient risks of falls and other accidents. Interventions will be implemented and evaluated to reduce the risk of injuries and other accidents.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from unnecessary psychotropic medications when the facility failed to follow physician recommendations/orders and discontinue a medication and by failing to ensure the resident had an adequate clinical indication for use regarding an antipsychotic medication. This affected two residents (#04 and #87) out of five residents reviewed for unnecessary medications. The facility census was 106. Findings include: 1. Review of the Resident #04's chart revealed Resident #04 admitted to the facility on [DATE] with diagnoses including major depressive disorder, chronic obstructive pulmonary disease (COPD) with exacerbation, congestive heart failure, acute kidney failure, atrial fibrillation, non-traumatic hematoma of soft tissue, severe persistent asthma hematoma of soft tissue, severe persistent asthma with exacerbation, Crohn's disease of both small and large intestine without complications, dysphagia, unspecified convulsions, aphasia, hyperlipidemia, hypertensive heart disease with heart failure, anemia and hypothyroidism. Review of the Resident #04's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #04 required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #04 required supervision with eating. Further review of Resident #04's MDS revealed Resident #04 was on anti-depressant during the review period. Review of Resident #04's pharmacy recommendations dated 03/07/22, revealed the patient had active medication orders for amitriptyline (antidepressant) for management of depression. Notes indicated due to strong anticholinergic properties, please consider an alternative to amitriptyline for this patient. Alternatives include fluoxetine (antidepressant), sertraline (antidepressant), escitalopram (antidepressant), and venlafaxine (antidepressant). Further review of the pharmacy recommendation revealed Nurse Practitioner (NP) #802 addressed and agreed with the pharmacy recommendation on 03/29/22 with a response to discontinue to the amitriptyline and start fluoxetine 20 milligrams (mgs) daily. Review of the Resident #04's physician orders revealed Resident #04 was ordered amitriptyline 25 mgs one time a day for major depressive disorder on 03/03/22 and the medication was not discontinued until 04/06/22. Review of the Resident #04's physician orders revealed Resident #04 was ordered fluoxetine tablet 20 mgs by mouth one time a day for major depressive disorder on 04/06/22. The medication was discontinued on 04/13/22. Interview with the Director of Nursing (DON) on 01/26/23 at 9:54 A.M. verified Resident #04's pharmacy's recommendations were addressed by the NP #802 on 03/29/22 with a response to discontinue to the amitriptyline and start fluoxetine 20 mg daily. The DON also verified that Resident #04's amitriptyline 25 mgs was not discontinued, and Resident #04's fluoxetine 20 mgs was not started until 04/06/22. 37447 2. Review of the record for Resident #87 revealed he was admitted [DATE] with diagnoses to include, but no limited to, Alzheimer's, dementia with behavioral disturbance, diabetes type 2, insomnia, hyperlipidemia, anxiety disorder, chronic kidney disease and major depressive disorder. Review of the quarterly assessment dated [DATE] for Resident #87, revealed residents Brief Interview of Mental Status (BIMS) score was nine indicating moderate cognitive impairment and he required supervision with eating, limited with bed mobility, transfers and toileting and extensive assistance with dressing and personal hygiene. There were no behaviors documented. Review of the quarterly MDS for 08/22/23 documented no behaviors. Review of the Care Plan dated 01/13/23, revealed Resident #87 had a behavior problem related to Dementia as evidenced by aggression, combative behavior, grabbing at fell ow residents, wandering, impulsivity. agitation and hallucinations. Notes was non-compliant with care and medication. Further, review of his Care Plan, revealed resident used psychotropic medications of Seroquel (antipsychotic) and Depakote (mood stabilizer) related to Dementia with behaviors. Review of the physician's Orders dated 09/22/22 for Resident #87, revealed resident was ordered to receive Depakote Delayed Release 375 milligrams twice daily for behaviors. Review of the physician's orders dated 09/24/22 for Resident #87, revealed resident was ordered to receive Seroquel 50 milligrams at bedtime related to dementia with behavioral disturbance. Review of the Psychiatric (psych) note dated 12/15/22, revealed Resident #87 was being seen for a follow up visit related to his psychiatric diagnoses and medication management. Note indicated no behavioral disturbance had been reported lately although he could be non-compliant at times. Documentation revealed he was confused but able to be redirected. During an interview on 01/26/23 at 9:48 A.M. with the facilities Nurse Practitioner (NP) (#804), she reported Depakote should be given for mood disorder and not for dementia with behaviors as listed in the Physician's Orders. NP #804 also verified Seroquel was not an appropriate medication for dementia with behaviors and should be changed to another medication. NP #804 acknowledged there was not a lot of documented evidence of behavioral concerns for Resident #87. During an interview on 01/26/23 at 10:00 A.M. with a Licensed Practical Nurse (LPN #24) she reported Resident #87's medications were effective with minimal breakthrough behaviors that could be managed by non-pharmacological techniques. Review of the Behavior Monitoring data for Resident #87 from admission on 06/16/22 to present revealed there were only four incidents (01/02/23, 01/13/23, 01/17/23, and 01/24/23) where behaviors were noted and the behaviors were able to be redirected. Review of the facility's anti psychotropic medication management policy dated October 2017 revealed clinicians will use psychotropic medications appropriately and will ensure appropriate use, evaluation, and monitoring.

