Every finding on record at Siena Gardens Rehabilitation & Transitional Care

Based on staff interview, medical record review, and review of facility policy, the facility failed to report an allegation of verbal abuse to the state survey agency (SSA). This affected one (#66) of two residents reviewed for abuse. The facility census was 93. Findings include:Review of Resident #66's medical record revealed an admission date of 12/13/24. Diagnoses included chronic peripheral venous insufficiency, cerebral infarction (stroke), and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Review of the plan of care, initiated 12/27/24, revealed Resident #66 experienced an alteration in mood or behavior as evidenced by being paranoid and making false accusations regarding staff. Interventions included to contact the resident's family for support as needed, explain procedures before beginning them, provide medications as ordered, and observe and report any changes in mental status. During an interview on 09/10/25 at 10:59 AM, the Director of Nursing (DON) stated that on 07/09/25 a staff member, whose name she could not recall, approached her and stated that Resident #66 wanted to speak to her. The DON stated she spoke with Resident #66 directly, and the resident alleged that a staff member, Certified Nursing Assistant (CNA) #3, had cursed at them approximately one month prior (June 2025). The DON stated she interviewed the alleged perpetrator and potential witnesses, who all denied that the incident happened. The DON verified she did not report the allegation of verbal abuse involving Resident #66 to the SSA because staff stated that the incident did not occur and because the resident had an existing care plan related to making false allegations against staff. During a follow-up interview on 09/10/25 at 1:59 PM, the DON stated if a resident alleged that a staff member had cursed at them, it was considered verbal abuse, and she would report any allegation of abuse. However, according to the DON, this incident was a special instance where the resident had a known history of false allegations, and the resident did not feel threatened or experience any mental anguish. During an interview on 09/10/25 at 2:35 PM, the Administrator revealed she was unaware of Resident #66's allegation of verbal abuse until today. The Administrator stated any new allegation of abuse was investigated and treated as potentially valid, even when a resident had a care planned history of false accusations. The Administrator stated stated that with Resident #66's history of false accusations, if the DON immediately investigated the allegation, she did not expect the incident to be reported to the SSA. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the advents that caused the allegation did not involve abuse and did not result in serious bodily injury to the Administrator or designee of the facility and to other officials, including the SSA in accordance with State law.

Based on facility personnel record review and staff interview the facility failed to ensure annual performance reviews were completed. This affected three of four State tested Nursing Assistants (STNAs) reviewed (STNAs #324, #325 and #397). The facility census was 94. Findings included: Review of STNA #324's personnel file revealed a date of hire on 08/23/21. Further review of the STNA's personnel file revealed no evidence of an annual performance review. Review of STNA #325's personnel file revealed a date of hire on 09/03/19. Further review of the STNA's personnel file revealed no evidence of an annual performance review. Review of STNA #397's personnel file revealed a date of hire on 10/04/21. Further review of the STNA's personnel file revealed no evidence of an annual performance review. Interview on 10/05/22 at 5:02 P.M. with Human Resources Director (HR) #396 revealed she was not able to provide evidence an annual performance review was completed on STNAs (#324, #325 or #397). Interview on 10/06/22 at 8:17 A.M. with the Director of Nursing (DON) confirmed no annual performance reviews were completed on STNAs (#324, #325 or #397).

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure physician ordered laboratory (lab) tests were completed as ordered. This affected one Resident (#75) of five residents reviewed for unnecessary medications. The facility census was 94. Findings include: Review of the medical record of Resident #75 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition. Review of the plan of care dated 03/01/22 revealed Resident #75 was at risk for [CONDITION(S)] (low blood sugar) and/or [CONDITION(S)] (elevated blood sugar) episodes related to insulin dependent diabetes mellitus (IDDM). Interventions included to complete labs as ordered and report results. Review of the pharmacist recommendations dated 05/06/22 addressed to the Attending Physician/Prescriber revealed the pharmacist recommended for Resident #75 to have a Hemoglobin A1C (three-month measurement of blood sugar) checked on the next lab day and every six months thereafter due to being on antidiabetic medications. The form was signed by the physician on 06/01/22 and the physician was in agreement with the recommendation and to write the order. Review of physician's orders for Resident #75 revealed an order dated 05/24/22 for resident to have laboratory work which included Hemoglobin A1C, complete blood count (CBC), complete metabolic panel (CMP), [CONDITION(S)] stimulating hormone (TSH), vitamin D level completed every six months. Review of lab results for Resident #75 revealed no Hemoglobin A1C labs obtained per physician orders on 05/24/22. Interview on 10/04/22 at 4:45 P.M., the Director of Nursing (DON) verified the Hemoglobin A1C lab for Resident #75 was not completed as ordered. Review of the facility policy titled, Diagnostic Testing, dated 10/21/21, revealed the facility will obtain diagnostic tests (laboratory and radiology) in accordance with the orders from the physician, in accordance with regulatory requirements.

