Every finding on record at Shelby Skilled Nursing and Rehabilitation

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of the facility fall investigation report, and policy review, the facility failed to ensure a neurological evaluation were timely initiated after a resident fall with reported head injury. This affected one (#02) out of the three residents reviewed for falls. The facility census was 44. Findings include: Review of the medical record for Resident #02 revealed an admission date of 09/04/25 with medical diagnoses of acute respiratory failure, anemia, Alzheimer's disease, heart failure, and hypertension. Review of the medical record for Resident #02 revealed an admission Minimum Data Set (MDS) dated [DATE] which indicated Resident #02 had severe cognitive impairment and required substantial/maximum staff assistance with toilet hygiene, supervision with transfers and bed mobility, and set-up assistance with eating. Review of the medical record for Resident #02 revealed a nurse's note, dated 10/16/25 at 9:43 A.M. which stated the nurse was alerted by a State Tested Nursing Assistant (STNA) that she had lowered Resident #02 to the floor after Resident #02 tried to sit down and missed the recliner. The note indicated Resident #02 did not have any injuries. Review of a nurse's note, dated 10/16/25 at 2:00 P.M., stated clarified with facility Nurse Practitioner to initiate neurological (neuro) checks as STNA reported though Resident #02 was lowered to the floor, resident's left temple bumped the bedside table. Review of the facility fall investigation report for Resident #02's fall on 10/16/25 at 9:43 A.M., revealed a written statement by STNA #123 which stated she lowered Resident #02 to the floor and Resident #02 swiped her head on bedside table. STNA #123 stated she informed Licensed Practical Nurse (LPN) #110 and LPN #135 that Resident #02 had fallen and swiped her head on the bedside table. Review of the statement by LPN #110 stated she was informed by STNA #123 that she had lowered Resident #02 to the floor on 10/16/25 and Resident #02 did not hit her head. Review of the statement by LPN #135 stated she was called to Resident #02's room by STNA #123 who stated she lowered Resident #02 to the floor. The statement by LPN #135 stated STNA #123 informed her that when she lowered Resident #02 to the floor she may have brushed her head against the tray table because Resident #02 was rubbing the back of her head. Review of the fall investigation revealed no documentation to support the facility staff-initiated neuro checks until 10/16/25 at 2:00 P.M. Interview on 11/25/25 at 8:03 A.M. with LPN #110 confirmed she was the nurse who took care of Resident #02 on 10/16/25 when she fell at 9:43 A.M. LPN #100 confirmed Resident #02 was cognitively impaired and confused. LPN #110 stated she was notified by STNA #123 that she had lowered Resident #02 to the floor and that Resident #02 didn't hit her head but could have brushed it on the bedside table. LPN #110 stated she asked Resident #02 if she hit her head and Resident #02 denied hitting her head on anything. LPN #110 confirmed she did not initiate neuro checks after Resident #02's fall on 10/16/25 at 9:43 A.M. Interview on 11/25/25 at 10:16 A.M. with Unit Manager #145 stated she was notified on 10/16/25 at 2:00 P.M. by the nursing staff that Resident #02 had been lowered to the floor and may have hit her head. Unit Manager #145 confirmed the staff had not initiated neuro checks. Unit Manager #145 stated an order was received to start neuro checks at that time. Unit Manager #145 confirmed the facility nurses should initiate neurological checks for any resident falls that are unwitnessed or if the resident hits their head. Review of the facility policy titled, Neurological Assessment, stated the purpose of the procedure was to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. The deficient practice was corrected on 10/20/25, when the facility implemented the following corrective actions: On 10/16/25, Unit Manager #145 assessed Resident #02 and was found to be absent from any adverse effects related to fall. On 10/16/25, Unit Manager #145 notified Resident #02's responsible party of the concern. On 10/16/25, Unit Manager #145 notified the facility Nurse Practitioner of delay in the initiation of proper neurological checks following the fall on 10/16/25 and gave directions to initiate neurological checks at the beginning interval, per protocol, at the time of notification. On 10/16/25, Administrator suspended LPN #110 upon identification of delay in initiating appropriate neurological check post fall for Resident #02 on 10/16/25. On 10/17/25, LPN #110's employment was terminated. On 10/17/25, Director of Nursing (DON) completed medical record audit of current facility residents who had fallen in the past 60 days to ensure neurological checks were initiated promptly as per protocol and documentation was complete and accurate. There were no variances as a result of the audit. On 10/17/25, DON or designee would audit all falls for head strike to ensure neurological checks were started as required five times per week for four weeks to ensure nurses are following post fall protocol. On 10/20/25, Unit Manager #145 educated the facility STNAs and nurses on fall management and neurological check policies. On 11/17/25, the results of audits will be reported to the Quality Assurance (QA) Committee. This deficiency represents non-compliance investigated under Complaint Number 2624383.

Based on medical record review, staff interview, and facility policy review, the facility failed to notify a physician of resident's weight loss. This affected one (#13) of two residents reviewed for nutrition. The census was 46. Findings include: Review of medical record for Resident #13 revealed admitted [DATE]. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin lymphoma, and stroke. The resident was documented as hospitalized on [DATE] and returned on 08/14/24, and had a second hospitalization on [DATE] and returned on 08/23/24. The resident remained in the facility during the survey. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was assessed with moderately impaired cognition, required supervision for eating, and maximum assistance for transfers, bed mobility, and toileting hygiene. Review of Resident #13's electronic medical record revealed the resident weighed 225.0 pounds on 07/22/24. Subsequent weights revealed on 07/29/24 the resident weighed 198.8 pounds, on 08/05/24 the resident weighed 177.5 pounds, on 08/14/24 the resident weighed 185.0 pounds, on 08/17/24 the resident weighed 183.5 pounds, and on 08/25/24 the resident weighed 177.6 pounds. Resident #13 experienced a 21.07 percent (%) weight loss since admission. Further review revealed weight loss was documented on 07/31/24, 08/05/24, 08/14/24, 08/17/24 and 08/25/24 with no indication the physician was notified of the weight loss. Record review of Resident #13's electronic and paper chart revealed no documentation the physician had been informed of weight loss. Interview on 08/28/24 at 11:32 A.M. with Dietician Consultant (DC) #167 revealed she had not seen Resident #13 since the resident's 07/21/24 admission, explaining Resident #13 was at the hospital when she came to the facility on Wednesdays. DC #167 acknowledged she had access to the electronic charting for Resident #13 to review weights and meal intakes. DC #167 stated on 07/31/24 she requested another weight due to the significant change in weight. DC #167 stated she was unaware if the physician had been notified of Resident #13's weight loss explaining she informed the nursing staff of resident weight loss with the expectation they would provide the notification to the physician. Interview on 08/28/24 at 3:12 P.M. with the Administrator and DON revealed Resident #13 had fluctuating weights at the facility as well as during her two recent hospitalization s. The DON stated Physician #169 assessed Resident #13 on 08/26/24 and did not document a concern for weight loss, and acknowledged Physician #169 was not notified by the facility of the documented weight losses. Review of the facility policy titled, Nutrition unplanned weight loss, revised 2017, revealed the staff would report to the physician significant weight loss or gain or any abrupt or persistent change from baseline or food intake.