Based on medical record review, observation, staff interview, review of the Centers for Disease Control (CDC) guidelines, review of the county risk data, and policy review, the facility failed to ensure staff wore personal protective equipment to help prevent the spread of the coronavirus (Covid-19). This affected one resident (#80) out of three residents reviewed for infection control. The facility census was 117. Findings included: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/27/22 at 10:50 A.M. revealed the State tested Nurse Aid (STNA) #422 and Registered Nurse (RN) #455 in the room assisting resident #80 to the bathroom. STNA #422 had a surgical mask, a face shield, and a yellow gown on. RN #455 was only wearing a surgical face mask. Observation on 07/27/22 at 10:51 A.M. the STNA #422 came out of Resident #80's room and took her yellow gown off and disposed of it in a tall black trash can located four feet away from the medication cart on the non-Covid side, of the Covid Unit. The tall black trash can lid was open, exposing a full can of used yellow gowns. Interview on 07/27/22 at 10:53 A.M., with the RN #455 said they did not have to wear Personal Protective Equipment (PPE) for this resident because Resident #80 was not Covid positive. Interview on 07/27/22 at 10:55 A.M., with the STNA #422 verified the tall black trash can, in the hall, had the lid open and was full of used gowns. Review of the Covid risk for the county dated 07/27/22 covidactnow.org revealed [NAME] County Ohio where the facility was located was listed as high risk level for the community. Interview on 07/27/22 at 12:45 P.M., with the Director of Nursing (DON) said the tall black trash can should not be on the side that was not Covid-19. The DON stated the doffing station should be on the other side of the rope with two poles or at the Covid-19 residents' door because it was the Covid-19 side. The trash can was moved by the Administrator at this time beyond the two poles and roped off area which was considered the Covid side. A follow-up interview on 07/27/22 at 2:30 P.M., with the DON revealed Resident #80 was in quarantine, and all employees should wear full PPE, inlcuding an N95 mask. The DON said Resident #80 had only one Covid-19 antigen test and it was negative. Review of the policy titled Infection Control Policy, revised date on 02/2022 revealed droplet precaution, in addition to standard precautions, implement droplet precautions for an individual documented or suspected to be infected with pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Respiratory droplets are generated when an infected person coughs, sneezes, talks, or has procedures such as suctioning or cardiopulmonary resuscitation. Exampled of infection indicating droplet precaution include Covid-19. Review of the CDC website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 598 stated to manage resident who are a new admissions and resident who leave the facility stated in general, all residents who are not up to date with all recommended Covid-19 vaccine doses and are new admission and readmissions should be placed in quarantine, even if they have a negative test upon admission, should be tested as described in the testing section. This deficiency substantiates Complaint Number OH 172.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place as ordered. This impacted three (#05, #74, and #03) of five residents reviewed for falls. The facility census was 125. Findings include: 1. Review of the medical record of Resident #05 revealed an admitted [DATE]. Diagnoses included major depressive disorder, type 2 diabetes mellitus with diabetic [CONDITION(S)], repeated falls, history of falling, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and did not exhibit any behaviors during the assessment period. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting and was dependent on two staff for bathing. Review of the Fall Risk Scale dated 01/11/22 revealed the resident was at an increased risk for falls. Review of the care plan dated 09/22/21 revealed the resident was at risk for falls related to confusion, gait/balance problems, history of falls, side effects of medications, and unaware of safety needs. Review of physician ' s orders revealed an order dated 11/04/20 for fall mats to the bedside. Observation on 03/15/22 at 11:43 A.M. revealed Resident #05 laying in bed. Two fall mats were observed leaning against the wall approximately three feet from the bed. Interview on 03/15/22 at 11:51 A.M., Nurse Aid (NA) #300 verified the fall mats in Resident #05 ' s room were leaning up against the wall instead of at the bedside. NA #300 stated it was probably night shift that placed them against the wall because the resident does not like having them at the bedside. 2. Review of the medical record of Resident #74 revealed an admitted [DATE]. Diagnoses included metabolic [CONDITION(S)], obstructive reflux and [CONDITION(S)], major depressive disorder, [CONDITION(S)], type 2 diabetes mellitus with diabetic [CONDITION(S)], altered mental status, and a history of falling. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident did not exhibit behaviors during the assessment period. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the Fall Risk Scale dated 01/04/22 revealed the resident was at an increased risk for falls. Review of the care plan dated 02/21/22 revealed the resident at risk for falls related to confusion, gait/balance problems, history of falls, incontinence, impaired mobility, and new environment. Review of the physician orders revealed an order dated 01/08/22 for fall mats to bedside. Observation on 03/15/22 at 2:45 P.M. revealed Resident #74 laying in bed. There were no fall mats observed at the bedside, nor anywhere in the room. Interview on 03/15/22 at 2:55 P.M., NA #325 verified there were no fall mats at Resident #74 ' s bedside, nor anywhere in the resident ' s room. 3. Review of the medical record of Resident #03 revealed an admitted [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, major depressive disorder, type 2 diabetes mellitus with diabetic polyneuropathy, [CONDITION(S)], and essential hypertension Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was assessed as rejecting care 1-3 days during the assessment period. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting and extensive assistance of one staff for locomotion. Review of the Fall Risk Scale dated 02/12/22 revealed Resident #03 was at an increased risk of falls. Review of the care plan dated 11/12/21 revealed the resident was at risk for falls related to confusion, gait/balance problems, incontinence, impaired mobility, and new environment. Interventions included an anti-tipper to the wheelchair. Observation on 03/15/22 at 2:10 P.M. revealed Resident #03 seated in his wheelchair next to his bed in his room. Further observation revealed there were no anti-tippers present on Resident #03 ' s wheelchair. Interview on 03/15/22 at 2:19 P.M., NA #320 verified there were no anti-tippers present on Resident #03 ' s wheelchair. NA #320 further verified there was nothing added to the back of the wheelchair. Review of the facility policy titled, Fall and Accident Management, dated 05/2016 revealed the facility should identify residents at risk for falls and accidents and interventions implemented to reduce the risk of injuries, falls, or other accidents. This deficiency substantiates Complaint Number OH 618.