Based on medical record review, hospital record review, interviews with facility staff, and review of the medication incident investigation, the facility failed to ensure residents were free from significant medication errors when one resident (#43) had not received the ordered anticoagulant medication for twenty-two days. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #43 when the resident had not received physician ordered anticoagulant medication, began complaining of right leg pain, chest pain and then subsequently required admission to the hospital with an acute right leg [MEDICAL CONDITION] (blood clot), and a [MEDICAL CONDITION] embolism (blood clot in the lung). This affected one resident (#43) of three reviewed for anticoagulant medication. The facility census was 80. On 02/25/21 at 3:15 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 01/21/21 when Resident #43 had not received her ordered anticoagulant medication for 22 days upon admission from the hospital that resulted in Resident #43 developing a blood clot in her right leg with a [MEDICAL CONDITION] embolism, and subsequently was admitted to the hospital. Review of the local hospital admission record dated 02/22/21 revealed the resident presented with chest pain and right lower extremity pain and swelling and the local hospital physician identified and confirmed Resident #43 had not received her anticoagulant medication since she was discharged from the hospital on [DATE]. While at the hospital, Resident #43 was placed on a cardiac telemetry unit with [MEDICATION NAME] treatment. The Immediate Jeopardy was removed on 02/26/21 when the facility audited all new admission medical records for medication discrepancies, audited medical records and assessed resident's with physician orders [REDACTED]. · On 02/12/21, the DON initiated a review of the case for clinical quality. The nurse, Licensed Practical Nurse (LPN) #20, who completed the initial admission was removed from the schedules until completion of the investigation and one-on-one education could be completed. · On 02/12/21 at 8:00 A.M., the DON completed audits of all admissions since 01/01/21 and 16 new admission records were identified (#75, #28, #18, #76, #77, #78, #43, #79, #17, #80, #03, #81, #82, #63, #26, and #04) with no further medication discrepancies noted. · On 02/12/21 at 9:00 A.M., Corporate Clinician #30 educated the DON regarding the admission order process. · On 02/12/21 at 12:00 P.M., the DON completed one-on-one education with Assistant Directors of Nursing (ADON) #10 and #40 regarding the admissions process. · On 02/12/21 at 12:00 P.M., immediate education on the Admissions Process and Change in Condition was completed with all nursing staff by the DON. All nurses were trained by the end of the day on 02/12/21. · On 02/12/21 at 12:00 P.M., on-going monitoring tools were put in place by the DON/Designee on the Admissions/Readmissions process and Change in Condition times four weeks. All new Admissions/Readmissions will be audited weekly for four weeks. Monitoring will be completed randomly thereafter, and any discrepancies will be addressed by the Quality Assessment and Process Improvement (QAPI) committee. · On 02/12/21 at 3:30 P.M., Medical Director #50, the DON, Administrator and Corporate Clinician #30 were notified, and a QAPI Plan was developed and implemented. · On 02/25/21, the DON, ADONs #10 and #40 initiated assessments for all residents who received anticoagulant medications. The facility identified 14 additional residents (#02, #08, #09, #15, #20, #36, #40, #56, #69, #70, #73, #85, #86, and #88) who received anticoagulant medication. No further issues were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a 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 the medical record revealed Resident #43 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #43 was discharged to the hospital on [DATE] and was readmitted from the hospital on [DATE]. Review of the hospital discharge and continuity of care form dated 01/20/21 revealed Xarelto 20 milligram (mg) one time daily was ordered from the hospital to begin on 01/21/21 and was last received in the hospital on [DATE] at 9:00 A.M. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severe cognitive deficits and received anticoagulant therapy. Review of the plan of care for Resident #43 revealed she received anticoagulant medication for [MEDICAL CONDITION] and was at risk for abnormal bleeding and/or hemorrhage. Interventions included administer medications as ordered and monitor for effectiveness and side effects. Review of the physician orders [REDACTED].#43 did not have an active order for Xarelto (anticoagulant medication) 20 mg by mouth one time daily. Review of the January and February 2021 Medication Administration Record [REDACTED]. Review of the nurse's note dated 01/20/21 and timed 5:20 P.M., documented the DON input the information from the continuity of care form and reviewed with the physician. Review of the nurse's note dated 02/11/21 revealed at 11:09 P.M., Resident #43 was alert and pleasant and had voiced concerns to facility staff regarding right leg and chest pain. The resident's right leg was assessed to be warm and hard to the touch. The physician and family were made aware and ordered the resident to be sent to the local hospital for evaluation. Review of the local hospital admission record dated 02/12/21 revealed the resident presented with right leg and chest pain and the local hospital physician identified and confirmed Resident #43 had not received her anticoagulant medication since she discharged from the hospital on [DATE]. The resident was diagnosed with [REDACTED]. The resident was admitted to the cardiac telemetry unit on a continuous intravenous (IV) [MEDICATION NAME] (anticoagulant medication) drip. Review of the medication incident investigation dated 02/12/21 revealed there was an error for an omitted medication (Xarelto) for Resident #43. The investigation documented LPN #20 had forgot to transcribe the medication as why the error occurred. Interview with the Administrator and the DON on 02/24/21 at 11:00 A.M. verified this was the only medication error they had. Follow up interview on 02/24/21 at 11:15 A.M., the DON revealed Resident #43 was sent out to the emergency roiagnom on [DATE] around 1:00 A.M. for complaints of leg and chest pain. Later the same day on 02/12/21, the DON received a call from the local hospital who requested a reconciliation of Resident #43's medications and the hospital staff asked about Resident #43's Xarelto and it was during this conversation when it was discovered Resident #43 had not received the Xarelto medication as ordered. She further stated LPN #20 had not transcribed the Xarelto medication upon the resident's original admission on 01/20/21. The DON verified Resident #43 had not received the Xarelto from 01/21/21 through 02/12/21, which was a total of 22 days due to the medication not being transcribed correctly. On 03/04/2021 at 10:30 A.M., a telephone interview was attempted with Medical Director #50. A message was left, and no return contact was made. During a telephone interview on 03/04/21 at 4:00 P.M., LPN #20 verified she checked the orders which had already been documented in the electronic health record and she also missed the Xarelto medication on the continuity of care form. Follow up interview on 03/08/21 at 3:05 P.M., the DON verified she entered the information in the queue in the electronic health record from the continuity of care form for Resident #43 and it was then the floor nurses responsibility to check all of the orders with the continuity of care form for a second check. This deficiency substantiates complaint number OH 260.

Based on medical record review, interview, review of the pharmacy delivery receipt, and policy review the facility failed to ensure medications were properly checked in, secured, and available for administration after they were delivered. This affected one resident (#43) of three reviewed for medication storage. The facility census was 80. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #43 was discharged to the hospital on [DATE] and was readmitted from the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severe cognitive deficits and received anticoagulant therapy. Review of physician orders revealed the resident was ordered Eliquis (anticoagulant medication) 5 milligram (mg) twice daily beginning on 02/23/21. Review of the Medication Administration Record [REDACTED].M., dose of the Eliquis medication as it was documented unavailable and documented as given at approximately 2:00 A.M. Review of the nurse progress notes dated 02/23/21 revealed the residents Eliquis was unavailable at the 7:00 P.M., dose and approximately 2:00 A.M., the dose was given, as the shipment of her medications was found by facility staff on a shelf under the nursing station. Review of the pharmacy delivery receipt revealed the shipment of medications for the resident arrived and was signed as received at approximately 9:35 A.M. on 02/23/21. Telephone Interview on 02/25/21 at 1:30 P.M., the Registered Nursing (RN) #199 revealed Resident #43 had not received the ordered dose of Eliquis on the evening of 02/23/21. She stated there were no medications in the medication cart for the resident, and the emergency box of contingency medications was out of Eliquis 5 mg tablets. RN #199 stated she called the pharmacy and was informed all medications for the resident was delivered to the facility on the morning of 02/23/21 at 9:35 A.M. RN #199 verified a small paper bag was found which contained all the medications delivered for Resident #43. RN #199 confirmed the bag was found unattended, below the desk of the nurses's station at approximately 2:00 A.M. on the morning of 02/24/21. Review of the facility policy titled Medication Storage dated 06/21/17 revealed all medications and biologicals are stored safely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members authorized to administer medications. Only licensed nurses, the Consultant Pharmacist, and those authorized to administer medications are allowed access to medications. Medication rooms, carts, and supplies are locked or attended by persons with authorized access. This deficiency substantiates complaint number OH 260.