Based on medical record review and staff interview, the facility failed to timely implement treatment of a wound. This affected one (#13) of 12 residents reviewed for treatments. The facility census was 46. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin's Lymphoma and stroke. The resident remained in the facility. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with moderately impaired cognition, required supervision for eating, and maximum assistance for transfers, bed mobility and toileting hygiene. Review of Resident #13's current care plan revealed a focus area for impaired skin integrity related to fragile skin, altered sensations, and impaired mobility. Interventions included to inspect skin during routine care, pad and protect skin as needed, and pericare after each incontinent episode. An intervention for barrier cream/ointment after each incontinent episode and as needed was added on 08/28/24. Review Resident #13's progress note dated 08/23/24 at 3:05 P.M. revealed Resident #13 was readmitted to the facility with left buttock shearing. Review of Resident #13's admission skin assessment dated [DATE] revealed documentation of left buttock shearing measuring 1.0 centimeter (cm) long by (x) 0.5 cm wide x 0.1 cm deep. Review of Resident #13's physician orders revealed treatment orders to cleanse the left buttock wound with soap and water, pat dry, apply vitamin A and D (A&D) ointment every shift until resolved with a start date of 08/27/24. Interview on 08/27/24 at 3:56 P.M. with the Director of Nursing (DON) verified there were no treatments orders for Resident #13's skin condition upon readmission on 08/23/24 put into place until 08/27/24.

Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to provide timely interventions to address resident weight loss. This affected one (#13) of two residents reviewed for nutrition. The census was 46. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin lymphoma, and stroke. The resident was documented as hospitalized on [DATE] and returned on 08/14/24 and had a second hospitalization on [DATE] and returned on 08/23/24. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with moderately impaired cognition, required supervision for eating, and maximum assistance for transfers, bed mobility, and toileting hygiene. Review of Resident #13's electronic medical record revealed the resident weighed 225.0 pounds on 07/22/24. Subsequent weights revealed on 07/29/24 the resident weighed 198.8 pounds, on 08/05/24 the resident weighed 177.5 pounds, on 08/14/24 the resident weighed 185.0 pounds, on 08/17/24 the resident weighed 183.5 pounds, and on 08/25/24 the resident weighed 177.6 pounds. Resident #13 experienced a 21.07 percent (%) weight loss since admission. Further review revealed weight loss was documented on 07/31/24, 08/05/24, 08/14/24, 08/17/24 and 08/25/24 with no indication the physician was notified of the weight loss. Review of Resident #13's physician note dated 08/26/24 revealed the chief complaint was concerns of fatigue, decreased appetite, anxiety, and depression. Further review revealed during the assessment, Resident #13 reported having fatigue and a decreased appetite, and denied current nausea and vomiting although it had been an issue in the past. Information was sought from nursing staff about current concerns that may need addressed with no documentation of weight loss that was communicated, reviewed, or addressed. Observation and interview on 08/26/24 at 7:55 A.M. and again at 12:52 P.M. with Resident #13 revealed she only wanted yogurt and milk for breakfast, and she felt better later in the afternoon, and ate about 50% for lunch. Observation and interview on 08/27/24 at 7:53 A.M. revealed Resident #13 requested toast and milk for breakfast because it was all she was in the mood for. Further observation revealed the resident ate one half piece of the two pieces of toast provided. During an interview on 08/27/24 at 3:56 P.M. the Director of Nursing (DON) acknowledged Resident #13 had a poor appetite she attributed to nausea as a side effect of medication. The DON explained Physician #169 and/or his team were informed, and the anti-nausea medication Zofran and laboratory work was ordered. The DON stated Resident #13 had also been hospitalized twice during her short admission to the facility. The DON acknowledged the dietician had only seen the resident once since her 07/21/24 admission, and despite her poor appetite/intake, no additional nutritional interventions had been ordered. Interview on 08/28/24 at 11:32 A.M. with Dietician Consultant (DC) #167 revealed she had not seen Resident #13 since her 07/21/24 admission, explaining Resident #13 was at the hospital when she came to the facility on Wednesdays. DC #167 acknowledged she had access to the electronic charting for Resident #13 to review weights and meal intake, and stated on 07/31/24, she had requested another weight due to the significant change in Resident #13's weight. DC #167 explained Resident #13 was on her radar and the resident was discussed weekly with the DON during her resident assessment, and she recommended supplements upon her returns from the hospital. DC #167 verified it was her expectation Resident #13 should have been started on a supplement and the physician should have been informed of the resident's weight loss. Interview on 08/28/24 at 2:40 P.M. with the Administrator and the DON revealed the medical staff was aware of Resident #13's nausea and had ordered laboratory work and Zofran to address the nausea. The DON acknowledged nutritional supplements for Resident #13 were not ordered until 08/28/24 after the 08/27/24 interview. Review of the facility policy titled, Nutrition unplanned weight loss, revised 2017, revealed the staff and physician will identify pertinent interventions based on identified causes and overall resident condition. The physician would authorize appropriate interventions as indicated.

Based on medical record review, staff interview, and review of a policy, the facility failed to ensure a blood pressure medication was held per ordered parameters. This affected one (#93) of six reviewed for unnecessary medications. The census was 46. Findings include: Review of Resident #93's medical record revealed an admitted [DATE]. Diagnoses listed included skin cancer, enlarged lymph nodes, cerebral infarction, muscle weakness, and type two diabetes mellitus. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was cognitively intact. Review of Resident #93's physician orders revealed an order dated 08/13/24 to give metoprolol tartrate (blood pressure medication) 50 milligrams (mg) one tablet via gastronomy tube (G-tube) three times a day for hypertension with instructions to hold if the heart rate (HR) was less than 65 beats per minute. Review of Resident #93's August 2024 medication administration record (MAR) revealed metoprolol tartrate 50 mg was administered to the resident on 08/16/24 at 2:00 P.M. with a HR of 60 beats per minute, on 08/20/24 at 6:00 A.M. with a HR of 56 beats per minute, and on 08/22/24 at 6:00 A.M. with a HR of 55 beats per minute. Interview with the Director of Nursing (DON) on 08/26/24 at 8:46 A.M. confirmed metoprolol tartrate was documented as being administered to Resident #93 on 08/16/24 at 2:00 P.M. with a HR of 60 beats per minute, on 08/20/24 at 6:00 A.M. with a HR of 56 beats per minute, and on 08/22/24 at 6:00 A.M. with a HR of 55 beats per minute. The DON confirmed metoprolol should have not been administered at those times due to Resident #93's HR being less than 65 beats per minute per physician order. Review of the facility's policy titled, Administering Medications, revised April 2019, revealed medications are administered in accordance with prescriber orders, including any required time frame.