Based on staff interview, record review and facility policy review, the facility failed to ensure catheter bags were emptied every shift as per facility protocol. This affected two residents (#205 and #74) of three residents reviewed for catheters. The facility census was 125. Findings include 1. Review of the medical record for Resident #205 revealed the resident admitted on [DATE] from an inpatient hospice facility. Resident #205 passed away in the facility on 02/19/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #205 ' s comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of one person for bed mobility, transferring, eating, and extensive assistance of two staff for toileting. The resident had an indwelling catheter (suprapubic) and was always incontinent of bowel. Review of Resident 205 ' s plan of care dated 02/12/22 revealed the resident had a suprapubic catheter related to urinary retention. Interventions included to monitor intake and output every shift and catheter care every shift and as needed. Review of Resident #205 ' s State tested Nursing Assistant (STNA) documentation for the task of catheter care identified the care was to be provided every shift and as needed. Review of the STNA documentation revealed multiple blank spaces in the documentation. Empty spaces were noted on 02/07/22 on the A.M., 02/08/22 on both A.M. and P.M. shift, 02/10/22 on the P.M. shift, on 02/12/22 on both the A.M. and the P.M. shift, on 02/13/22 on both the A.M. and the P.M. shift, on 02/14/22 on the P.M. shift, and on 02/16/22 on both the A.M. and P.M. shift. 2. Review of Resident #74 ' s medical record revealed an admitted [DATE]. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #74 ' s MDS dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) of eight which indicated moderate cognitive deficit. The MDS revealed the resident required extensive two-person assistance for bed mobility, transfers, and toileting. The resident required extensive one-person assistance for dressing and personal hygiene. The resident required supervision with set up for eating. The MDS revealed the resident had an indwelling catheter. Review of Resident #74 ' s plan of care dated 01/10/22 revealed the resident had an indwelling catheter. The interventions identified to monitor intake and output every shift. Review of Resident #74 ' s task documentation from 03/01/22 through 03/15/22 revealed the output was not documented on the night shift on 03/01/22, 03/04/22, 03/08/22, 03/09/22, and 03/10/22. The output was not documented on day shift on 03/14/22. Interview on 03/16/22 at 3:09 P.M. with the Director of Nursing (DON) clarified the responsibility of the State tested Nursing Assistants (STNA) was to empty the catheter bags, document output and to provide the catheter care. The DON confirmed the catheter care policy does not identity whether the actual care for the catheter was to be provided by the STNA or by the nurse. The DON confirmed she was not able to provide any documentation Resident #205 and Resident #74 had the catheter bags emptied on the days that were not documented by the STNA. The DON confirmed the absence of documentation did not comply with the residents ' plan of care or the physician ' s order. The DON confirmed emptying and recording the output was all part of catheter care. Review of the facility policy titled, Urinary Catheter Care, dated 01/2019 revealed to record the amount and to report any unusual findings such as color, odor, sediment, and abnormal amounts to the charge nurse. This deficiency substantiated the complaint OH 618.

Based on medical record review, staff, Nurse Practitioner (NP) and Physician interview, review of facility policy, and review of online professional medication resource from Medscape and online resource from the Centers for Disease Control (CDC), the facility failed to ensure a resident was free from unnecessary medications when the facility failed to monitor for signs and symptoms of opioid overdose and failed to address concerns regarding ongoing long term opioid administration. This affected one (#56) of three residents reviewed for medications. The census was 112. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #56 dated 10/24/21 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Review of the care plan for Resident #56 dated 02/25/21 revealed the resident had potential for alteration in comfort related to chronic pain and immobility. Interventions included the following: administer pain medications and other non-pharmacological interventions as indicated, anticipate the resident's need for pain relief, assess for presence/location of pain, if able have resident rate/describe pain, monitor for side effects of pain medication, observe for constipation, falling, and drowsiness, report occurrences to the clinician. Review of November 2021 physician orders for Resident #56 revealed orders dated 