Based on record review, observation, staff interview, review of facility policy, and review of online resources, the facility staff failed to appropriately use facemask's at the facility entrance when screening employees and essential visitors and while moving throughout the resident care area in order to prevent the potential transmission of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 76 residents residing in the facility. Additionally, the facility staff failed to appropriately disinfect glucometers between resident use which had the potential to affect Residents #2 and #59, two facility-identified insulin-dependent diabetics residing on the 500 Hall. Additionally, the facility failed to use appropriate infection control measures during medication administration which had the potential to affect Resident #72. The census was 76. Findings include: 1. Observation on 06/16/20 at 10:30 A.M. revealed State tested Nursing Assistant (STNA) #100 screened a visiting x-ray technician at the front desk prior to permitting admittance to the facility. STNA #100 was at less than six feet from the visitor while she asked questions regarding possible signs and symptoms of COVID-19 and took the visitor's body temperature. STNA #100 was wearing a facemask which was pulled down below her nose. Observation on 06/16/20 at 10:35 A.M. revealed STNA #100 attempted to take surveyor's body temperature and did not pull her facemask up over her nose until requested to do so by the surveyor. Interview on 06/16/20 at 10:40 A.M. with STNA #100 confirmed she had screened the visiting x-ray technician with her facemask exposing her nose. Observation on 06/16/20 at 10:43 A.M. of Medical Records Clerk #200 revealed she was talking to Resident #58 in the common area of the facility, and they were within six feet of one another. Both Medical Records Clerk #200 and Resident #58 were wearing facemask's but both individuals had their masks pulled down exposing their noses and mouths. Interview on 06/16/20 at 10:45 A.M. with Medical Records Clerk #200 confirmed her facemask was pulled down exposing her nose and mouth while conversing with Resident #58. Medical Records Clerk #200 further confirmed she and Resident #58 were within six feet of one another and the resident's mask was also pulled down exposing his nose and mouth. Interview on 06/16/20 at 10:48 A.M. with the Administrator confirmed facemask's should be worn inside the facility especially when coming into contact with other persons and should cover the nose, mouth, and chin. The facility confirmed this had the potential to affect all residents residing in the facility. Review of facility policy titled Novel Coronavirus Prevention and Response dated 04/09/20 revealed the facility would educate the staff on the proper use of personal protective equipment (PPE) and would implement staff wearing of facemask's in accordance with local, state, and national directives. 2. Observation of medication administration on 06/16/20 at 11:07 A.M. with Licensed Practical Nurse (LPN) #300 revealed nurse cleaned glucometer following a blood sugar check for Resident #59 using an alcohol pad. Interview on 06/16/20 at 11:08 A.M. with LPN #300 confirmed she usually used a disinfectant wipe to clean glucometers, but she didn't have any available on her cart. LPN #300 confirmed the glucometer was used for two residents on the 500 Hall, Residents #2 and #59. Interview on 06/23/20 at 9:16 A.M. with the Director of Nursing (DON) confirmed nurses should clean glucometers with disinfectant wipes and an alcohol pad was not effective for properly cleaning glucometers. Review of facility policy titled Glucometer Cleaning dated April 2015 revealed glucometers should be cleaned after each use with an approved disinfectant wipe. Review of online resource shared per facility https://www.cloroxpro.com/products/Clorox/Clorox-disinfecting-wipes/ on 06/22/20 revealed wipes were appropriate for use on nonporous hard surfaces and for proper disinfection to wipe the surface so it would remain visibly wet for four minutes. Further review of the directions revealed the surface should be allowed to air dry after disinfectant wipe was used and wipes were effective in killing a wide variety of bacteria [MEDICAL CONDITION] including human immunodeficiency virus ,[MEDICAL CONDITION]. and coronavirus. 3. Review of record for Resident #72 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Observation on 06/16/20 at 11:42 A.M. of medication administration per LPN #400 revealed nurse sanitized her hands, opened the medication cart, unlocked the narcotic drawer, and attempted to obtain a dose of [MEDICATION NAME] for Resident #72. The [MEDICATION NAME] tablet fell into the bottom of the narcotic drawer adjacent to other resident's narcotic medication cards. LPN #400 retrieved the [MEDICATION NAME] tablet with her bare hands, placed it in plastic cup, locked the narcotic drawer and the medication cart, and walked to the Resident #72's room to administer the [MEDICATION NAME]. The surveyor interviewed LPN #400 on 06/16/20 at 11:44 A.M. and asked LPN #400 regarding the potential administration of a dose of [MEDICATION NAME] which had been touched with bare hands and had fallen into the narcotic drawer. Interview on 06/16/20 at 11:44 A.M. with LPN #400 confirmed if surveyor had not interviewed/asked her about the [MEDICATION NAME] tablet, she would have administered the dose of [MEDICATION NAME] to Resident #72. Interview on 06/23/20 at 9:16 A.M. with the Director of Nursing (DON) confirmed nurses should not touch resident medication with their bare hands and if a medication falls on the ground or another surface during retrieval it should be wasted and not administered to a resident. Review of facility policy titled Medication Administration dated 06/21/17 revealed the nurse should never touch the resident's medication with their fingers.

Based on medical record review, staff interview, review of medication error reports and review of facility policy, the facility failed administer resident's medications as physician ordered. This affected four (#1, #2, #4 and #6) out of five residents reviewed for medication administration. The facility census was 76. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #6 dated 03/22/20 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Review of physician orders [REDACTED]. Review of the nurse progress note for Resident #6 dated 05/11/20 timed at 7:50 A.M. revealed resident's blood sugar was 29 and nurse attempted to administer glucose gel solution by mouth but resident spit it out and was not able to swallow. Resident #6's blood sugar was rechecked at 8:00 A.M. and was 41 and was checked again at 8:05 A.M. and was 40. Nurse called 911 and resident was sent to the hospital. Review of the Medication Administration Record [REDACTED]. Review of the hospital note for Resident #6 dated 05/11/20 revealed the resident arrived in the emergency room at 8:36 A.M. and the emergency personnel reported the resident's blood sugar was 42 when they picked resident up from the facility. Further review of the hospital note revealed the resident's blood sugar was checked frequently while at the hospital and ranged from 113 to 347. Review of the note revealed the resident was sent back to the facility on [DATE] after her blood sugar had stabilized. Interview on 06/22/20 at 4:28 P.M. with Registered Nurse (RN) #600 confirmed she had been Resident #6's nurse on 05/11/20 and had checked resident's blood sugar at 7:50 A.M. at 29, at 8:00 A.M. at 41, and at 8:05 A.M. at 42. RN #600 confirmed she attempted to care for resident's [DIAGNOSES REDACTED] by administering oral glucose gel, but resident couldn't swallow so it was ineffective. RN #600 confirmed she was aware Resident #6 had a physician's orders [REDACTED]. RN #600 confirmed the [MEDICATION NAME] was not available in the facility and if [MEDICATION NAME] injection had been available, she would have administered it as she felt it would have been effective at stabilizing the resident's blood sugar. 2. Review of the medical record for Resident #2 revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of the MDS for Resident #2 dated 05/18/20 revealed resident was cognitively impaired and required extensive assistance of two staff with ADLs. Review of the May 2020 physician orders [REDACTED]. Review of the care plan for Resident #2 dated 05/26/20 revealed resident was at risk for hypo/[MEDICAL CONDITION] episodes related to insulin dependent diabetes mellitus. Interventions included the following: monitor blood sugar levels as ordered, monitor for signs and symptoms of [DIAGNOSES REDACTED], treat hypo/[MEDICAL CONDITION] episodes as ordered Review of the nurse progress note for Resident #2 dated 05/26/20 timed at 3:00 P.M. revealed. resident was noted to be minimally responsive with a blood sugar of 46. Further review of the note revealed the nurse attempted to obtain [MEDICATION NAME] to administer by injection to treat the resident's [DIAGNOSES REDACTED], but it was not available, and resident was sent to the emergency room via 911. Review of the nurse progress note for Resident #2 dated 05/26/20 timed at 8:36 P.M. revealed the resident had been admitted to the hospital with [REDACTED]. Review of hospital record for Resident #2 dated 05/26/20 revealed resident arrived at the emergency room with altered mental status and blood sugars in the 30's. Further review of the hospital record revealed the resident was given [MEDICATION NAME] (sugar) intravenously in the emergency room and his blood sugar returned to the normal range. Review of the record revealed resident was admitted with a [DIAGNOSES REDACTED]. Interview on 06/23/20 at 9:16 A.M. with the Director of Nursing (DON) confirmed [MEDICATION NAME] was not available for administration to Resident #6 on 05/11/20 nor for Resident #2 on 05/26/20. Review of facility policy titled [DIAGNOSES REDACTED] dated April 2015 revealed if a resident's blood glucose level was less than 70 milligrams per deciliter and the resident was unable to swallow and/or was unresponsive staff should administer [MEDICATION NAME] via intramuscular injection when ordered. 3. Review of the medical record for Resident #1 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #1 dated 05/20/20 revealed resident was cognitively intact and required supervision with activities of daily living. Review of nurse progress note for Resident #1 dated 06/11/20 revealed the resident reported the night shift nurse had given her something to drink earlier for her potassium and she only took a few drinks because it tasted like sand and resident didn't think there was anything wrong with her potassium levels. Review of facility medication error report dated 06/11/20 revealed Licensed Practical Nurse (LPN) #700 had administered Kayexelate (a medication to treat high potassium levels) to Resident #1, but resident did not have a physician's orders [REDACTED]. Review of June 2020 physician orders [REDACTED]. Interview on 06/22/20 at 2:30 P.M. with the Administrator confirmed Resident #1 received Kayexelate per LPN #700 on 06/11/20, but the medication was supposed to be administered to Resident #4. 4. Review of the medical record for Resident #4 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS for Resident #4 dated 04/14/20 revealed resident was cognitively impaired and required extensive assistance of one staff with ADLs. Review of care plan for Resident #4 dated 01/20/20 revealed resident had impaired cardiac function related to [MEDICAL CONDITION], hypertension, and [MEDICAL CONDITION]. Interventions included the following: medications as ordered, monitor for side effects of cardiac medications. Review of lab results for Resident #4 dated 06/10/20 revealed resident's potassium level was 5.6 which was elevated with a normal range being 3.5-5.3. Review of nurse progress note for Resident #4 dated 06/11/20 per LPN #300 revealed nurse received a physician's orders [REDACTED]. Further review of Medication Administration Record [REDACTED]. Review of nurse progress note for Resident #4 dated 06/15/20 per LPN #300 revealed order for Kayexelate was discontinued. Interview on 06/23/20 at 9:16 A.M. with the Director of Nursing (DON) confirmed LPN #700 had administered Kayexelate to Resident #1 without a physician's orders [REDACTED]. Review of the facility medication error log for June 2020 revealed only one error in which Resident #1 was administered Kayexelate per LPN #700 without a physician's orders [REDACTED].>Review of facility policy titled Medication Administration dated 06/21/17 revealed medications should be administered in accordance with accepted standards of clinical practice. This deficiency substantiates Complaint Number OH 378.