Based on medical record review, staff interview, and policy review, the facility failed to timely implement infection control precautions for residents with infections. This affected one (#13) of eight residents reviewed for infection control. The census was 46. Findings include: Review of medical record for Resident #13 revealed an admitted [DATE]. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, hypothyroidism, epilepsy, history of Hodgkin's lymphoma, and stroke. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with moderate cognitive impairment, required supervision for eating, and maximum assistance for transfers, bed mobility, and toileting hygiene. Review of Resident #13's nursing progress notes dated 08/23/24 revealed the resident was readmitted to the facility with a diagnosis of a bacterial infection, Extended-Spectrum Beta-Lactamase (ESBL). Review of the current plan of care revealed Resident #13 had a target area for isolation due to ESBL with interventions which included for isolation to be maintained by staff during the infection period and to monitor the resident for signs and symptoms of depression. Review of Resident #13's physician orders revealed an order for contact isolation with a start date of 08/25/24. Interview with the Director of Nursing (DON) on 08/27/24 at 3:56 P.M. confirmed Resident #13 returned to the facility on [DATE] with a diagnosis of ESBL and was not ordered contact precautions until 08/25/24. The DON verified it would be the expectation she would have been notified of the infection and the resident placed in contact isolation upon the readmission to the facility on [DATE]. Review of the facility policy, Isolation-Categories of Transmission-Based Precautions dated 2001, revealed contacted precautions are implemented for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact or indirect with environmental contact with environmental surfaces or resident-care items in the resident's environment.