04/19/19 for [MEDICATION(S)] (an opioid pain reliever) 7.5 milligrams (mg) oxycodone with 325 mg acetaminophen tablet twice daily and [MEDICATION(S)] 10 mg oxycodone with 325 mg acetaminophen at bedtime. Review of October and November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR's revealed the facility monitored and tracked resident's pain level but did not include monitoring or tracking of opioid side effects. Review of the nurse progress for Resident #56 dated 10/18/21 revealed resident sent to the hospital per instructions of insurance company and family member. Review of hospital visit note for Resident #56 dated 10/18/21 revealed resident presented to the emergency room with altered mental status and was minimally responsive secondary to opioid use. Further review of notes revealed resident's treating diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of note revealed resident became awake and responsive after receiving [MEDICATION(S)]. The ER physician discussed with Resident #56 and her family the importance of minimizing opioid usage as overdose could happen again. Discharge instructions for opioid overdose were provided and included follow up with physician as a key part of treatment and safety. Review of NP #150 dated 10/20/21 revealed Resident #56 was sent to the hospital on 10/18/21 and received [MEDICATION(S)] which improved resident's mentation and lethargy, and resident had diagnosed her with opioid overdose by the hospital. Further review of the note revealed the resident had been on the same dose of [MEDICATION(S)] for years. NP #150 did not recommend any change to Resident #56's medication regime. Review of the medical record for Resident #56 revealed the last note from resident's attending physician was dated 06/18/20 and did not address resident's opioid use. Interview on 11/10/21 at 3:40 P.M. with NP #150 confirmed Resident #56 had been receiving [MEDICATION(S)] three times daily routinely without a change in dosage since 04/19/19. NP #150 confirmed she reviewed the hospital note dated 10/18/21 which diagnosed Resident #56 with opioid overdose. NP #150 confirmed she had not recommended a change in Resident's medication regime following the hospital visit. Interview on 11/10/21 at 4:53 P.M. with Physician #200 confirmed Resident #56 had been receiving [MEDICATION(S)] three times daily routinely without a change in dosage since 04/19/19. Interview further confirmed Physician #200 was not aware until 11/10/21 that Resident #56 had received [MEDICATION(S)] at theER on [DATE] and was diagnosed with opioid overdose. Physician #200 confirmed in light of this information, Resident #56's [MEDICATION(S)] regimen should be reviewed and adjusted to prevent possible recurrence. Interview on 11/10/21 at 5:45 P.M. with the Administrator confirmed the following: Resident #56 had received [MEDICATION(S)] three times daily since 04/19/19, resident's record did not include monitoring for opioid side effects, Resident #56 was sent to theER on [DATE] and was treated with [MEDICATION(S)] for opioid overdose, and there had been no changes to resident's care plan or medication regime related to the opioid overdose. Review of the facility policy titled Pain Management dated June 2015 revealed the facility would monitor the resident for side effects of pain medications. Review of online resource Medscape at https://reference.medscape.com/drug/[MEDICATION(S)]-oxycodone-acetaminophen- 4#5 revealed there was a black box warning for [MEDICATION(S)]. Further review revealed the following concerns: risk of addiction, abuse, and misuse, which can lead to overdose and death, assess patient's risk before prescribing, and monitor regularly for development of these behaviors or conditions, serious, life-threatening, or fatal respiratory depression may occur, life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients; monitor closely, patient access to [MEDICATION(S)] for emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of online resource per the CDC titled CDC Guideline for Prescribing Opioids for Chronic Pain at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm revealed clinicians should evaluate benefits and harms of continued opioid therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. This deficiency substantiates Complaint Number OH 924.