Based on record review, interview, and review of facility policy the facility failed to ensure the attending physician timely addressed pharmacy recommendations. This affected one (Resident #61) of five residents reviewed for unnecessary medications. The facility census was 64. Findings include: Record review revealed Resident #61 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia without behavioral disturbance, pain in both shoulders, [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris, [MEDICAL CONDITION], [MEDICAL CONDITIONS], age related [MEDICAL CONDITION] without current pathological fracture, major [MEDICAL CONDITIONS], diabetes mellitus, gastro [MEDICAL CONDITION] reflux disease without esophagitis, essential hypertension and type two diabetes mellitus. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, eating and personal hygiene. Resident #61 also required total dependence with transfers and toileting. Review of Resident #61's pharmacy recommendation dated 02/20/19 revealed Resident #61's [MEDICATION NAME] 0.5 milligram (mg) every four hours as needed for anxiety on 02/19/19 was recommended to have a duration of treatment for [REDACTED]. Further review of the pharmacy recommendation revealed Nurse Practitioner #500 did not address the pharmacy recommendation until 04/08/19. Review of Resident #61's pharmacy recommendation dated 03/14/19 revealed Resident #61's [MEDICATION NAME] 40 mg was recommended to have routine labs. Further review of the pharmacy recommendation revealed Nurse Practitioner #500 did not address the pharmacy recommendation until 04/08/19. Review of Resident #61's physician's visits revealed the resident was seen by Nurse Practitioner #500 on 02/22/19 and 03/21/19. Resident #61 was also seen by her physician on 03/15/19. Interview with the Director of Nursing (DON) on 10/02/19 at 4:57 P.M. verified Resident #61's pharmacy recommendations dated 02/20/19 and 03/14/19 were not addressed by Nurse Practitioner #500 until 04/08/19. Review of the facility's Medication Monitoring policy dated 06/21/17 revealed the attending physician must address the pharmacy recommendations in a timely manner that meets the needs of the residents but no later than their next routine visit to assess the resident.

Based on medical record review, staff interview, and review of facility policy the facility failed to timely notify the physician about a resident's weight gain. This affected one (Resident #38) of 16 residents reviewed during the investigative phase of the annual survey. The facility census was 64. Findings include: Medical record review revealed Resident #38 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38's cognition was slightly impaired. The resident required extensive physical assistance of two persons for bed mobility, transfers, dressing and toileting. Resident #38 was noted as having required limited assistance with eating and was always continent of both bladder and bowel. Review of Resident #38's active physician's orders revealed an order which indicated to weigh daily, and to notify the physician if weight was greater than two and one-half pounds in 24 hours or greater than five pounds in a week. Review of Resident #38's (MONTH) 2019 Treatment Administration Record (TAR) revealed on 09/20/19 a weight of 202 pounds was charted. On 09/21/19 a weight of 211 pounds was charted, this was an increase of nine pounds in 24 hours. Review of Resident #38's progress notes which were silent for physician notification until 09/24/19. Interview on 10/03/19 at 3:11 P.M. with Registered Nurse (RN) #300 verified the facility did not timely notify the physician of Resident #38's weight gain. Review of the facility policy titled Change of Condition revision date (MONTH) 2003 revealed a change of condition as a significant change in the resident's clinical condition or status which included but not limited to cardiovascular. Procedures included notifying the physician and documenting the notification in the medical record.

Based on record review and interview, the facility failed to ensure a significant change comprehensive assessment was completed within 14 days of a resident being admitted to hospice services. This affected one (Resident #21) of 16 residents reviewed for significant change assessments. The facility census was 64. Findings include: Record review revealed Resident #21 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia without behavioral disturbance, unspecified [MEDICAL CONDITION] end of right radius, type two diabetes mellitus without complications, [DIAGNOSES REDACTED], essential hypertension, [MEDICAL CONDITION], cerebral infarction and [MEDICAL CONDITION]. Review of Resident #21's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive assistance with bed mobility, dressing, transfers, toileting and personal hygiene. Resident #21 also required limited assistance with eating. Further review of the MDS revealed the resident was not on hospice services. Further review of the medical record revealed resident was admitted to hospice services on 07/20/19 with a [DIAGNOSES REDACTED].#21's medical record after she was admitted to hospice services. Interview with Regional Nurse Consultant #300 on 10/02/19 at 1:24 P.M. verified Resident #21 did not have a significant change comprehensive assessment completed within 14 days of the resident being admitted to hospice services.