Based on personnel file review and staff interview, the facility failed to complete performance reviews of nurse aides at least every 12 months as required. This affected three of four state tested nurse aides (STNAs) reviews with potential to affect all residents residing in the facility. The facility census was 46. Findings include: 1. Review of STNA #115's personnel file revealed a hire date of 03/05/01. The file was absent of any performance review for the previous 12 months. 2. Review of STNA #118's personnel file revealed a hire date of 04/03/23. The file was absent of any performance review for the previous 12 months. 3. Review of STNA #133's personnel file revealed a hire date of 05/16/22. The file was absent of any performance review for the previous 12 months. Interview on 08/28/24 at 3:30 P.M. with Administrator verified STNA #115, STNA #118, and STNA #133 did not have performance reviews completed at least every 12 months as required.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record reviews, staff and resident interviews, facility investigation reviews, and facility policy review, the facility failed to ensure resident's medications were administered as ordered resulting in significant medication errors. This affected two (#12 and #13) out of four reviewed for medication administration. The facility census was 36. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of osteoarthritis, gout, hyperparathyroidism, diabetes mellitus (DM), obesity, end stage renal disease (ESRD), and atrial fibrillation. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/19/24, which indicated Resident #13 was cognitively intact and required moderate staff assistance with toilet hygiene and bed mobility and maximum staff assistance with bathing and transfers. Review of a facility investigation report, dated 04/10/24, stated Resident #13 was inadvertently administered a dose of Lyrica in error. The report did not indicate the dose of Lyrica that was administered. The report stated Resident #13 complained of feeling loopy but denied any pain or dizziness. The report continued to indicate Resident #13 stated she received a white pill in the morning. The report stated Resident #13's nurse prepared another resident's medications and was interrupted during the task to assist another staff member. The report stated the nurse locked the prepared medications in the medication cart and when she returned, she mistakenly administered the wrong medication to Resident #13. Per the report, Resident #13 remained alert and oriented to person, place, time, and situation and did not have adverse reaction to the medication administration error. Per the investigation report, the facility staff monitored Resident #13 for any adverse reactions on the day of the medication error, 04/11/24, and 04/13/24. No adverse reactions were reported. Review of the medical record for Resident #13 revealed no documentation related to the medication administration error on 04/10/24. Interview on 05/08/24 at 9:21 A.M. with Resident #13 stated she was informed by the nurse that she was administered a medication in error. Resident #13 stated her lips felt numb, she felt weird, and had some mood swings after the medication was administered. Resident #13 stated staff observed her for a change of condition closely for several days. Resident #13 denied any adverse reactions related to the allegation. Interview on 05/08/24 at 1:18 P.M. with Director of Nursing (DON) confirmed Resident #13 received a medication that was not ordered for her on 04/10/24. DON stated Resident #13 did not experience a change of condition from the medication administration error. DON stated Resident #13 and the physician were notified of the medication administration error. 2. Review of the medical record Resident #12 revealed an admitted [DATE] with medical diagnoses of cellulitis, multiple sclerosis, bipolar disorder, hypertension (HTN), and hypothyroidism. Review of the medical record for Resident #12 revealed an admission MDS assessment, dated 03/22/24 which indicated Resident #12 was cognitively intact and required moderate staff assistance with toilet hygiene, bed mobility, and bathing and supervision with transfers. Review of the medical record for Resident #12 revealed a physician order dated 03/16/24 for Lyrica 150 milligram (mg) capsule, give one capsule by mouth three times a day for neuropathy. Review of the medical record for Resident #12 revealed a nurse's progress note dated 04/23/24 at 11:55 A.M. which stated Resident #12 was given an extra dose of Lyrica with morning medication pass. No adverse effects noted, assessment done, vitals taken. The note stated the physician was notified and staff were to monitor Resident #12 for sedation per the physician. Review of a facility investigation report, dated 04/23/24, stated Resident #12 was given an extra dose of Lyrica 150 mg by mouth with morning medication pass. The report stated Resident #12 was alert and oriented to person, place, time, and situation and was notified of the medication administration error. The report also stated Resident #12's physician was notified of the medication administration error. The report indicated the staff monitored Resident #12 for any adverse reactions the day of the medication administration error, 04/24/24, and 04/25/24. No adverse reactions were reported. Interview on 05/08/24 at 1:18 P.M. with DON confirmed Resident #12 received an extra dose of Lyrica on 04/23/24. DON stated Resident #12 did not have a change of condition and remained alert and oriented to person, place, and time. DON stated Resident #12 and her physician were notified of the medication administration error. Review of the facility policy titled, Administering Medications, revised April 2019, stated medications are to be administered in accordance with prescriber's orders. The policy also stated any medication errors are documented, reported, and reviewed by the Quality Assurance Improvement Performance (QAPI) committee to inform process changes and or the need for additional staffing. As a result of the incident, the facility took actions to correct the deficient practice by 05/07/24: On 04/10/24, the DON provided education to Licensed Practical Nurse #9, that was responsible for the medication error involving Resident #13, on medication administration policy, Five Rights of Medication Administration, and verification of resident identity using photo identification on Medication Administration Record (MAR). On 04/10/24, facility physician was notified regarding the medication error for Resident #13 by DON/designee. On 04/10/24 A medication observation was completed by DON/designee to ensure there were no like incidents and no additional variances were identified. On 04/10/24, facility nurses were educated on medication administration, Five Rights of medication administration, and verification of resident identity via MAR photo by DON/designee. On 04/10/24, DON/designee audited medication administration by observation three times weekly for four weeks to ensure medications are administered as ordered. On 04/23/24, DON provided education to Registered Nurse (RN) #10, that was responsible for the medication administration error involving Resident #12, on the Five Rights of medication administration and medications errors. RN #10 was observed for medication administration prior to the next shift by DON/designee. On 04/23/24, all resident was assessed for adverse changes and/or sedation with no variances from baseline by DON/designee. On 04/23/24, Resident #12 was notified of medication administration error by DON/designee. Resident #12 was self-responsible. On 04/23/24, physician was notified of medication administration error involving Resident #12 with no new orders by DON/designee. On 04/27/24, all licensed nurses received education related to the Five Rights of medication administration and medication errors prior to or on their next scheduled shift by DON/designee. On 04/27/24, all licensed nurses were administered the medication competency test and passed the test prior to or on their next scheduled shift by DON/designee. On 04/27/24, all licensed nurses received education related to use of the electronic MAR prior to their next scheduled shift by DON/designee. On 04/27/24, medication pass observation was completed for all licensed nurses prior to them taking a medication cart on their next scheduled shift by the DON/designee. Starting on 04/27/24, DON/designee would complete medication pass observation audits five days weekly on varying shifts. As of 05/07/24, there had been no further medication errors identified. On 04/27/24, results of these audits would be reported to the Interdisciplinary Team (IDT) and on-going compliance will be maintained through recommendations of the IDT team. This deficiency represents non-compliance investigated under Complaint Number OH00153184.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's medical record contained documentation involving a medication error. This affected one (#13) out of four residents reviewed for medication administration. The facility census was 36. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of osteoarthritis, gout, hyperparathyroidism, diabetes mellitus (DM), obesity, end stage renal disease (ESRD), and atrial fibrillation. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/19/24, which indicated Resident #13 was cognitively intact and required moderate staff assistance with toilet hygiene and bed mobility and maximum staff assistance with bathing and transfers. Review of a facility investigation report, dated 04/10/24, stated Resident #13 was inadvertently administered a dose of Lyrica in error. The report did not indicate the dose of Lyrica that was administered. The report stated Resident #13 complained of feeling loopy but denied any pain or dizziness. The report continued to indicate Resident #13 stated she received a white pill in the morning. The report stated Resident #13's nurse prepared another resident's medications and was interrupted during the task to assist another staff member. The report stated the nurse locked the prepared medications in the medication cart and when she returned, she mistakenly administered the wrong medication to Resident #13. Per the report, Resident #13 remained alert and oriented to person, place, time, and situation and did not have adverse reaction to the medication administration error. Per the investigation report, the facility staff monitored Resident #13 for any adverse reactions on the day of the medication error, 04/11/24, and 04/13/24. No adverse reactions were reported. Review of the medical record for Resident #13 revealed no documentation related to the medication administration error on 04/10/24. Interview on 0508/24 at 1:18 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #13 did not contain documentation related to the medication administration error on 04/10/24. Review of the policy titled, Administering Medications, revised April 2019, stated medications are to be administered in accordance with prescriber's orders. The policy also stated any medication errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement committee to inform process changes and or the need for additional staffing. This deficiency represents non-compliance investigated under Complaint Number OH00153184. This deficiency represents ongoing noncompliance from the survey dated 04/14/24.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#14) resident out of the two residents observed for medication administration. The facility census was 36. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with medical diagnoses of hypertension, chronic obstructive pulmonary disease, and encephalopathy. Review of the medical record for Resident #14 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/29/24, which indicated Resident #14 had severe cognitive impairment and required maximum staff assistance with toilet hygiene and bathing, moderate staff assistance with bed mobility and supervision with eating. Review of the medical record for Resident #14 revealed physician orders dated 01/22/24 for carvedilol 3.125 milligram (mg) one tablet by mouth every 12 hours; levetiracetam 500 mg one tablet by mouth two times per day; and senna plus 8.6 mg one tablet by mouth two times per day. The medical record revealed physician orders dated 01/23/24 for amlodipine besylate 5 mg one tablet by mouth daily; folic acid 1 mg one tablet by mouth daily; and thiamine 100 mg one tablet by mouth daily. Observation on 05/08/24 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #153 prepared medications for administration to Resident #14. LPN #153 was observed to drop amlodipine besylate 5 mg tablet and carvedilol 3.125 mg tablet onto the medication cart and pick both medications up with her bare hands and place the medications into the medication cup along with Resident #14's other medications. Observations revealed LPN #153 then administered medications to Resident #14 and used hand sanitizer upon exiting Resident #14's room. Interview on 05/08/24 at 7:33 A.M. with LPN #153 confirmed she picked the amlodipine besylate and carvedilol tablets off the medication cart with her bare hands and placed the medications into a medication cup along with Resident #14's other medications. LPN #153 confirmed she then administered the medications to Resident #14. Review of the policy titled, Administering Medications, revised April 2019, stated the staff would follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff and resident interviews, and policy review, the facility failed to ensure a resident was provided with showers. This affected one (#21) out of four residents reviewed for showering. The facility census was 42. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis included spinal stenosis. Review of the care plan dated 09/22/23 revealed Resident #21 was at risk for decline in activities of daily living (ADL) function related to weakness alteration in ADL performance/participation, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident requires partial assistance for toileting hygiene, bathing, lower body dressing, and personal hygiene. Review of the MDS also revealed Resident #21 was cognitively intact. Review of physician order dated 03/15/24 revealed an order for Vitamin A & Vitamin D (A&D) Ointment to moisture associated skin damage (MASD) - bilateral buttocks. Apply after each incontinent episode, as needed for Moisture Associated Skin Damage. Apply after each incontinent episode. Interview on 04/13/24 at 7:32 A.M. with State tested Nursing Assistant (STNA) #292 confirmed on 04/01/24 Resident #21 did not get a shower. Interview with STNA #292 confirmed she marked No in the computerized charting instead of refusal because he did not refuse his shower. Interview on 04/13/24 at 8:48 A.M. with Resident #21 confirmed he does not always get his shower and that he did not receive a shower on 04/01/24 and he did not receive his shower a couple of times in the last two weeks. Resident #21 reports he does not like to miss his showers due to being a heavier person who can not perform all his own cares. Interview on 04/14/24 at 9:54 A.M. with STNA #292 confirmed a shower sheet dated 04/01/24 showing Resident #21 refused his shower. Interview with STNA #292 confirmed the Director of Nursing (DON) came to her this morning, 04/14/24, with a shower sheet and asked her to fill it out for Resident #21 with a date of 04/01/24 and to write Refused across the top. Interview on 04/14/24 at 10:30 A.M. with the DON confirmed she did have STNA #92 complete a shower sheet this morning for Resident #21. The DON confirmed she did not make STNA #292 fill it out, she asked her to fill it out with a date of 04/01/24 and the comment Refused across the top of the shower sheet. Interview with the DON also confirmed she knows Resident #21 did not refuse a shower on 04/01/24, but sometimes he does and she just wanted to give the surveyor something. The DON confirmed the documentation reflecting Resident #21 refused the shower would not be accurate and the documentation will be corrected to accurately reflect the resident did not receive a shower. Interview with the DON also confirmed Resident #21's Brief Interview of Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Further review of the Shower Schedule dated 04/04/24 revealed residents are schedule for a shower two times weekly. Shower sheets are to be signed by the nurse on duty NO EXCEPTIONS. A refusal of care MUST be reported to the nurse on duty and documented in computer charting system. Review of the Follow Up Question Report for Resident #21 revealed on 03/28/24 and 04/01/24 for bathing the task completed response was no. Review of the Bath, Shower/Tub policy dated 02/18 revealed the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Report other information in accordance with facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00152522.