Based on medical record review, interviews with staff, the resident, and the nurse practitioner, and review of the manufacturing insert for [MEDICATION NAME] insulin, the facility failed to ensure a resident was free from a significant medication error when Registered Nurse (RN) #94 failed to administer [MEDICATION NAME]as recommended by the manufacturer. This resulted in Immediate Jeopardy for one (Resident #5) of nine residents reviewed for insulin administration. Resident #5 suffered actual harm when he was given fast acting insulin without a meal and suffered [MEDICAL CONDITION] due to a critically low blood sugar. In addition, the facility identified 13 residents currently residing in the facility as having their dosage of [MEDICATION NAME]scheduled prior to meals outside of the recommended timeframe. The Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were notified on 12/23/15 at 10:25 A.M. the Immediate Jeopardy began on 12/17/15 at 6:00 A.M. when Resident #5, who was at risk for fluctuating blood sugars, received [MEDICATION NAME](a fast-acting insulin) 17 units subcutaneous after the resident's blood sugar was checked and was 94 milligrams per deciliter (mg/dl). Resident #5 did not receive a breakfast tray that morning until 7:45 A.M., a time period of one hour and forty-five minutes after the insulin had been administered. The resident was discovered with a critically low blood sugar level of 23 mg/dl at 8:45 A.M., began having [MEDICAL CONDITION], and had to be sent to the emergency room (ER) for treatment. The Immediate Jeopardy was removed on 12/18/15 when all 13 residents currently residing in the facility with a [DIAGNOSES REDACTED]. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 12/29/15 when the facility implemented the following corrective actions: · On 12/18/15 each resident with the [DIAGNOSES REDACTED]. The facility individualized the administration time for each of these respective residents to ensure optimal medication effectiveness. · On 12/18/15, in-servicing was initiated by the DON, ADON and/or Unit Managers for licensed nurses in regards to proper timing of diabetic medication administration with meal intake according to physician orders [REDACTED]. · On 12/19/15, at approximately 10:00 A.M. a Performance Improvement (PI) audit was initiated to monitor medication administration in accordance with physician orders, including insulin. The PI would be completed by the DON or designee three times weekly for four weeks, then weekly for one month and monthly thereafter. · On 12/22/15, all licensed nurses were in-serviced prior to working any scheduled shift. On 12/22/15 around 4:00 P.M., the DON completed one-on-one in-servicing with Licensed Practical Nurse (LPN) #95 and RN #94 on insulin administration, including insulin administration related to finger stick blood sugar results and meal intake. · On 12/23/15, an additional PI audit was initiated to verify insulin pass times in accordance with physician orders [REDACTED]. This PI audit would be completed by the DON or designee daily for one month, then weekly for four weeks, then weekly for one month and monthly thereafter. If issues are noted, the DON or designee would take appropriate action at the time the concern is noted. The PI worksheet results would be reported to the Quality Assurance Committee for additional comments/interventions and for a determination of the need of continued formal ongoing monitoring. · On 12/23/15, a Quality Assurance (QA) meeting was held to review issues and findings and to discuss the plan of correction related to the significant medication error. · In-servicing was completed by the DON for all nurses starting on 12/24/15 on [MEDICATION NAME]guidelines, residents who are new admissions with diabetes and insulin timing. · In-servicing was completed by the DON for all State tested Nurse Aides (STNA) on 12/24/15 on the signs and symptoms of [DIAGNOSES REDACTED]. · On 12/29/15, a second Quality Assurance meeting was held to review the plan of correction and audit findings. At that time, the committee determined that the plan implemented was effective and no further issues were noted. The QA Committee would continue to monitor through the usual committee process and make recommendations if indicated. · On 01/13/15 starting at 7:45 A.M., RN #124 and #192, and LPN #3, #59, #72 and #95 were interviewed about the in-service they received regarding insulin guidelines and timing. All staff interviewed was able to correctly articulate the information given in the in-service. Findings include: Resident #5 was admitted to the facility from an acute care hospital on [DATE] and discharged to an acute care hospital on [DATE]. The resident had [DIAGNOSES REDACTED]. The hospital discharge summary dated 12/16/15 for Resident #5 documented prior to admission to the facility the resident was admitted to the hospital on [DATE]. His admitting [DIAGNOSES REDACTED]. A review of the discharge summary revealed the medication list included [MEDICATION NAME] to use 17 units three times daily with meals and to use [MEDICATION NAME]sliding scale in addition to 15 units three times daily with meals. The scheduled dosage was not clear whether it was to be 17 units or 15 units at meals and the actual scale for blood sugar and corresponding insulin doses were not included on the discharge summary. The medication list also included [MEDICATION NAME] SC (subcutaneous) to use 25 units subcutaneously at bedtime. Review of Resident #5's medical record revealed an Order Summary Report was generated by LPN #95 on 12/16/15 at 3:29 P.M. The order summary included [MEDICATION NAME] Solution 100 units/milliliter to inject 25 units subcutaneous at bedtime. It did not include an order for [REDACTED].