Based on record review and interview, the facility failed to ensure a resident's discharge recapitulation summary included the resident's medications. This affected one (Resident #63) of one resident reviewed for a discharge to the community. The facility census was 64. Findings include: Record review revealed Resident #63 was admitted to the facility on [DATE] with the following diagnoses; unilateral primary [MEDICAL CONDITION], other symbolic dysfunctions, difficulty in walking, dysphagia, muscle weakness, [MEDICAL CONDITION], spinal stenosis, age related [MEDICAL CONDITION] without current pathological fracture, [MEDICAL CONDITION], restless leg syndrome and major [MEDICAL CONDITION]. Resident #63 discharged from the facility on 08/10/19. Review of Resident #63's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, transfer and toileting. Resident #63 also required limited assistance with eating and personal hygiene. Review of the facility's discharge assessment signed by the resident on 08/10/19 revealed no information regarding the resident's medications, reconciliation of the resident's medications, education of the resident on her medications nor a medication list being provided to the resident. Review of Resident #63's progress notes dated 08/10/19 revealed the resident discharged home on[DATE] with skilled nursing, physical therapy, occupational therapy and speech therapy through a home health provider. Further review of Resident #63's progress note revealed no medications were sent with the resident and the resident left the facility in a wheelchair with her resident representative. Interview with Regional Nurse Consultant #300 on 10/03/19 at 1:39 P.M. verified that Resident #63's discharge recapitulation did not include any information regarding the resident's medications that the resident was to continue after discharge.

Based on medical record review and staff interview, the facility failed to obtain weights and blood pressure readings per physician orders. This affected two Residents (#28 and #38) of 16 reviewed during the investigative phase of the survey. The facility census was 64. Finding include: 1. Medical record review revealed Resident #38 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38's cognition was slightly impaired, and the resident required extensive physical assistance of two persons for bed mobility, transfers, dressing and toileting. Resident #38 required limited assistance with eating and was always continent of both bladder and bowel. Review of Resident #38's active physician's orders [REDACTED]. Review of the facility provided weights and vitals summary dated 08/01/19 to 10/03/19 revealed no weight was recorded for the following days: 08/06/19 through 08/12/19, 08/14/19, 08/15/19, 08/21/19, 08/24/19, 08/26/19, 08/30/19, 09/03/19, 09/04/19, 09/05/19, 09/08/19, 09/15/19, 09/16/19, 09/17/19 and 09/20/19. Interview on 10/03/19 at 3:11 P.M. with Registered Nurse (RN) #300 who verified facility had no evidence that they were obtaining the weights every day per physician orders. 2. Review of Resident #28's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #28's quarterly MDS dated [DATE] revealed her cognition was intact, and the resident required one person physical assistance for most activities of daily living except eating which was noted as set up help only. Review of Resident #28's active physician's orders [REDACTED]. Review of the facility provided weights and vitals summary dated 11/02/18 to 10/03/19 revealed the facility was not obtaining the blood pressures twice a day as ordered by the physician. Interview on 10/03/19 at 3:11 P.M. with Registered Nurse (RN) #300 verified the facility had no evidence that they were obtaining the blood pressure readings per physician orders.

Based on medical record review, observation, resident interview and staff interview, the facility failed to ensure a resident was provided appropriate assistance during incontinence care to prevent an avoidable fall. This affected one (Resident #56) of seven residents reviewed for falls. The facility census was 64. Findings include: Medical record review revealed Resident #56 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56's cognition was severely impaired. Resident #56 was noted under section G in the MDS as a two person physical assist for bed mobility, dressing and toileting. Review of the plan of care for activities of daily living self-performance revealed Resident #56 was noted as non-ambulatory and having been dependent required assistance of two persons for bed mobility and positioning. Review of a progress note dated 09/28/19 at 11:55 P.M. revealed an State tested Nurse Aide (STNA) the the nurse the resident had a major fall. The nurse went assessed the resident who was lying on her back with her right hand under her head. Review of a progress note dated 09/29/19 at 12:50 [NAME]M. revealed the physician and family were notified of the fall and Resident #56 was sent out to the local hospital. The nurse called the hospital and was informed Resident #56 would be returning to the facility. Resident #56 was found with no abnormalities after testing and evaluation at a local hospital. Review of a progress note dated 09/29/19 at 1:16 [NAME]M. revealed Resident #56 returned to the facility at 1:15 [NAME]M. Resident #56's vital signs were stable, neurological checks were recommenced. The oral report from the hospital revealed the computerized topography (CT) tests revealed no abnormalities. The writer of the note documented Resident #56's left side of the face including the left cheek was swollen with a contusion noted. The left side of the head in front was noted with a bruise. Review of a progress noted dated 09/29/19 at 8:07 [NAME]M. revealed the resident had bluish discoloration on the left eye. Review of a progress note dated 09/29/19 at 3:49 P.M. revealed the resident had bruising to her left eye, left cheek, left side of forehead and some swelling was also noted. The resident had complained of pain and had been given Tylenol (pain reliever). Review of a progress noted dated 09/29/19 at 6:05 P.M. revealed Resident #56's pain score was zero and her pain medication (Tylenol) was effective. Review of progress note dated 10/01/19 at 9:18 P.M. revealed Resident #56 was sent back to a local hospital due to complaints of a headache and lethargy (tiredness). The physician and family were notified. Review of a progress note dated 10/02/19 at 12:32 [NAME]M. revealed Resident #56 returned to the facility with new orders for [MEDICATION NAME] (narcotic pain reliever) five-325 milligrams (mg) for three days as needed for pain, [MEDICATION NAME] (anti-emetic for nausea and vomiting) and [MEDICATION NAME] (antibiotic) 300 mg by mouth twice daily for 10 days for a urinary tract infection. Further review of the progress note revealed a new [DIAGNOSES REDACTED]. The resident's [MEDICATION NAME] bag (collection for urine) was noted to have been changed upon her return. The writer of the note documented calls were made to the physician and the family. Vitals were obtained and were within normal limits. No new skin issues were noted. Observation on 10/02/19 at 12:39 P.M. revealed Resident #56 in bed and the left side of the resident's face and neck were observed with bruising. STNA #320 was feeding the resident. Interview with STNA #320 at the time of the observation stated normally the resident ate in the dining room but the resident had not been feeling well the past few days and had been eating in her room. Interview on 10/02/19 at 12:49 P.M. with Licensed Practical Nurse (LPN) #324 stated Resident #56 required a Hoyer (mechanical lift) for transfers and she had a fall recently. LPN #324 stated she was not working at that time of the fall and was not sure what happened. Interview on 10/02/19 at 1:33 P.M. with STNA #382 stated Resident #56 required a Hoyer to get out of bed and she knew the resident had a fall on night shift, but was not aware of the details of the fall. Interview and observation on 10/03/19 at 9:19 [NAME]M. with Resident #56 revealed bruising to her left face, check and neck. Resident #56 stated her pain had been under control and she had not had increased pain. Resident #56 stated the facility was assessing her pain and her bruising on a regular basis. She stated she bruised easy because of her medications. She was unable to recall the name of which STNA was working on the night she fell (09/28/19). She stated she was not able to assist much with her check and changes (incontinence care). She stated typically the facility used one to two persons to perform her check and changes for incontinence care but she felt more comfortable when two persons were used. She stated the STNA had rolled her toward the window to perform the check and change, then rolled her toward the other side (the left side), she simply got to close to the edge of the bed and rolled out and hit the floor. She indicated fall mats were added after her fall. She indicated the fall was an accident that she was too close to the edge of the bed and rolled off. Interview on 10/03/19 at 1:51 P.M. with STNA #393 stated Resident #56 was not able to use her legs, but was capable of using her arms and hands. STNA #393 stated the resident was a two person for bed mobility, rolling and check and change. STNA #393 stated the online tool for STNAs to use for residents called a Kardex stated one to two persons for bed mobility but STNA #393 stated the resident required a Hoyer for transfers. STNA #393 stated in report she had been told the resident was a two person for bed mobility and check and change. STNA #393 stated she had always known Resident #56 as a two person assist. Interview on 10/03/19 at 2:22 P.M. with Registered Nurse (RN) #300 and the Director of Nursing (DON) who reviewed the facility fall investigation. The DON stated the resident had stated she rolled out of bed and the nurse did not witness the fall. The nurse walked in and found the resident laying on her back next to the bed. The DON indicated the nurse obtained vital signs, did a head to toe assessment with no active bleeding observed. The facility notified the physician who stated to send the resident out due to the resident being on [MEDICATION NAME] (blood thinner). The resident was sent out to the hospital and neurological checks were completed upon return. Review of the statement from the STNA who provided care to the resident at the time of fall revealed the STNA was providing incontinence care for the resident and indicated the resident rolled out of bed. The STNA was working by herself when performing the care for the resident. As an immediate fall intervention, fall mats were added. This deficiency substantiates Complaint Number OH 324.