Based on record review, resident and staff interviews and policy review, the facility failed to ensure documentation was accurate regarding a resident's showers. This affected one (#21) out of four residents reviewed for accuracy of the medical records. Facility census was 42. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis included spinal stenosis. Review of the care plan dated 09/22/23 revealed Resident #21 was at risk for decline in activities of daily living (ADL) function related to weakness alteration in ADL performance/participation, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident requires partial assistance for toileting hygiene, bathing, lower body dressing, and personal hygiene. Review of the MDS also revealed Resident #21 was cognitively intact. Review of physician order dated 03/15/24 revealed an order for Vitamin A & Vitamin D (A&D) Ointment to moisture associated skin damage (MASD) - bilateral buttocks. Apply after each incontinent episode, as needed for Moisture Associated Skin Damage. Apply after each incontinent episode. Interview on 04/13/24 at 7:32 A.M. with State tested Nursing Assistant (STNA) #292 confirmed on 04/01/24 Resident #21 did not get a shower. Interview with STNA #292 confirmed she marked No in the computerized charting instead of refusal because he did not refuse his shower. Interview on 04/13/24 at 8:48 A.M. with Resident #21 confirmed he does not always get his shower and that he did not receive a shower on 04/01/24 and he did not receive his shower a couple of times in the last two weeks. Resident #21 reports he does not like to miss his showers due to being a heavier person who can not perform all his own cares. Interview on 04/14/24 at 9:54 A.M. with STNA #292 confirmed a shower sheet dated 04/01/24 showing Resident #21 refused his shower. Interview with STNA #292 confirmed the Director of Nursing (DON) came to her this morning, 04/14/24, with a shower sheet and asked her to fill it out for Resident #21 with a date of 04/01/24 and to write Refused across the top. Interview on 04/14/24 at 10:30 A.M. with the DON confirmed she did have STNA #92 complete a shower sheet this morning for Resident #21. The DON confirmed she did not make STNA #292 fill it out, she asked her to fill it out with a date of 04/01/24 and the comment Refused across the top of the shower sheet. Interview with the DON also confirmed she knows Resident #21 did not refuse a shower on 04/01/24, but sometimes he does and she just wanted to give the surveyor something. The DON confirmed the documentation reflecting Resident #21 refused the shower would not be accurate and the documentation will be corrected to accurately reflect the resident did not receive a shower. Interview with the DON also confirmed Resident #21's Brief Interview of Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Further review of the Shower Schedule dated 04/04/24 revealed residents are schedule for a shower two times weekly. Shower sheets are to be signed by the nurse on duty NO EXCEPTIONS. A refusal of care MUST be reported to the nurse on duty and documented in computer charting system. Review of the Follow Up Question Report for Resident #21 revealed on 03/28/24 and 04/01/24 for bathing the task completed response was no. Review of the Bath, Shower/Tub policy dated 02/18 revealed the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Report other information in accordance with facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00152522.

Based on review of an employee file, review of Board of Executives of Long-Term Services and Supports (BELTSS) website and staff interview, the facility failed to ensure an Administrator of the facility had an active license through BELTSS while employed at the facility from [DATE]-[DATE]. This had the potential to affect all 35 residents residing in the facility. The facility census was 35. Findings include: Review of the employee record for former Administrator #94 revealed a hire date of [DATE]. Review of former Administrator #94's employee record revealed the staff served as facility Administrator from [DATE] to [DATE]. Further review of the employee record revealed no documentation to support former Administrator #94 had an active Nursing Home Administrator license. Review of the BELTSS website revealed documentation that former Administrator #94's Nursing Home Administrator License expired on [DATE]. Interview on [DATE] at 3:07 P.M. with Regional Director of Clinical Operations (RDCO) #92 confirmed former Administrator #94 was employed as the Administrator of the facility from [DATE] to [DATE]. RDCO #92 stated he was not aware former Administrator #94's license was not active according to BELTSS website. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on resident record review, staff interview, and review of a facility policy; the facility failed to respond to pharmacy medication regimen reviews in a timely manner. This affected one (#16) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: Medical record review for Resident #16 revealed admitted [DATE]. Diagnoses included dementia with behavioral disturbance and presence of right artificial knee joint. Review of physician orders dated 04/29/21 revealed [MEDICATION(S)] 100 milligrams (mg) two times a day for infection, end date 08/30/21. Review of physician orders dated 11/23/21 revealed [MEDICATION(S)] 5 mg give two tablets by mouth one time a day and give one tablet by mouth at bedtime. Review of the Consultation Report dated 06/10/21 revealed repeated recommendation from 04/29/21. Resident receives [MEDICATION(S)] 100 milligrams (mg) orally twice a day since 04/20/21. The order does not list a stop date. Physician's Response: I have re-evaluated this therapy and wish to implement the following changes: Stop Doxy, undated. Review of the Consultation Report dated 08/03/21 revealed Resident receives [MEDICATION(S)] [MEDICATION(S)] 5 mg two times a day and has tolerated treatment for at least one continuous week. No orders were found in the medical record to up-titrate the dose. Please up-titrate the dose as follows: 10 mg each morning (AM) and 5 mg each nighttime (PM) for seven days, then 10 mg twice daily as a maintenance dose. Rationale for recommendation: The usual dose of [MEDICATION(S)] is 20 mg/day for the immediate-release formulation, or 28 mg/day for the extended-release (XR) formulation. A handwritten notation to See Response was noted. There was no Physician's Response checked, no physician signature or date. Consultation Report dated 10/05/21 revealed the above recommendation. Physician's Response: I accept the recommendations above, please implement as written. Increase [MEDICATION(S)] to 10 mg every AM and 5 mg PM, dated 10/05/21. These findings were verified on 06/15/22 at 2:53 P.M. by Regional Quality Assurance Nurse #553. The Regional Nurse stated the notation See Response for 08/03/21 reflected the Physician's Response dated 10/05/21. The Regional Quality Assurance Nurse stated she had been on maternity leave and when she came back, she had to follow-up on tasks that were incomplete. She stated the Director of Nursing and Assistant Director of Nursing were new to their roles and she had to train them. Review of facility policy titled Medication Regimen Reviews, dated 05/2019, revealed the Consultant Pharmacist reviews the medication regimen of each resident at least monthly. 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 2. Medication regimen reviews are done at least monthly, or more frequently if indicated. 3. The goal of the MMR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 4. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example: medications a. ordered in excessive doses or without clinical indication; b. medication regimens that appear inconsistent with the resident's stated preferences; c. duplicative therapies or omissions of ordered medication; d. inadequate monitoring for adverse consequences; e. potentially significant drug-drug or drug-food interactions; f. potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences; g. incorrect medications, administration times or dosage forms; or other h. medication errors, including those related to documentation. 5. The medication regimen and associated treatment goals involve collaboration with the resident (or representative), family members, and the interdisciplinary team (IDT). As such, the MRR includes a review of the resident's (or representative's) stated preferences, the comprehensive care plans and information provided about the risks and benefits of the medication regimen. In addition to reviewing the medical record the Consultant Pharmacist may also meet with staff, the resident or representatives, or the IDT. 7. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains: a. The resident's name; b. the name of the medication; c. the identified irregularity; and e. the pharmacist's recommendation. 8. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards or practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. 10. If the physician does not provide a timely or adequate response, the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. 11. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. 12. An acute change of condition may prompt a request for a MRR. The staff member who identifies the change of condition follows reporting procedures to notify the physician. The physician may request a MRR be conducted within a specific timeframe (e.g. within 24 hours).