#200 on 12/16/15 at 3:40 P.M., which was signed by LPN #95 and LPN #3. Review of the medical record for Resident #5 revealed in an Order Recap Report the resident had an order dated 12/16/15 for [MEDICATION NAME] insulin, 100 units/milliliter to inject 17 units subcutaneous before meals and at bedtime which was ordered on [DATE] at 7:04 P.M. and discontinued on 12/17/15 at 6:46 A.M. An order dated 12/17/15 at 5:47 A.M., written by RN #94, listed [MEDICATION NAME] Solution 100 units/milliliter to inject 17 units subcutaneous with meals. It also included [MEDICATION NAME] Solution 100 units/milliliter to inject 25 units subcutaneous at bedtime. A review of Resident #5's electronic Medication Administration Record (MAR) revealed the resident received [MEDICATION NAME] 25 units subcutaneously on 12/16/15 at 9:00 P.M. The [MEDICATION NAME]17 units was not given at bedtime on 12/16/15 at 9:00 P.M. The progress note dated 12/16/15 at 10:42 P.M. by RN #94 indicated under the order that the medication was to be given with meals and had been retimed. On 12/17/15 at 6:00 A.M., [MEDICATION NAME] 17 units was documented as being given by RN #94. There were no blood sugar results documented on the MAR or in the progress notes. There was an order on the MAR to monitor for [DIAGNOSES REDACTED] (i.e. headache, change in level of consciousness, fatigue/weakness, cool clammy skin, diaphoretic, [MEDICAL CONDITION] impaired vision, irritability, tremors) and monitor for [MEDICAL CONDITION] (i.e. headache, fatigue/weakness, frequent thirst/urination, nausea/vomiting, blurred vision, sweet/fruity breath, dry/flushed face). The directions were to document Y if monitored and asymptomatic and document N if symptomatic and write a progress note every day and night shift. This was not initialed as being done. The Interdisciplinary Progress Note dated 12/17/15 at 9:12 A.M., written by NP #200, indicated she attempted to see the resident for an initial visit. [MEDICAL CONDITION] activity was noted, gurgling, oxygen in place and blood sugar 23 mg/dl. The Emergency Medical Service (EMS) was called. Three doses of [MEDICATION NAME] were given intramuscularly and the blood sugar measured at 22 mg/dl. EMS placed peripheral intravenous (IV) access in Resident #5 ' s right hand, and attempted to administer one [MEDICATION NAME] of [MEDICATION NAME]. Only half was given due to the resident jerking and pulling out the IV. A fourth [MEDICATION NAME] was given and the resident ' s blood sugar came up to 55 mg/dl. EMS transported the resident to the hospital with [DIAGNOSES REDACTED]. A communication form and progress note dated 12/17/15 at 12:32 P.M., written by RN #63, documented the resident was found in his room at 8:30 A.M. with [MEDICAL CONDITION]- like twitching and shaking. The resident was unresponsive to voice and was gurgling and grunting. The nursing note section of the document revealed at 8:45 A.M. the patient was found in the room unresponsive staring at the ceiling. The patient was experiencing [MEDICAL CONDITION] episodes and gurgling. NP #200 came to the room with other nursing staff. At 8:47 A.M., 911 was called. At 8:48 A.M. nursing staff were unable to obtain a blood pressure. At 8:47 A.M. Resident #5 ' s blood sugar was 23 mg/dl and [MEDICATION NAME] was given three times, two injections in the left arm and one in the right arm. At 8:56 A.M. his blood pressure was 142/78 millimeters of mercury (mm Hg) and he was having [MEDICAL CONDITION] episodes [MEDICATION NAME] three to five seconds with a blood sugar of 22 mg/dl. At 8:57 A.M., EMS entered the room and started IV access in the left hand and his blood pressure was 142/78 mm Hg. At 9:00 A.M., 15 cubic centimeters (cc) of a bolus of 50 percent [MEDICATION NAME] was given by EMS. At 9:01 A.M., the patient pulled out the IV and a fourth injection of [MEDICATION NAME] was given in the left arm. At 9:02 A.M., a second attempt at an IV in the right hand was unsuccessful. At 9:05 A.M. his blood sugar was 54 mg/dl, there was no [MEDICAL CONDITION] activity noted at that time, and EMS transferred the patient to the hospital. A review of a Medication Error Report Form dated 12/17/15 involving Resident #5, signed on 12/23/15 by the DON, revealed the date of incident was 12/17/15 at 6:00 A.M. when [MEDICATION NAME]17 units ordered with meals on admission from the hospital was ordered at 6:00 A.M., 12:00 P.M. and 5:00 P.M. caused by a transcribing error on admission by LPN #95. Telephone interview with RN #94 on 12/22/15 at 2:02 P.M. revealed she was the night shift nurse on 12/16/15. She stated she did check Resident #5's blood sugar at 6:00 A.M. but it was not recorded on the MAR, she had only written it on her report sheet. She stated she did not check Resident #5's blood sugar on 12/16/15 at bedtime due to him only getting [MEDICATION NAME]. It was checked in the morning prior to his insulin. She stated Resident #5 did not receive [MEDICATION NAME]that night (12/16/15), and that the order was to be clarified. She remembered that his blood sugar was under 100 mg/dl but not less than 90 mg/dl. She stated she asked him if he generally takes insulin when his blood sugar was at that level and he said he always takes his insulin and that he had to have it. She indicated there were no signs of [DIAGNOSES REDACTED] experienced by Resident #5 during the night and that he was alert and oriented. She stated she would not administer the insulin if the blood sugar was under 70. She stated if he was not alert and oriented when she checked his blood sugar on 12/17/15, she would have called the doctor. Interview with RN #63 on 12/22/15 at 2:46 P.M. revealed she was the oncoming day shift nurse on 12/17/15. She stated STNA #170 came to her at 8:00 A.M. and stated Resident #5 seemed very confused. When RN #63 saw the resident, he was sitting up and eating breakfast. She stated she asked him at that time if he was ok and she stated he just looked at her. About 20 minutes later or more STNA #170 came back to get his tray and he was making a noise like a snore and jerking. STNA #170 came and got her and said something was not right. She told STNA #170 to get a set of vitals, the ADON was notified and she and NP #200 came back in. NP #200 said to call 911 and emergency intervention was started. She stated RN #94, who she got report from, stated she had checked Resident #5's blood sugar and it was in the 90's. She stated that nurse would have left by 7:00 A.M. STNA #170 stated during interview on 12/22/15 at 3:05 P.M. when she came in she got report that per family request and per the unit manager she needed to check on Resident #5 every hour. She checked on him about 6:10 A.M. and he nodded and groaned but he did not actually talk to her. In report she was told he was alert and oriented, but confused at times. She indicated she got his order for breakfast at 7:00 A.M., but at about 7:45 A.M. when he got his tray he seemed out of it . She stated she sat him up and set up his tray. She talked to RN #63 about 8:00 A.M. and asked what she got in report concerning Resident #5 and asked the nurse to check on him. RN #63 called the ADON and after that they, (RN #63 and STNA #170), went into the room and he started to jerk. The ADON, LPN #17 and NP #200 came in and checked his blood sugar and administered [MEDICATION NAME]. She stated 911 was called immediately. LPN #95 stated during telephone interview on 12/22/15 at 4:19 P.M., she started Resident #5's admission and that he came in around 4:30 P.M. She stated there was not a sliding scale for the insulin listed on the hospital discharge record. She indicated she spoke to NP #200 by phone and told her she had orders for Resident #5 that she needed to verify. NP #200 asked if Resident #5 was on a lot of medication and LPN #95 said yes. She stated NP #200 did not listen to the orders and stated the orders were verified and that she would be in to see him in the morning. When the next nurse, RN #94, came in she gave report and she let her know what had happened. She was unsure about what to do with the sliding scale. She stated she had not talked to the doctor that supervised NP #200. She indicated she did not give him any insulin and did not check his blood sugar. She stated she should have checked his blood sugar. NP #200 was interviewed via telephone on 12/22/15 at 4:40 P.M. and stated Resident #5's orders were read to her and verified she always listens to all of the orders prior to verifying them. She stated she did not like sliding scale dosages and that she liked to look at the residents' blood sugars and HGBA1C prior to ordering insulin. She indicated the orders for Resident #5 were to give the [MEDICATION NAME] as ordered but to hold the [MEDICATION NAME] until she was able to review the record the next morning. She stated the [MEDICATION NAME] should not be given until five to ten minutes before a meal. She stated she was in to see him on 12/17/15 at 8:48 A.M. when he was discovered with a blood sugar of 23 mg/dl, treated, and sent to the ER after a call to 911. RN #94 stated during a telephone interview on 12/23/15 at 11:30 A.M. she believes she gave insulin to Resident #5 on 12/17/15 at 6:00 A.M., but could not remember the exact time. A review of the [MEDICATION NAME]product insert, issue date 02/25/15, revealed under Dosage and Administration , subcutaneous injection of [MEDICATION NAME] should generally be given immediately (within five to ten minutes) prior to the start of a meal. This deficiency substantiates Complaint Number OH 022.