Based on record review and interview, the facility failed to ensure a resident's discharge order was accurately documented in the chart. This affected one (Resident #63) of 16 residents reviewed for accurate medical records. The facility census was 64. Findings include: Record review revealed Resident #63 was admitted to the facility on [DATE] with the following diagnoses; unilateral primary [MEDICAL CONDITION], other symbolic dysfunctions, difficulty in walking, dysphagia, muscle weakness, [MEDICAL CONDITION], spinal stenosis, age related [MEDICAL CONDITION] without current pathological fracture, [MEDICAL CONDITION], restless leg syndrome and major [MEDICAL CONDITION]. Resident #63 discharged from the facility on 08/10/19. Review of Resident #63's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, transfer and toileting. Resident #63 also required limited assistance with eating and personal hygiene. Review of Resident #63's physicians order dated 08/07/19 revealed the resident was to discharge home on 08/11/19 with skilled nursing, physical therapy, occupational therapy and speech therapy through a home health provided. Review of the facility's discharge assessment signed by the resident on 08/10/19 revealed no information regarding the resident's medications, reconciliation of the resident's medications, education of the resident on her medications and a medication list being provided to the resident. Review of Resident #63's progress notes dated 08/10/19 revealed resident discharged home on[DATE] with skilled nursing, physical therapy, occupational therapy and speech therapy through a home health provider. Interview with Regional Nurse Consultant #300 on 10/03/19 at 1:39 P.M. verified Resident #63 was discharged from on the facility on 08/10/19. Regional Nurse Consultant #300 also confirmed Resident #63's discharge order dated 08/07/19 indicated resident was to discharge from the facility on 08/11/19. Regional Nurse Consultant #300 reported the discharge order was incorrectly entered for the wrong date.

Based on record review and interview, the facility failed to provide a copy of the transfer and discharge notification to the Ombudsman for a discharge from the facility. This affected one (Resident #61) of three residents reviewed for discharge notification. The facility census was 64. Findings include: Record review revealed Resident #61 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia without behavioral disturbance, pain in both shoulders, [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris, [MEDICAL CONDITION], [MEDICAL CONDITIONS], age related [MEDICAL CONDITION] without current pathological fracture, major [MEDICAL CONDITIONS], diabetes mellitus, gastro [MEDICAL CONDITION] reflux disease without esophagitis, essential hypertension and type two diabetes mellitus. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, eating and personal hygiene. Resident #61 also required total dependence with transfers and toileting. Further review of Resident #61's medical revealed the resident was discharged to the hospital on [DATE] with right broken hip and returned to the facility on [DATE]. Further review of the medical record revealed no notification to the Ombudsman regarding Resident #61's discharge to the hospital on [DATE]. Interview with Regional Nurse Consultant #300 on 10/02/19 at 5:23 P.M. verified the Ombudsman was not notified of Resident #61's discharge from the facility to the hospital on [DATE].

Based on staff interview and medical record review, the facility failed to ensure all falls were documented in the medical record. This affected one (Resident #5) of three residents reviewed for falls. The facility census was 61. Findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/19, revealed the resident had moderately impaired cognitive skills for daily decision making and extensive assistance was required with bed mobility and transfers. Review of the nursing progress note dated 07/08/19 at 11:30 A.M. revealed the nurse was called to Resident #5's room by family. Resident #5's right wrist was wrapped with a wash cloth and handkerchief. The family removed the wrap and asked if the residents wrist was broken. Swelling and purple, green, yellow bruising, approximately the size of a half dollar noted just below the right hand, where the hand attached to the wrist, on the inner side. No bruising was noted to the top of the hand, wrist or forearm. No grimacing, crying out, guarding or pulling away was done by the resident. Resident was able to move all five fingers. The hand was able to be gently bent back but due to swelling, the hand was unable to bend all the way down. The family was informed an x-ray could be obtained but if the wrist was broke, the resident would have to be sent out to have the wrist cast. The family member reported needing to discuss this with other family members. By the end of the shift, the family had not been back in contact with the nurse. Information was passed along to oncoming nurse. Review of the nursing progress note, dated 07/09/19 at 2:45 P.M., revealed the family informed the nurse Resident #5 had increased bruising to the right hand/wrist and it was slightly swollen. Upon assessment, Resident #5 did not show any signs of discomfort. The physician was notified and x-rays were ordered. Review of the nursing progress note, dated 07/09/19 at 7:57 P.M., revealed the x-ray results revealed impacted [MEDICAL CONDITION] radius. Physician notified and resident transported to the hospital for splinting. Review of nursing progress note dated 07/10/19 at 12:48 A.M. revealed Resident #5 returned to the facility and the family was asked how the resident obtained the injury. The family member informed staff they needed to talk to a different family member to obtain the story. The medical record was silent to the resident had a fall. Review of the right wrist x-ray result, dated 07/09/19, revealed an impacted distal radial fracture. Review of emergency physician note, dated 07/09/19, revealed the resident presented to the emergency room with a impacted right distal radius fracture for splinting. Interview on 07/13/19 at 4:48 P.M. with the Director of Nursing (DON) to review falls reported Resident #5 fell on [DATE] at 7:00 A.M. Resident #5's family came in prior to breakfast, the resident was up in a wheelchair, the family member turned to straighten up the residents bed, and heard a boom. Resident #5 had placed her arm through the opening of the wheelchair, under the arm rest and fell forward in the wheelchair resulting in a wrist fracture. The DON verified the fall was not documented in the residents medical record as it was not discovered until after the wrist fracture was diagnosed .

Based on staff interview, medical record review, and review of the facility's abuse policy, the facility failed to immediately report an injury of unknown source to the Administrator and/or management. This affected one (Resident #5) of three residents reviewed during the survey. The facility census was 61. Findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/19, revealed the resident had moderately impaired cognitive skills for daily decision making and extensive assistance was required with bed mobility and transfers. Review of nursing progress note dated 07/08/19 at 11:30 A.M. revealed the nurse was called to Resident #5's room by family. Resident #5's right wrist was wrapped with a wash cloth and handkerchief. The family removed the wrap and asked if the residents wrist was broken. Swelling and purple, green, yellow bruising, approximately the size of a half dollar noted just below the right hand, where the hand attached to the wrist, on the inner side. No bruising was noted to the top of the hand, wrist or forearm. No grimacing, crying out, guarding or pulling away was done by the resident. Resident was able to move all five fingers. The hand was able to be gently bent back but due to swelling, the hand was unable to bend all the way down. The family was informed an x-ray could be obtained but if the wrist was broke, the resident would have to be sent out to have the wrist cast. The family member reported needing to discuss this with other family members. By the end of the shift, the family had not been back in contact with the nurse. Information was passed along to oncoming nurse. Review of the nursing progress note, dated 07/09/19 at 2:45 P.M., revealed the family informed the nurse Resident #5 had increased bruising to the right hand/wrist and it was slightly swollen. Upon assessment, Resident #5 did not show any signs of discomfort. The physician was notified and x-rays were ordered. Review of the nursing progress note, dated 07/09/19 at 7:57 P.M., revealed the x-ray results revealed impacted [MEDICAL CONDITION] radius. Physician notified and resident transported to the hospital for splinting. Review of nursing progress note dated 07/10/19 at 12:48 A.M. revealed Resident #5 returned to the facility and the family was asked how the resident obtained the injury. The family member informed staff they needed to talk to a different family member to obtain the story. Review of the right wrist x-ray result, dated 07/09/19, revealed an impacted distal radial fracture. Review of the emergency physician note, dated 07/09/19, revealed the resident presented to the emergency room with a impacted right distal radius fracture for splinting. Interview on 07/13/19 at 4:48 P.M. with the Director of Nursing (DON) reported Resident #5 fell on [DATE] at 7:00 A.M. Resident #5's family came in prior to breakfast, the resident was up in a wheelchair, the family member turned to straighten up the resident's bed, and heard a boom. Resident #5 had placed her arm through the opening of the wheelchair, under the arm rest and fell forward in the wheelchair resulting in a wrist fracture. The DON acknowledged the fall was not documented in the residents medical record as it was not discovered until after the wrist fracture was diagnosed . The family member present with the resident when the incident occurred did not inform staff about the fall but just requested the nurse assess the residents wrist. The nurse assessed the wrist on 07/08/19, noted swelling and bruising, and was unaware how the resident obtained the injury. The nurse didn't inform the physician or management about the injury and left it up to the family to decide what treatment they wanted to pursue. On 07/09/19, a different family member came to the facility and requested another nurse to assess the hand. The physician was then notified about the injury, an x-ray was obtained which showed a fracture and the resident was transported to the hospital for treatment. Upon return to the facility from the hospital, the family member still did not provide any information about the circumstances of the injury. Once the resident returned to the facility from the hospital with a diagnosed wrist fracture, the DON was notified about the injury. The DON then contacted the Administrator whom arrived at the facility early on 07/10/19 to meet with the family. It was at the meeting with the family on 07/10/19 when the circumstances of the fall and wrist injury were explained to the Administrator. The DON confirmed the nurse did not notify management about an injury of unknown source for over 24 hours until after the wrist fracture was diagnosed and treated. Review of Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy, dated 11/21/16, revealed an injury classified as an injury of unknown source when both the following conditions were met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. All incident and allegation of Abuse, Neglect, Exploitation, Mistreatment of [REDACTED].

Based on staff interview, medical record review, and review of facility policy, the facility failed to timely notify the physician about a hand/wrist injury. This affected one (Resident #5) of three residents reviewed during the survey. The facility census was 61. Findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/19/19, revealed the resident had moderately impaired cognitive skills for daily decision making and extensive assistance was required with bed mobility and transfers. Review of nursing progress note dated 07/08/19 at 11:30 A.M. revealed the nurse was called to Resident #5's room by family. Resident #5's right wrist was wrapped with a wash cloth and handkerchief. The family removed the wrap and asked if the residents wrist was broken. Swelling and purple, green, yellow bruising, approximately the size of a half dollar noted just below the right hand, where the hand attached to the wrist, on the inner side. No bruising was noted to the top of the hand, wrist or forearm. No grimacing, crying out, guarding or pulling away was done by the resident. Resident was able to move all five fingers. The hand was able to be gently bent back but due to swelling, the hand was unable to bend all the way down. The family was informed an x-ray could be obtained but if the wrist was broke, the resident would have to be sent out to have the wrist cast. The family member reported needing to discuss this with other family members. By the end of the shift, the family had not been back in contact with the nurse. Information was passed along to oncoming nurse. The medical record was silent to the notification to the physician of the resident's right wrist with swelling and purple, green,and yellow bruising. Review of the nursing progress note, dated 07/09/19 at 2:45 P.M., revealed the family informed the nurse Resident #5 had increased bruising to the right hand/wrist and it was slightly swollen. Upon assessment, Resident #5 did not show any signs of discomfort. The physician was notified and x-rays were ordered. Review of the nursing progress note, dated 07/09/19 at 7:57 P.M., revealed the x-ray results revealed impacted [MEDICAL CONDITION] radius. Physician notified and resident transported to the hospital for splinting. Review of nursing progress note dated 07/10/19 at 12:48 A.M. revealed Resident #5 returned to the facility and the family was asked how the resident obtained the injury. The family member informed staff they needed to talk to a different family member to obtain the story. Review of the right wrist x-ray result, dated 07/09/19, revealed an impacted distal radial fracture. Interview on 07/13/19 at 4:48 P.M. with the Director of Nursing (DON) to review falls reported Resident #5's fell on [DATE] at 7:00 A.M. Resident #5's family came in prior to breakfast, the resident was up in a wheelchair, the family member turned to straighten up the resident's bed, and heard a boom. Resident #5 had placed her arm through the opening of the wheelchair, under the arm rest and fell forward in the wheelchair resulting in a wrist fracture. The DON acknowledged the fall was not documented in the resident's medical record as it was not discovered until after the wrist fracture was diagnosed . The nurse didn't inform the physician or management about the injury and left it up to the family to decide what treatment they wanted to pursue. The DON confirmed the physician was not notified until the following day after the injury was discovered to Resident #5's hand/wrist. Review of the Change of Condition policy, dated 10/18/01, revealed a change of condition was defined as deterioration in the health, mental, or psychosocial status of a resident related to a life-threatening condition, a significant alteration in treatment, or a significant change in the resident's clinical condition or status. Significant alteration in treatment is defined as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new treatment, or the decision to transfer a resident to a hospital. Life-threatening conditions may include broken bones, depending on severity. The charge nurse will notify the resident, physician and guardian/interested family member of all changes.

Based on medical record review, review of facility policy and resident, family and staff interviews, the facility failed to ensure one (#1) of six sampled residents received proper assistive devices to prevent accidents. Actual harm occurred when Resident #1 suffered right proximal and distal fibula and tibia fractures as well as right fractures to the first and second toes following an improper transfer by facility staff. The facility identified 56 residents who required assistance or were dependent on staff for transfers. The facility census was 59. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care, dated 10/22/18, revealed the resident was at risk for falls due to weakness, [MEDICAL CONDITION] and being non-ambulatory. Interventions included a Hoyer lift for all transfers. Review of the plan of care, dated 12/03/19, revealed the resident had impaired activities of daily living (ADL) self-performance due to weakness deconditioning and impaired mobility. Interventions included the use of a Hoyer lift for transfers. Review of the fall risk assessment, dated 01/18/19, identified the resident as being a fall risk. Review of a quarterly Minimum Data Set (MDS) assessment, dated 01/22/19, revealed Resident #1 had a good memory and recall. The resident required total dependence of two staff members for bed mobility and transfers. Resident #1 was identified as a mechanical (Hoyer) lift for transfers. Review of the physician order, dated 02/07/19, revealed the order was for the use of a Hoyer lift for transfers on every shift. Review of the nurse's notes, dated 03/30/19 at 12:23 A.M., revealed the nurse assessed the resident to have bilateral swollen extremities. There was bruising on top of the first three toes starting with the great toe. The resident also had bruising on the front of right lower extremity. The resident complained that during a transfer, she was lowered to the ground and was now complaining of right lower extremity pain. The physician ordered x-rays of right lower extremity and they were negative for any fractures at this time. Further review of the nurse's notes, dated 03/31/19 at 9:42 A.M., revealed the resident continued to complain of right lower extremity pain, the area very warm to touch and unequal warmth to her left leg. The skin above her knee was bluish in color, her lateral right knee was red, the top of her right foot was bluish, and her right great toe was red. The progress note, dated 04/02/19 at 1:32 P.M., revealed the physician gave an order to use ice on right lower extremity on for 20 minutes with barrier in between three times a day as needed every eight hours. On 04/03/19 at 2:38 P.M., the bilateral lower extremities x-rays were completed. On 04/03/19 at 4:39 P.M., the physician gave an order to send the resident to the emergency department due to the result of the x-ray revealed suspected fractures of the first metatarsal, distal tibia and fibula. On 04/03/19 at 5:55 P.M., the resident was transported to the emergency department. On 04/03/19 at 11:46 P.M., the hospital called the facility and confirmed Resident #1 was being admitted to the hospital for multiple fractures including the right femur, tibia/ fibula, two toes and top of the foot. Review of the hospital emergency room physician documentation, dated 04/03/19 at 6:16 P.M., revealed Resident #1 arrived at the emergency room with a complaint of right ankle pain and right knee pain after being transferred from a bed to the wheelchair on 03/29/19 and being dropped during the transfer. Resident #1 told the physician she landed on the right leg and has had pain since. The physician's assessment revealed Resident #1's right knee, right lower leg, right ankle and right foot were swollen and tender to palpation with a decrease in range of motion. The left lower leg had bruising. X-rays at that time showed multiple fractures to the right lower extremity in the foot and tibia/fibula. Review of the Orthopedic Surgeons documentation, dated 04/04/19 at 12:10 P.M., revealed that he was treating her for right proximal and distal fibula and tibia fractures as well as right fractures to the first and second toes, resulting from the inappropriate transfer on 03/29/19. Review of State tested Nursing Aide's (STNA) #5 written statement, dated 04/02/19, revealed on 03/29/19, she was assisting a transfer with her supervisor, Former Registered Nurse (FRN) #8. Resident #1's plan of care required a Hoyer lift but her supervisor, FRN #8, suggested they do a two-person transfer. She expressed that she had never transferred Resident #1 in that way, but she decided to go forward with the transfer as directed by her supervisor, FRN #8. Review of FRN #8's written statement, dated 04/02/19, revealed on 03/29/19, she was helping STNA #5 to get weights. She took Resident #1's wheelchair down to get it weighed but did not put the Hoyer lift pad in the chair to be included in the weight. FRN #8 and STNA #5 tried to do a two person assist, and not use the Hoyer lift, to transfer Resident #1 from her bed into the wheelchair. Resident #1 has zero lower body strength and said the resident was going down, dead weight, at that time. Resident #1 was on her knees. STNA #5 and FRN #8 were able to lift her from this position but not enough to get her bottom into the wheelchair. Resident #1 was then laid down onto the floor, rolled over and the Hoyer lift pad was placed under her. Once connected to the lift, she was raised off the floor and put into the wheelchair. Resident #1 was then taken to the shower room and weighed. FRN #8 told Resident #1 that the floor nurse would be told of having to lower her to the floor. Interview on 04/23/19 at 12:00 P.M. with Resident #1 confirmed that on 03/29/19, around lunch time, STNA #5 and FRN #8 told her that they needed to get her out of the bed to obtain her weight. Resident #1 stated that the staff told her they were going to have to lift her out of the bed into the wheelchair. Resident #1 revealed she had never been transferred that way before. The staff had always used the Hoyer lift. Both FRN #8 and STNA #5 helped set her on the side of the bed. They then put their arms under hers and lifted. Once her feet touched the floor, she could not stand. At that time, FRN #8 could not hold her up, so both FRN #8 and STNA #5 lowered her down onto the floor on her knees. Resident #1 revealed that this was very painful, and she begged the staff to get extra help in getting her up. Both FRN #8 and STNA #5 told her they would be able to get her up. They helped her to lay down on the floor and put the Hoyer lift pad under her. After that, they lifted her off the floor with the Hoyer lift and placed her into the wheelchair. FRN #8 then took her down to the shower room to get her weight. Once FRN #8 finished obtaining the weight, she was taken back to her room. Resident #1 revealed she has not stood and bared any weight since being admitted to the facility. Resident #1 stated that the inappropriate transfer did result in fractures to her right leg, foot and toes. Interview on 04/23/19 at 1:29 P.M. with STNA #5 confirmed on 03/29/19 around lunch time, she was requested to assist getting Resident #1 out of bed for a weight by her supervisor, FRN #8. FRN #8 took the resident's wheelchair to get it weighed before the transfer. When she returned to the room, she realized she had not put the Hoyer lift pad in the wheelchair when she weighed the wheelchair. FRN #8 told STNA #5 said they would complete the transfer with a two-person assistance from her bed to her wheelchair, versus using the Hoyer lift, since it was lunch time and they were in a hurry. STNA #5 revealed that FRN #8 was her supervisor and she did not want to get into trouble by refusing to do the two-person assist transfer, but she had only transferred Resident #1 with a Hoyer lift in the past. As they assisted the resident over to the wheelchair, she became too heavy as she was not bearing any weight and FRN #8 could not hold her up. At that time, they put her down on the floor. When she went down onto the floor, she was resting on her knees. They then had to get the Hoyer lift, laid her down on the floor, rolled her over, and placed the lift pad under her. At that time, they raised her off the floor with the Hoyer lift. She was taken to the dining room but did not want to eat there as she was complaining of pain. So, she was taken back to her room where she sat at her bedside table and ate lunch. Resident #1 was complaining of pain to her legs. FRN #8 told Resident #1 that she would report the incident to the floor nurse who would address her pain. Interview on 04/24/19 at 2:00 P.M. with Medical Director #400 confirmed that she expected a resident to be transferred as assessed, care planned and as physician ordered. The Medical Director revealed that by using the inappropriate mode of transfer, it did result in the fractures to Resident #1's leg. Telephone interview on 04/24/19 at 6:30 P.M. with Resident #1's son revealed on 03/29/19, his mother called him and told him he needed to come to the facility right then at that time. Resident #1's son revealed her tone of voice was different, as if she was hurting. He arrived at the facility around 10:00 P.M. and he observed his mother's legs were swollen. His mother told him about how the facility transferred her and did not use the Hoyer lift. Review of the facilities policy on fall management, dated 10/17/19, revealed each resident will be assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed ad updated as necessary to reflect each resident's current safety needs and fall reduction interventions. The care plan will be reviewed throughout the course of treatment by the interdisciplinary team to assure the most recent specific fall reduction interventions have been incorporated as necessary into the plan of care. This deficiency substantiates Complaint Number OH 690.