Based on resident record review and staff interview, the facility failed to appropriately distribute a resident's personal funds after the resident's death. This affected one (#04) of three residents reviewed for personal funds. The facility identified only one (#04) resident in the past year who required money to be distributed back after discharge. The census was 22. Findings include: Review of the medical record for Resident #04 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident died at the facility on [DATE]. Review of a document titled, Resident Statement Landscape dated ,[DATE] through ,[DATE], revealed Resident #04 had a credit of 1200.00 dollars deposited into the account on [DATE]. The funds account statement identified the 1200.00 dollars was deposited into the account from the Internal Revenue Service (IRS) treasury. Continued review of the statement revealed the only activity in the account, other than the IRS deposit, were credits from Social Security Administration (SSA) treasury (treas), credits from interest, debits for resident care costs, and a final dispersement of funds. The final dispersement amount was 1655.33 dollars. Review of a receipt dated [DATE], revealed 1655.33 dollars was sent to the Ohio Department of Medicaid (ODM). Interview on [DATE] at 10:54 A.M. with the Administrator revealed Resident #04 did not remove funds from the account to make purchases and the resident's Power of Attorney (POA) had never made any request for funds to make purchases for the resident. The Administrator further revealed in the Ohio Administrative Code (OAC), someone would have to file for executor of the estate to have access to the resident's assets after death. The Administrator revealed the resident's POA did not notify the facility of being executor of the estate and never made a request for the IRS money, so the 1200.00 dollars of IRS money was sent back with the remaining Medicaid funds. The Administrator verified the money returned to Medicaid totaled 1655.33 dollars, 1200.00 dollars which was IRS money and 455.33 dollars which was SSA funding. The Administrator verified the facility does not have a policy for distribution of funds after a resident death. This deficiency substantiates the allegations in Complaint Number OH 950.

Based on observation and staff interview, the facility failed to ensure the environment remains as free of hazards as is possible, by allowing a portable space heating device in a Resident's room. This affected one (Resident #9) of three residents reviewed for environment. This deficient practice had the potential to affect six resident's, that the facility identified as cognitively impaired and independently mobile in the facility that could have access to Resident #9's room. The facility Census was 23. Findings include: Observation on 12/23/20 at 11:08 A.M. revealed a portable space heating device was located in Resident #9's room. An interview with resident confirmed that the space heating device did belong to the facility. Interview with the Administrator on 12/23/20 at 4:05 P.M. verified that portable space heating devices are not to be used in resident rooms. The Administrator removed the portable space heating device from Resident #9's room immediately. Review of the manufacturer instructions revealed the(NAME)[MEDICATION NAME]/Quartz Heater was a one touch operation for easy temperature setting and shut off instantly if accidentally knocked over. The temperature settings go from 60-80 degrees at 10 degree increments.

Based on the unprecedented global Coronavirus (COVID-19)pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Nursing Home Guidance from the Centers for Disease Control (CDC), Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, review of the facility's Infection Control Special Precautions and Coronavirus (COVID-19) policies, medical record review and interviews with staff , the facility failed to implement the recommended infection control practices to prevent the spread of the infectious disease not testing staff according to their county positivity rate and community spread. This had the potential to affect 12 residents in the facility (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #8, Resident #9, Resident #14, Resident #15, Resident #16, Resident #20 and Resident #21) that had not contracted COVID-19 since the twice per week required testing. Findings include: Review of the staff testing logs revealed the facility staff were tested on ce per week on 10/29/20, 11/05/20, 11/12/20, 11/19/20, 11/24/20, 12/03/20, 12/10/20, 12/17/20 and 12/21/20. Review of the COVID-19 positivity rates for(NAME)County in Ohio on 10/28/20 were 19.8%, 11/04/20 were 26.2%, 11/11/20 were 26.5%, 11/18/20 were 24.8%, 11/25/20 were 21.9% and 12/02/20 were 23.4%. According to the Ohio Public Health Advisory System(NAME)County, Ohio has been coded red indicating a very high exposure rate since 10/28/20. Staff interview on 12/23/20 at 1:30 P.M. with the Administrator, verified the facility was testing staff once per week, not twice per week as recommended by CMS. Review of the memo Review of CMS, COVID-19 Long-Term Care Facility Guidance, dated 04/02/20 revealed facilities should refer to CDC's guidance for long-term care facilities. Review of the CMS QSO memo 20-38 NH dated 08/20/20 revealed: Testing of Staff and Residents in Response to an Outbreak An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. See CDC guidance Testing Guidelines for Nursing Homes section Non-diagnostic testing of asymptomatic residents without known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]-CoV-2. For individuals who test positive for COVID-19, repeat testing is not recommended. A symptom-based strategy is intended to replace the need for repeated testing. Facilities should follow the CDC guidance Test-Based Strategy for Discontinuing Transmission-Based Precautions Discontinuing Transmission-Based Precautions for residents and Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. Routine Testing of Staff Routine testing should be based on the extent of [MEDICAL CONDITION] in the community; therefore, facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Reports of COVID-19 county-level positivity rates will be available on the following website by August 28, 2020 (see section titled, COVID-19 Testing): https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg Review of the CDC website COVID-19 guidelines titled, Use of Testing to Inform the Response to COVID-19 in Nursing Homes (https://www.cdc.gov/coronavirus/2019ncov/hcp/nursing-homes-responding.html), dated 04/30/20, revealed if testing capacity allows use of facility wide testing following identification of newly identified [DIAGNOSES REDACTED]-CoV-2 infected residents or healthcare personal could be particularly important. Facility wide testing can help identify a symptomatic or pre-symptomatic resident with COVID-19 to guide movement into COVID-19 designated spaces.

Based on observations, staff and local health department (LHD) personnel interview, resident record review, review of an allocation document, review of Food and Drug Administration (FDA) guidelines, and the Centers for Disease Control (CDC) guidelines, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was distributed to staff caring for residents on the Coronavirus Disease 2019 (COVID-19) unit and residents on quarantine for possible exposure to COVID-19. This had the potential to affect 17 (#4, #5, #6, #7, #9, #10, #11, #13, #15, #16, #17, #18, #20, #21, #22, #24 and #25) residents residing on the COVID-19 unit and eight (#1, #2, #3, #8, #12, #14, #19 and #23) residents that were in quarantine for possible exposure to COVID-19. The facility census was 25. Findings include: Observations on 09/21/20 from 2:05 P.M. to 2:15 P.M. of the COVID-19 unit revealed Licensed Practical Nurse (LPN) #50 was wearing a KN95 mask with ear loops and a surgical mask overtop of the KN95. A visible gap was observed between LPN #50's nose/cheek area and KN95 mask. Review of the medical record Residents #10, #15 and #20, revealed a [DIAGNOSES REDACTED].#10, #15, and #20. Continued record review revealed Resident #10, #15 and #20 resided on the COVID-19 unit. Interview on 09/21/20 at 1:16 P.M. with the Corporate Nurse (CN) #52 revealed all residents residing in the facility were under quarantine for either COVID-19 [DIAGNOSES REDACTED]. COVID-19 positive residents were residing on the facility's COVID-19 unit while exposed residents were residing in the remainder of the building. Interview on 09/21/20 at 2:10 P.M. with LPN #50 reported using whatever PPE the facility provided. Interview on 09/21/20 at 2:10 P.M. with the CN #52 confirmed staff working the COVID-19 unit were provided with KN95 masks. Interview on 09/22/20 at 11:41 A.M. with the LHD Personnel #100 revealed the facility had asked for either KN95 masks or N95 masks. LHD Personnel #100 confirmed at the time of the facilities request, there was a supply of both N95 and KN95 masks. LHD Personnel #100 further reported because the facility asked for either mask (KN95 or N95), LHD Personnel #100 stated she asked the facility if they would take KN95 masks because there were more available than the N95 masks. LHD Personnel #100 reported the facility said they would take the KN95 masks. LHD Personnel #100 stated N95 masks were available for distribution and would have been provided to the facility if the facility had specifically requested N95 masks. Interview on 09/22/20 at 3:35 P.M. with the Director of Nursing (DON) and Human Resources/Central Supply (HR/CS) confirmed HR/CS ordered supplies for the facility but did not order the PPE. The DON reported the Administrator was responsible for ordering PPE. The DON did not know where the facility's PPE came from. Interview on 09/22/20 at 4:00 PM with the Vice President of Operations (VP) revealed the facility utilized Vendor #53 as their supplier for PPE and further reported N95 masks were not allocated to the facility. The VP revealed there was no evidence of the facility attempting to obtain N95 masks from Vendor #53 or other suppliers/vendors. On 09/23/20, the VP verified 17 (#4, #5, #6, #7, #9, #10, #11, #13, #15, #16, #17, #18, #20, #21, #22, #24 and #25) residents resided on the COVID-19 unit and eight (#1, #2, #3, #8, #12, #14, #19 and #23) residents resided on the quarantine unit for possible exposure to COVID-19. Review of a document titled, Partial Product Allocations by Customer and Items dated 09/22/20, revealed evidence of allocations for PPE such as gloves and gowns. N95 masks were not listed on the document. Review of a document titled, COVID-19 Supply Request Form undated, revealed the facility had made a request for 300 KN95/N95. The document revealed the facility had 250 N95/KN95 masks on hand and used 50 per week. Review of a second document titled, COVID-19 Supply Request Form undated, revealed the facility had made a request for 300 KN95/N95. The document revealed the facility had 150 N95/KN95 masks on hand and used 75 per week. Review of CDC website (https://www.cdc.gov/niosh/npptl/respirators/testing/results/MTT-2020-174.3_International_GuangzhouPowecom_Powecom-KN95-APR-21-V2_TestReport_Redacted-508.pdf and https://www.cdc.gov/niosh/npptl/respirators/testing/NonNIOSHresults.html) revealed, KN95 masks manufactured by Guangzhou Powercom Labor Insurance Supplies Co., Ltd, GB2626-2006 is an ear loop design. Further review of website revealed there were no NIOSH-approved products with ear loops and assessment of ear loop designs indicated difficulty achieving a proper fit. Review of the FDA website (https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/personal-protective-equipment-euas#respirators) content current as of 09/21/20, revealed KN95 masks manufactured by Guangzhou Powercom Labor Insurance Supplies Co., Ltd are not approved by the National Institutes of Occupational Safety and Health (NIOSH). The masks were approved for emergency use only.

Based on record review and staff interview, the facility failed to ensure straight catheterization was performed as ordered. This affected one (Resident #38) of three residents reviewed for bladder elimination. The facility census was 37. Findings include: Review of the medical record for Resident #38 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 09/27/19 revealed Resident #38 was alert and oriented. The resident required extensive assistance with bed mobility, transfers, toileting and personal hygiene and was frequently incontinent of bladder. Review of Resident #38's physician orders [REDACTED]. Review of the Treatment Administration Record (TARs) for (MONTH) and (MONTH) 2019 revealed no documentation the straight catheterization was performed on 09/25/19, 09/26/19, 09/29/19, 09/30/19, 10/03/19 and 10/07/19. Interview on 11/20/19 at 11:15 [NAME]M. with the Director of Nursing (DON) and Regional Quality Assurance Manager #9 confirmed there was no documentation the straight catheterization was performed on the above dates. This deficiency substantiates Complaint Number OH 375.

Based on medical record review and interview, the facility failed to ensure weights were obtained, monitored and documented while the resident was receiving a diuretic medication and failed to ensure the physician was notified of blood sugar results. This affected one (Resident #38) of three residents sampled residents. The census was 37. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of Resident #38's admission assessment on 09/20/19 revealed a weight of 204 pounds. There were no weights documented on 09/21/19, 09/22/19, 09/23/19, 09/24/19, 09/25/19, 09/26/19 and 09/28/19. The resident weighed 227.2 pounds on 09/29/19; 227.4 pounds on 09/30/19; 230 pounds on 10/01/19; 230.4 pounds on 10/02/19; 232 pounds on 10/03/19; 233.2 pounds on 10/04/19; 231 pounds on 10/05/19; 230.6 pounds on 10/06/19. Review of the physician notes dated 10/03/19 revealed nursing staff reporting the resident gained another three pounds. The note indicated minimal [MEDICAL CONDITION] and that the resident was morbidly obese making it difficult to tell about fluid with certainty but it did not look as if she was in fluid overload. The plan was to monitor the weight and fluid status. Review of the physician note dated 10/07/19 revealed the resident to have increasing [MEDICAL CONDITION] with considerable [MEDICAL CONDITION] noted. Lungs were documented as being fairly clear. The physician ordered an additional dose of [MEDICATION NAME] one mg. The notes documented the plan was to start the resident [MEDICATION NAME] (diuretic) before the [MEDICATION NAME] (diuretic) and monitor weights. The resident was subsequently admitted to the hospital on [DATE]. During interview on 11/20/19 at 11:15 [NAME]M. the Director of Nursing and the Regional Quality Assurance Manager #9 confirmed the resident's weights were not documented daily as ordered. 2. Physcian orders for Resident #38 dated 09/20/19 revealed Tresiba Flextouch U-100 insulin with 38 units to be administered subcutaneously daily for diabetes mellitus. Review of the nursing notes dated 09/25/19 at 8:00 [NAME]M. revealed the nurse entered the resident's room and found the resident unresponsive to verbal stimuli and to be diaphoretic. Her blood sugar was 38 g/dL. Physician #11 was notified and resident was administered [MEDICATION NAME] (emergent medication to treat low blood sugar, one injection subcutaneously and one Glucose Gel (emergent medication to treat low blood sugar) orally with orders to repeat the blood sugar after 15 minutes. Repeat blood sugar was performed at 8:15 [NAME]M. and was 150 g/dL. At 9:00 P.M. the resident refused the insulin due to fear of her blood sugar going low again and accepted bedtime snack. Review of the physician's orders [REDACTED]. Review of Resident #38's progress notes revealed no documentation the physician was notified of the resident's blood sugar results on 09/25/19, 09/26/19, 09/27/19 and 09/28/19 as ordered. An order dated 10/01/19 reduced the resiba Flextouch U-100 insulin to ten units; later on 10/01/19, an order was received to stop the Triseba. During interview on 11/20/19 at 11:15 [NAME]M., the Director of Nursing and the Regional Quality Assurance Manager #9 confirmed there was no documentation that the physician was notified of the blood sugars as ordered for the dates specified. This deficiency substantiates Complaint Number OH 375.

Based on medical record review, observation, staff and resident interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to provide appropriate assessment including monitoring for a pressure ulcer and the development of a baseline care plan regarding pressure ulcer preventative measures. This resulted in actual harm when Resident #138's stage one pressure ulcer to the coccyx deteriorated to an unstagable area with slough and drainage. This affected one (#138) out of three residents review for pressure ulcers. The facility currently identified four resident with pressure ulcers. Facility census was 38. Findings include: Review of the medical record for Resident #138 revealed an original admission date of [DATE] and a readmitted d of 05/08/18 with [DIAGNOSES REDACTED]. Review of the treatment administration record dated 04/17/18 documented Resident #138 had an ordered dressing change completed to the coccyx with no assessment or monitoring of the area documented. Review of the admission assessment dated [DATE] documented Resident #138 was alert and oriented to person, place, and time. Further review revealed the resident had an old blister area to her right heel and her coccyx was documented as being red. Review of the pressure ulcer risk/Braden scale assessment documented the resident was not at high risk for pressure ulcers. Review of the medical record for Resident #138 revealed there was no acute 48-hour care plan completed after the admission assessment. Review of physician orders dated 05/08/18 documented there was an order for [REDACTED]. Review of the wound assessment progress report dated 05/08/18 documented the resident had a pressure area to her right heel measuring 4.0 centimeters (cm) by 2.0 cm that was dark purple and black with no drainage. It was documented as unstageable. Further review of the document lacked any assessment of Resident #138's reddened coccyx and there was no further assessment and monitoring since 05/08/18 of Resident #138's right heel pressure ulcer. Review of physician progress notes [REDACTED].#138 had a reddened area to her coccyx with a plan to monitor the area. Further review lacked an assessment and documentation of the unstageable right heel pressure ulcer. He also documented the resident was at risk for decubitus ulcer due to her immobility. Review of the weekly skin sweep dated 05/14/18 documented there was no new skin impairments. Review of the wound assessment progress report dated 05/20/18 documented Resident #138's coccyx wound was pressure, measuring 0.4 cm by 0.8 cm and the depth was undetermined. This assessment was completed after surveyor observation. On 05/20/18 at 10:00 A.M., interview with Resident #138 revealed she had a big sore on her buttocks and it has been bothering her for about a week. On 05/20/18 at 1:55 P.M. an observation was made of Resident #138 coccyx with Licensed Practical Nurse (LPN) #345. At this time Resident #138's coccyx was observed to have an open area with serous drainage on the old dressing that was removed. LPN #345 verified the area was open but was unable to provide a full assessment with staging. The pressure area appeared to have yellow slough present. On 05/20/18 at 2:36 P.M., interview with the Director of Nursing (DON) verified Resident #138's pressure ulcers were not being assessed and monitored appropriately as required. She further verified Resident #138 did have a stage one on her coccyx on admission and confirmed there was no further assessment or monitoring of the area until 05/20/18. On 05/21/18 at 11:34 A.M., an observation was made of Resident #138's pressure ulcers. The resident's right heel remained unstageable with no drainage, measuring 2.0 cm by 3.5 cm. The wound to the coccyx measured 0.8 cm by 1.0 cm with slough present in the wound bed and the wound bed was unable to be visualized. It was verified with the DON the wound on the coccyx was currently unstageable due to slough covering the wound bed. On 05/21/18 at 5:21 P.M., interview with LPN #350 revealed when she changed the resident's dressing on 04/17/18, Resident #138 did not have any open areas and the area was pink and blanchable. She stated she did not have any documentation of her assessment completed with the dressing change. Review of the facility policy titled skin management standards (undated) documented pressure areas/skin will be assessed for upon admission and then on a weekly basis during body audits. Any changes in condition will be immediately reported to the supervising nurse. Further review documented the wound will assessed and monitored by the DON on a weekly basis. Review of information from the NPUAP revealed an unstageable pressure injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Further review of the NPUAP revealed to develop a plan of care based on the areas of risk, rather than on the total risk assessment score. Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices.