Every finding on record at Smithville Western Care Center

Based on observation, interview, and facility policy review, the facility failed to ensure they maintained all areas of the facility in good repair and in a safe and sanitary condition when they did not ensure their basement was free from standing water and a black mold-like substance. This had the potential to affect all 97 residents residing in the facility.Findings include:During an observation and interview on 08/05/26 at 1:52 P.M., the Maintenance Director (MD) revealed that when the door to the basement was opened there was a musty odor coming up from the basement. The basement was enclosed with a keypad locked door and consisted of cinder block walls and a solid ceiling. At the bottom of the stairs, there was standing water. Through the door, the first room was a large storage room with shelves around the perimeter of the room and a rack in the center of the room with boxes of records in it. There were two hot water heaters in the basement along the outside of the wall. There was also a huge sprinkler riser in the corner upon entering the room. There was moisture on the floor in the main room in a spot approximately one foot wide by approximately two feet long. On the inside wall of the large room were double wooden doors. The MD pulled on the door but was unable to easily open the door due to the wood having expanded. The MD stated that the doors did that because of the humidity. Once inside that door, there was another larger room with a large water holding tank. The floor was covered with standing water, which prevented the surveyor from walking into the room. The MD took several steps into the room, and the water could be seen splashing under his feet. The MD stated the holding tank was for the old fire suppression system they had prior to them building the pond in front of the facility that now fed the sprinkler system. There was a large number of boxes that were stacked approximately five feet to six feet high in the room that were visibly wet and damaged that dated back to 2016. On the far side of the room where the water tank was located were steps down to the bottom of the tank. There was water standing on the floor of the room that was draining towards the tank where the MD stated there was a drain at the bottom of the stairs by the holding tank. Over the large number of boxes in the second room was a cream-colored beam that ran between the two pillars in the room; the beam ran along the ceiling covering approximately half of the room and measured approximately two feet by one foot. There was a black mold-like substance covering approximately 80% of the side and underneath the beam, which made it impossible to determine the construction of the beam (whether a metal beam or sheetrock construction). The MD confirmed that it was probably mildew or mold. He stated that he felt that it was there because of the moisture in the room. Water could be seen dripping onto the tops of the boxes underneath the beam. Water could also be heard dripping on the floor across the room and seemed to be coming from where the stairs were. The MD stated that there were no vents or air ducts in the basement that would lead to the resident-use areas above. No one accessed the basement except for him. He had not considered getting dehumidifiers for the basement but could see how they would be helpful. He thought that the water came up from underground and seeped onto the basement floor, then drained out to their sewer system and away from the facility. There were two drains in the basement area; one was in the first room, and one was at the bottom of the stairs in the second room where the holding tank was located. During an interview on 08/05/26 at 2:45 P.M., the Administrator stated he did not go to the basement and had only been down there a couple of times. He usually went down and just poked his head in the door and looked around. He stated he had only been in the back room once, and that was during his tour of the facility in January 2025. He stated that at the time there was no standing water on the floor. The MD kept the code to the door close and did not even like to share it with him. He knew there were a lot of boxes down there. He had not seen any of the water on the floor, but he would go down and take a look. He was not aware there was standing water in the basement. During an interview on 08/05/26 at 3:48 P.M., the Administrator stated that he did go to the basement. He stated that he did not realize that there was such an issue with the standing water. He knew the records should be protected. He knew they needed to be taking care of the records and would need to get the issue mitigated. During an interview on 08/06/26 at 11:33 A.M., the Director of Nursing (DON) stated that she had worked at the facility for nine years and had never heard any talk about there being mold in the basement. Nursing had no reason to be down there. At one time, they could go down there but they put a lock on the door, and they could not go down there. She expected maintenance to investigate it, and if it was determined to be a housekeeping issue, they would get involved. During an interview on 08/06/26 at 12:06 P.M., the Administrator stated that he expected all areas of the facility to be safe and in working order. It was impossible to always be that way, but he expected any issues to be fixed as soon as possible and to always be safe. They were already talking about how to fix the issues in the basement with things like fans, dehumidifiers, and offsite storage for a lot of the documents that were down there and destroying what was already damaged. He stated that he saw records down there that dated back to the 1990s. When asked what he felt the size and capacity was of the water holding tank, he estimated it to be about 30 feet long and 10 feet wide, then figured it would probably have held about 25,000 gallons of water when it was in use.During an interview on 08/06/26 at 1:29 P.M., the Regional Director of Operations (RDO) stated they were unable to find a policy dealing with the building maintenance. They did not have any documentation of any policy for the maintenance of the building.A facility policy titled, Housekeeping Cleaning Policy, dated 03/2021, revealed, It is the policy of [the facility] to establish and maintain infection control techniques while cleaning the facility daily or as often as needed.This deficiency represents non-compliance investigated under Complaint Number 2977262.

Based on observation, interview, record review, and facility policy review, the facility failed to perform hand hygiene before medication administration and failed to implement enhanced barrier precautions (EBP) during medication administration. This affected one (Resident #83) of three residents observed for medication administration. The facility census was 97.Findings include:Review of the admission record indicated the facility admitted Resident #83 on 05/29/26 with a diagnosis including osteomyelitis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, with an Assessment Reference Date (ARD) of 07/14/26, revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had intravenous (IV) access and required IV medications within the last 14 days.Review of Resident #83's Care Plan Report included an undated focus area that indicated the resident had a need for EBP related to an increased risk of multidrug-resistant organism (MDRO) acquisition related to an indwelling medical device. Interventions directed staff to put on appropriate personal protective equipment (PPE) prior to providing high-contact resident care activities and EBP related to a peripherally inserted central catheter (PICC) line. Review of Resident #83's Order Summary Report with active orders as of 08/05/26, revealed an order dated 07/09/26, for EBP related to a PICC line every shift; an order dated 07/09/26, for cefepime hydrochloride (HCL)) (an antibiotic) IV solution 2 grams per 100 milliliters (mL), use 200 milligrams (mg) intravenously three times a day for osteomyelitis until 08/21/26; and an order dated 07/09/26, for vancomycin HCL (an antibiotic) IV solution 1750 mg per 350 mL, use 1750 mg intravenously in the morning for osteomyelitis until 08/21/26. During medication administration observation on 08/05/26 at 8:52 A.M., Registered Nurse (RN) #2 did not perform hand hygiene before she began to prepare medications to administer to Resident #83. RN #2 was also noted not to wear a gown when she administered IV medications to Resident #83. During an interview on 08/05/26 at 9:12 A.M., RN #2 stated she forgot to perform hand hygiene before she entered Resident #83's room to administer the resident their medications. RN #2 stated she should have worn a gown when she administered Resident #83's IV medications. During an interview on 08/05/26 at 2:04 P.M., the Director of Nursing (DON) stated staff were expected to follow infection control practices for EBP. During an interview on 08/06/26 at 1:40 P.M., the Administrator stated it was his expectation that staff followed infection control policies and practices.Review of the facility policy titled, Enhanced Barrier Precautions, dated 07/2022, indicated, It is the policy of [facility name] that enhanced-barrier precautions will be used in adjunct with standard precautions for residents known to be colonized or infected with a multi-drug resistant organism (MDRO) as well as those at increased risk of MDRO acquisition. PROTOCOL: Definitions: Enhanced Barrier Precautions: Are designed to reduce transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at risk of acquiring an MDRO. Examples of high-contact resident care activities: * Dressing * Bathing/Showering * Transferring * Providing hygiene * Changing linens * Changing briefs or assisting with toileting * Device care or use: central line, urinary catheter feeding tube, tracheostomy/ventilator * Wound care. Review of the facility policy titled, Handwashing Policy, dated 10/2022, indicated, It is the policy of [facility name] to reduce potential for spread for unknown pathogens that health care workers may be exposed to when performing daily tasks. Protocol: Hands will be washed with soap and water or decontaminated using an approved alcohol-based hand sanitizer: * Before and after each work shift. * Before and after contact with each resident Before dispensing medications.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure and maintain accurate and complete drug records for the residents. This affected four (Residents #38, #84, #95 and #99) of four residents reviewed for pharmacy services. The facility census was 89. Findings include: 1. Record review for Resident #38 revealed an admitted [DATE]. Diagnosis included Alzheimer's dementia, chronic pain syndrome, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was rarely or never understood. Review of the physician orders for Resident #38 revealed an order for Ativan (a controlled medication) oral tablet 0.5 milligrams (mg) one tablet by mouth every eight hours as needed for anxiety/restlessness for 14 days. The order was initiated 01/10/25 to be discontinued after 01/23/24. Review of the Controlled Drug Record for Resident #38 revealed Ativan 0.5 mg dated 11/26/24 take one tablet by mouth every 12 hours as needed for 14 days. The Controlled Drug Record was initiated 11/27/24 signed by Licensed Practical Nurse (LPN) #251. The same controlled drug record continued through 03/26/25. Review of the Controlled Drug Record revealed on 01/25/25 at 8:22 P.M. Registered Nurse (RN) #306 signed the Controlled Drug Record for the removal of an Ativan 0.5 mg from Resident #38's controlled medications. Review of the medication administration record (MAR) for Resident #38 revealed for the order for the Ativan 0.5 mg, the box dated 01/25/25 (where the nurse initials she administered the medication to the resident) had an x in the box indicating the order was no longer active. The medical record for Resident #38 revealed no indication (or physician order) indicating Resident #38 had an order for or received the Ativan 0.5 mg on 01/25/25. Review of the physician orders for Resident #38 revealed an order for Norco (a controlled medication) oral tablet 5-325 mg give one tablet by mouth every eight hours as needed for pain initiated 01/22/25. Review of the Controlled Drug Record for Resident #38 revealed on 01/26/25 at 5:23 A.M., RN #306 dated and signed the Controlled Drug Record for the Norco oral tablet 5-325 mg. RN #306 then drew one line through the date, time and signature (indicating an error, the medication was not administered). Review of the MAR for Resident #38 for the order for the Norco oral tablet 5-325 mg revealed on 01/26/25 at 5:23 A.M., Resident #38 had a pain level of seven. RN #306 administered the Norco 5-325 mg and the medication was effective. Interview on 04/28/25 at 12:41 P.M. with Director of Nursing (DON) revealed the nurses sign the controlled drug record when they remove a resident's controlled medication. Each controlled medication is numbered with the amount delivered from the pharmacy and the amount remaining. The nurses (oncoming and off going) count each controlled drug together at the beginning and end of each shift to ensure the controlled medications are accurate. DON revealed the nurse would sign the controlled drug record when they removed a controlled drug from the secured storage area; once the medication was signed out as removed by the nurse, they would then sign the MAR indicating the medication was administered to the resident it was ordered for. DON confirmed Resident #38's Ativan removed from the secured drug box by RN #306 on 01/25/25 was not documented in Resident #38's medical record or MAR as administered to that resident. In addition, the Ativan was discontinued on 01/25/25 so there was no order to administer the drug. The controlled drug audit for the Norco tablet 5-325 mg was signed by RN #306 on 01/26/25 at 5:23 A.M. then errored off. The MAR was documented as the medication was given for pain and effective but it couldn't have been given because the count was accurate on the controlled drug record reflecting the medication was not given when both nurses counted at the end of the shift. 2. Record review for Resident #84 revealed an admitted [DATE]. Diagnoses included paraplegia, contracture of unspecified muscle, and low back pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was cognitively intact and received scheduled pain medications. Review of the physician orders for Resident #84 dated 01/19/25 revealed an order for Oxycodone HCL (controlled medication) oral tablet five milligrams (mg) give one tablet by mouth every six hours as needed for pain score of seven to 10 for three days. Review of the Controlled Drug Record for Resident #84 revealed on 01/12/25, there was an order for Oxycodone HCL oral tablet five mg give one tablet by mouth every six hours as needed for pain score of seven to 10 (from pain level of zero no pain to 10 most severe pain) for three days. On 01/26/25 at (unreadable time), Registered Nurse (RN) #306 signed out Resident #84's Oxycodone from the secured medication storage. Review of the medication administration record (MAR) for Resident #84 revealed Oxycodone had a start date of 01/19/25 and an end date of 01/22/25 (four days). The box dated 01/25/25 (where the nurse initialed she administered the medication to the resident) had an x in the box indicating the order was no longer active. The medical record for Resident # 84 revealed no indication (or physician order) indicating Resident #84 had an order for or received the Oxycodone HCL five mg on 01/26/25. Interview on 04/28/25 at 12:41 P.M. with the Director of Nursing (DON) confirmed on 01/26/25 at (unreadable time), RN #306 signed out Resident #84's Oxycodone from the secured medication storage. DON confirmed there was no order to administer the medication and the medication was not documented in Resident 84's medical record as administered. 3. Record review for Resident #95 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cerebral infarction and dysarthria following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was cognitively intact and received scheduled pain medication. Review of the physician orders for Resident #95 revealed an order for an admission to hospice ordered 01/24/25. Additional orders dated 01/24/25 included morphine sulfate (controlled medication) oral solution 20 milligrams (mg) per milliliter (ml) give 0.5 ml by mouth every two hours as needed for pain/shortness of breath (SOB). Review of the Controlled Drug Record for Resident #95 with the Director of Nursing (DON) on 04/28/25 at 12:45 P.M. revealed the controlled drug record did not indicate the name of the controlled drug (morphine sulfate oral solution 20 mg per ml) with directions for use. DON confirmed this was the controlled drug record for Resident #95's morphine sulfate oral solution 20 mg per ml. The controlled drug record indicated the drug was initiated for Resident #95 on 01/25/25. The Controlled Drug Record revealed RN #306 documented morphine sulfate 0.5 ml was removed on 01/26/25 at 10:00 P.M., 01/27/25 at 12:30 A.M. and 4:00 A.M. Review of the MAR and medical record for Resident #95 with the DON confirmed no documentation Resident #95 received the morphine on 01/26/25 at 10:00 P.M. or 01/27/25 at 4:00 A.M.; The MAR indicated on 01/27/25 Resident #95 received morphine sulfate 0.5 ml at 1:00 A.M. administered by Registered Nurse (RN) #306. 4. Record review for Resident #99 revealed an admitted [DATE]. Diagnosis included toxic encephalopathy. Review of the physician orders for Resident #99 revealed an order for Hydrocodone -Acetaminophen oral tablet 5-325 milligrams (mg) give one tablet every six hours as needed for pain with a start date of 08/09/24. Review of the Controlled Drug Record for Resident #99 with the Director of Nursing (DON) on 04/28/25 at 12:47 P.M. revealed the Hydrocodone -Acetaminophen oral tablet 5-325 mg was signed on 02/03/25 by Registered Nurse (RN) #306 at 8:35 P.M.; RN #306 signed again on 02/03/25 (unreadable time) directly under the 8:35 P.M. that the medication was again removed; To the left of the documented dates and times was a hand written wasted dropped. DON confirmed there was no second nurse signature to verify the medication was wasted. DON revealed if a controlled medication was wasted, two nurses were required to waist the medication, and both nurses sign the controlled drug form verifying the medication was wasted. Review of the MAR revealed on 02/03/25 at 8:58 P.M., Resident #99 received one dose of Hydrocodone -Acetaminophen oral tablet 5-325. Review of the facility's undated policy titled Managing Controlled Substances revealed immediately after a dose of a controlled drug is administered, the licensed nurse administering the drug is to enter all of the following information on the proof-of-use record: a) Date and time of administering b) Dose administered c) Signature of the nurse administering the dose d) Remaining doses e) The controlled substance administration must also be recorded on the Medication Administration Record (MAR). If a dose is removed from the container for administration but refused by the patient or not given for any reason, it should not be put back into the container. Rather, it is to be destroyed in the presence of two (2) licensed nurses. The disposal must be documented on the proof-of-use record on the line presenting the dose. This deficiency represents non-compliance investigated under Control Number OH00164423.

Based on resident and staff interview, review of the Almanac Weather History, medical record review, and review of the facility policy, the facility failed to ensure a resident's room maintained a comfortable temperature for Resident #97. This affected one (Resident #97) of three residents reviewed for safe environment. The facility census was 89. Findings include: Record review for Resident #97 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included diabetes mellitus, depression, and anxiety disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the census history revealed Resident #97 was admitted to [room [ROOM NUMBER]] on 03/20/25. On 03/24/25, Resident #97 was transferred to [room [ROOM NUMBER]]. Review of the Almanac Weather History for [NAME] Ohio revealed on 03/20/25, the outdoor temperature ranged from 35 to 71 degrees Fahrenheit (F); On 03/21/25, the temperature ranged from 28 to 63 degrees F; On 03/22/25, the temperature ranged from 28 to 51.1 degrees F; On 03/23/25, the temperature ranged from 21 to 46 degrees F; and on 03/24/25, the temperature ranged from 37 to 50 degrees F. Interview on 04/28/25 at 10:40 A.M. with Resident #97 revealed on 03/20/25, when he was admitted to room [ROOM NUMBER], it was cold, there was no heat in that room. Resident #97 told staff and they said they wrote something up, and they gave me a blanket. His wife and daughter had to wear a coat to visit him. Resident #97 said it really got colder at night. Resident #97 said the blanket the staff provided didn't really help because the whole room was so cold. Resident #97 stated maintenance came in, looked at the heater, and said he couldn't fix it. and had to get part so they moved me. Resident #97 stated he was so cold and miserable while in the room and he and did not understand why they did not do something about it right away. Resident #97 confirmed he was not offered a room change over the weekend. Interview on 04/28/25 between 9:27 A.M. and 11:00 A.M. with Registered Nurse (RN) #292 confirmed she worked on Saturday 03/22/25 and Sunday 03/23/25 with Resident #97. RN #292 revealed Resident #97 expressed concerns on those days about his room temperature and said his room was cold. RN #292 revealed she put a Maintenance ticket in and gave him an extra blanket. RN #292 revealed she did not recall how cold the room was. Interview on 04/28/25 at 10:01 A.M. with Maintenance Assistant #254 revealed each room had baseboard heating that was used during the winter months. Maintenance Assistant #254 revealed he was aware of the room temperature concern with Resident #97. When he returned to work Monday, 03/24/25, he was told about the concern and revealed the heater in the room went out and stated It was a little chill but he didn't know why Resident #97 stayed in room [ROOM NUMBER] during the weekend. Maintenance Assistant #254 confirmed the Maintenance department did not routinely work the weekends. Interview on 04/28/25 at 10:56 A.M. with RN Unit Manager #301 revealed he did not work the weekend of 03/22/25 or 03/23/25 but he did work 03/24/25 and assisted in moving Resident #97 to a different room. RN Unit Manager #301 stated the room he was in was cold, and he didn't know why Resident #97 was not moved to a different room when the room got cold. Nursing put it in a work order through the maintenance electronic messaging system); However, maintenance doesn't work over the weekend. RN Unit Manager #302 confirmed staff could have offered Resident #97 a room change over the weekend and didn't know why the didn't do this. Interview on 04/28/25 at 11:15 A.M. with the Administrator revealed if a resident room was cold and there was a problem with the heat, the staff can move the resident to a different room. Interview on 04/28/25 at 11:15 A.M. with Maintenance Director #255 revealed the facility had an HVAC system. When the temperature outside gets cold, the facility supplements the heat with baseboard heating. In [room [ROOM NUMBER]], the thermocouple went out, unsure when, so the baseboard heating was not working. Reviewed the work orders with Maintenance Director #255 revealed on Saturday, 03/22/25, Certified Nursing Assistant (CNA) #256 placed a maintenance ticket for [room [ROOM NUMBER]] with a summary Please turn on heat, resident says room is cold. On 03/24/25 at 5:32 A.M. CNA #259 placed a maintenance ticket for [room [ROOM NUMBER]] with a summary, Room too cold patient complaining. Review of the facility's undated policy titled Safe Environment revealed the resident has the right to a safe, clean, comfortable, and home-like environment, comfortable and safe temperature levels, must maintain a temperature of 71 to 81 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00165134.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #81's physician's orders were followed to ensure proper diabetic insulin management, and failed to ensure Resident #86's open area to his abdominal fold was evaluated and treated. This affected two resident's (Resident #81 and Resident #86) out of three residents reviewed for quality of care. The facility census was 85. Findings include: 1. Review of Resident #81's medical record revealed an admitted [DATE] and diagnoses included type one diabetes mellitus with hyperglycemia, type two diabetes mellitus with hypoglycemia without coma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #81's care plan dated 05/14/24 included Resident #81 had the potential for hyperglycemia and hypoglycemia related to type one diabetes mellitus. Resident #81's blood sugars would remain stable, skin would remain intact, and resident would be compliant with diet. Interventions included to check accu checks per D.O. (doctors orders) and as needed; administer insulin per order; observe for hypoglycemia, hyperglycemia including symptoms of thirst, urination, hunger, shaking, sweating, blurred vision; monitor food intake. Review of Resident #81's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #81 was cognitively intact. Resident #81 required set-up and clean-up assistance with eating. Resident #81 received insulin injections. Review of Resident #81's physician orders dated 09/27/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject 6 units subcutaneously with meals related to type one diabetes mellitus with hyperglycemia, hold for blood sugar less than 120. Review of Resident #81's physician orders dated 09/27/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject per sliding scale, subcutaneously after meals for hyperglycemia: if blood sugar 200 to 250 inject 2 units, if blood sugar 251 to 300 inject 4 units, if blood sugar 301 to 350 inject 6 units, it blood sugar 351 to 400 inject 8 units, if blood sugar 401 to 450 inject 10 units, if blood sugar is above 450 call the physician. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject 6 units subcutaneously with meals, hold for blood sugar less than 120, scheduled to be administered at 8:00 A.M. with meals was administered at 7:24 A.M. Review of Resident #81's Medication Administration Record (MAR), progress notes, and blood sugars dated 10/03/24 did not reveal evidence a blood sugar was checked prior to the administration of insulin aspart 6 units at 7:24 A.M. The insulin was ordered to be held if Resident #81's blood sugar was less than 120. Review of Resident #81's blood sugars dated 10/03/24 revealed blood sugars were checked at 9:10 A.M., 11:18 A.M., 1:52 P.M., 4:02 P.M., and 7:42 P.M. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject 6 units subcutaneously with meals, hold for blood sugar less than 120, scheduled to be administered at 12:00 P.M. with meals was administered at 11:19 A.M. and Resident #81's blood sugar was 359. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject per sliding scale, subcutaneously after meals for hyperglycemia, was scheduled to be administered after meals, and 8 units was administered at 11:18 A.M. for a blood sugar of 359. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed Resident #81's insulin aspart was administered at 11:18 A.M., but the physician orders were for insulin aspart 6 units to be administered with meals, hold for blood sugar less than 120, and a sliding scale of insulin aspart was ordered to be given after meals. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject 6 units subcutaneously with meals, hold for blood sugar less than 120, scheduled to be administered at 5:00 P.M. with meals was administered at 4:02 P.M. and Resident #81's blood sugar was 429. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed insulin aspart flexpen subcutaneous solution pen-injector 100 units per ml, inject per sliding scale, subcutaneously after meals for hyperglycemia, was scheduled to be administered after meals, and 10 units was administered at 4:02 P.M. for a blood sugar of 429. Review of Resident #81's Medication Administration Audit Report dated 10/03/24 revealed Resident #81's insulin aspart was administered at 4:02 P.M., but the physicians orders were for insulin aspart 6 units to be administered with meals, hold for blood sugar less than 120, and a sliding scale of insulin aspart was ordered to be given after meals. Interview on 01/14/25 at 1:19 P.M. of the Director of Nursing (DON) revealed blood sugars should be checked per physician order, and if a resident was exhibiting any signs and symptoms of high or low blood sugar a blood sugar check should be completed. The DON stated nursing judgement and critical thinking were important for the overall picture. The DON confirmed on 10/03/24 Resident #81 did not receive insulin per physician orders. Interview on 01/14/25 at 2:37 P.M. of Licensed Practical Nurse (LPN) #207 revealed on the nursing unit Resident #81 resided on the dinner meal was served at 5:00 P.M. or later. LPN #207 stated the nursing unit was the last nursing unit to be served at all the meals. LPN #207 stated Resident #81's blood sugars alternate between high and low a lot and she usually tried to check Resident #81's blood sugars before meals. LPN #207 indicated if Resident #81 did not eat her blood sugar dropped quickly. LPN #207 confirmed on 10/03/24 she checked Resident #81's blood sugar at 4:02 P.M. and gave her insulin pretty soon after that and confirmed she administered both insulin injections at the same time. Observation on 01/14/25 at 2:56 P.M. of Resident #81 revealed she was sitting in a wheelchair in her room watching television. Resident #81 was alert and answered questions pleasantly. Resident #81 remembered she was transported to the hospital Emergency Department on 10/03/24 but could not remember any details about what happened. Resident #81 stated her blood sugar goes up and down a lot. Interview on 01/15/24 at 11:41 A.M. of Physician #202 revealed Resident #81 was living at home, became hypoglycemic, fell and had a fracture of her arm. Physician #202 stated Resident #81 was taken to the hospital and after her hospital stay was admitted to the facility. Physician #202 indicated Resident #81 was a brittle diabetic, her blood sugars could be very low or very high, and she was always eating snacks and drinks. Physician #202 stated multiple variables could impact Resident #81's blood sugars including stress and diet. Physician #202 confirmed Resident #81's blood sugars should be checked with meals and held if less than 120 and after meals according to a sliding scale. Physician #202 stated it was important to stick to scheduled times for insulin administration and she worked with an endocrinologist to manage Resident #81's blood sugars. Review of an email sent on 01/15/25 at 1:00 P.M. from the DON confirmed on 10/03/24 Resident #81's two orders for insulin aspart were given at the same time for the lunch meal and the dinner meal and not as ordered which was to give 6 un insulin aspart with meals after checking a blood sugar to make sure Resident #81's blood sugar was not below 120 before administering. The second order was to administer insulin aspart per sliding scale after Resident #81's meal. The email also confirmed there was no blood sugar checked before 6 units insulin aspart was administered to Resident #81 for the breakfast meal. The email stated Resident #81 consumed 100 percent of her meals for breakfast, lunch, dinner. Review of the facility policy titled Blood Glucose Testing Protocol undated included it was the facility policy to ensure residents blood glucose levels were tested and recorded appropriately and accurately. Check physician's order for specific instructions. Record blood sugar in the resident's medical record. Review of the facility policy titled Medication Administration Policy undated included it was the policy to the facility to ensure medications were administered in a safe and sanitary manner. Licensed nurses would ensure the six medication rights were followed, the right resident, the right drug, the right dose, the right time, the right route and the right documentation. 2. Review of Resident #86's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included pneumonia, acute respiratory failure with hypoxia and hypercapnia, morbid obesity, bacteremia and type two diabetes mellitus with hyperglycemia. Review of Resident #86's physician orders dated 11/27/24 revealed orders for miconazole external powder 2 percent (miconazole nitrate topical), apply to abdominal folds, armpits, groin topically every morning and at bedtime for fungal infection for 14 days. This order was discontinued on 12/11/24. Review of Resident #86's care plan did not reveal a care plan related to Resident #86's open area on his right lower abdomen. Review of Resident #86's Admission Minimum Data Set assessment dated [DATE] revealed Resident #86 was cognitively intact. Resident #86 was dependent for toileting, upper and lower body dressing, and the ability to bathe self was not attempted due to medical condition or safety concerns. Review of Resident #86's Weekly Skin Check dated 12/11/24 included skin was not intact, skin area noted was chronic. Resident #86 had redness, mild, open, in right lower abdominal fold, and folds were treated with antifungal powder and none were red but this one spot. Review of Resident #86's progress notes dated 12/11/24 through 12/15/24 did not reveal evidence Resident #86's open, reddened area to the right lower abdominal fold was evaluated and treated. Review of Resident #86's physician orders dated 12/11/24 through 12/15/24 did not reveal treatment orders for Resident #86's open, reddened area to his right lower abdominal fold. Review of Resident #86's assessments from 12/11/24 through 12/15/24 did not reveal a Wound Track assessment. Interview on 01/09/25 at 11:09 A.M. with Resident #86 and Family Member (FM) #200 revealed he was discharged from the facility after he was transported to the Emergency Department and was at home now. Resident #86 stated one of the issues he had at the facility was that an unidentified aide roughed me up, but he did not know the name of the aide. Resident #86 stated the aide was rough with him and used tremendous force causing an open area on his abdomen. The open area was not charted or treated timely, and an unidentified aide put a sheet in the abdominal fold and left it for a couple days, took it out and placed another sheet in the fold. Resident #86 stated when the sheet was taken out it was covered with blood. Resident #86 revealed he told the unidentifed aide that the spot on his abdomen was sensitive to touch and was hurting and no one had looked at it or treated it, but no one came in to check the area or treat it. Resident #86 stated he told a nurse he had an area on his right lower abdomen that needed evaluated, and the nurse looked at it, but he could not remember what day this occurred. Resident #86 indicated care was sporadic and no one looked at his wounds every day. Interview on 01/13/25 at 10:49 A.M. of Registered Nurse (RN) #201 revealed Resident #86 was frequently yeasty and would not keep a pillow case in the folds. RN #201 indicated if a resident had heavy skin on skin she always put something in the area. RN #201 stated on 12/11/25 an area to Resident #86's right pannus opened up, it was not a huge open wound, and it freaked him out. RN #201 stated she cleaned the area with soap and water, patted it dry, put nystatin powder (treats fungus infections) on the area and placed an ABD (abdominal pad) in the fold where the open area was to get skin off skin to help avoid a yeast infection and skin friction. RN #201 stated she did not call the physician or obtain a treatment order because a treatment was already in place. RN #201 indicated she found the open area on Resident #86's abdomen during routine care. RN #201 stated Resident #86 complained and said someone washed him too hard causing the area to open up, but when she looked at the area it did not look like it was scrubbed raw, it just looked yeasty and yeast infections could cause the skin to be sensitive. Interview on 01/13/25 at 2:53 P.M. of the Director of Nursing (DON) revealed Resident #86 had a yeast infection and was ordered miconazole powder for treatment. The DON confirmed the miconazole powder was discontinued on 12/11/24, but stated the treatment would be the same for the open area on Resident #86's lower abdominal fold because it was yeast related. The DON did not provide evidence of additional orders, treatments or documentation of Resident #86's open area on his lower right abdominal fold. Review of the facility policy titled Wound Prevention and Management Policy revised 10/2022 included an appropriate treatment would be implemented for any existing skin breakdown. A Wound Track Assessment would be documented at the time of discovery of the skin breakdown and then weekly thereafter. A care plan would be initiated and updated as necessary until the area was resolved. Weekly skin checks would be performed by licensed nurses. CNA's would monitor resident's skin during care, for signs of breakdown and notify the charge nurse. This deficiency represents non-compliance investigated under Master Complaint Number OH00160965, Complaint Number OH00160980, and Complaint Number OH00160438.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, Self-Reported Incident (SRI) review, and review of facility policy the facility failed to ensure Resident #88's privacy was maintained. This affected one resident (Resident #88) out of three residents reviewed for privacy. The facility census was 88. Findings Include: Review of Resident #88's medical record revealed an admitted [DATE], a re-entry date of 05/01/23 and a discharge date of [DATE]. Diagnoses included paraplegia, type two diabetes mellitus with diabetic neuropathy, morbid obesity, bipolar disorder and anxiety disorder. Review of Resident #88's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #88 was cognitively intact. Resident #88 was dependent for toileting and personal hygiene, and upper and lower body dressing. Review of Resident #88's care plan dated 02/09/23 included Resident #88 had the potential for altered behavior patterns, disruptive interactions, disruptive verbally, resistive to care, violence, anger, agitation and, or anxiety. Resident #88 was verbally abusive to staff, cursed at staff, and was rude and demanding. Resident #88 made sexually inappropriate comments to staff at times, used inappropriate language including racial slurs. Resident #88 would be calm in a secure environment. Resident #88 would cope with routine, occurrences were minimized and Resident #88 would interact with staff and others appropriately. Interventions included to removed from public area when behavior was unacceptable, keep environment calm and relaxed, convey acceptance of resident during periods of inappropriate behavior and obtain help if resident became abusive or resistive; praise positive behavior, watch for signs of increasing anxiety and, or agitation, keep voice soft, establish routines and redirect as needed. Review of Resident #88's progress notes dated 10/05/24 through 10/08/24 did not reveal documentation regarding an incident on 10/07/24 involving Resident #88, Licensed Practical Nurse (LPN) #204 and other staff members. Review of a SRI Form tracking number 252783 dated 10/08/24 revealed on 10/08/24 Certified Nursing Assistant (CNA) #208 reported LPN #204 was allegedly arguing with Resident #88 and allegedly had her phone out and was possibly recording the conversation. LPN #204 was immediately removed from the schedule and suspended until the facility investigation was completed. CNA #208 stated she did not witness the allegations but heard it from CNA #205. CNA #205 allegedly witnessed LPN #204 and Resident #88 in a heated verbal exchange in Resident #88's room. CNA #205 alleged seeing LPN #204's cell phone on the treatment cart recording the altercation and witnessed CNA #209 with her phone out recording the altercation. CNA #209 was suspended pending the facility investigation outcome. Interview of staff revealed Resident #88 was yelling at LPN #204 and calling her racial names throughout the night. The interviews revealed LPN #204 voice recorded the conversation she had with Resident #88 with his permission. Review of the recording revealed no identifying information. The interviews revealed CNA #209 did not have her phone out in Resident #88's room and was not recording. Staff would be educated on cell phone use, abuse policy, and call light policy. LPN #204 would complete additional education for customer service. Resident #88 experienced no change in condition and remained at his baseline. Abuse was not suspected. Review of a witness statement dated 10/08/24 revealed after the altercation between Resident #88 and LPN #204, CNA #210 saw LPN #204 sitting at the nurses station playing a voice recording that she said she took in room [ROOM NUMBER] (Resident #88's room). CNA #210 stated she could hear the recording but could not tell what was being said. Review of a statement from CNA #205 to Director of Human Resources and Corporate Compliance (DHRCC) #211 dated 10/09/24 at 4:40 A.M. revealed on 10/07/24 at approximately 1:58 A.M. CNA #205 heard yelling and screaming from the hall Resident #88 resided on, and walked down the hall to see what the commotion was. CNA #205 stated she heard LPN #204 and Resident #88 having a heated verbal exchange, and observed LPN #204's cell phone on the treatment cart, and it was recording the altercation. CNA #205 also witnessed CNA #209 recording the altercation with her cell phone. CNA #205 stated it looked like abuse and intimidation of a resident and also a HIPPA violation. CNA #205 stated she reported the situation to Unit Manager (UM) #212. Review of a witness statement undated and written by UM #212 revealed CNA #205 reported chaos happening out into the 300 hall and she went to investigate the situation. UM #212 stated she heard Resident #88 yelling and asking staff for their names and license number and things like that, and was able to calm Resident #88 down. UM #212 stated she heard staff arguing with each other in the hall and at the nurses station. UM #212 stated she did not see or hear any form of abuse. Interview on 01/09/25 at 2:34 P.M. with CNA #205 revealed she made a formal complaint when she witnessed the incident between Resident #88 and LPN #204 and other staff members, and the incident happened on 10/07/24. CNA #205 stated she told the staff members involved in the incident that she was going to file a complaint and the staff members started screaming at her, things escalated and almost became physical. CNA #205 indicated she witnessed a verbal altercation between Resident #88 and LPN #204 and they were screaming at each other. CNA #205 stated it was so loud it could be heard all the way to the other side of the building. CNA #205 stated she saw LPN #204 and CNA #209 recording the heated verbal exchange with Resident #88. Interview on 01/09/25 at 3:58 P.M. with Resident #88 revealed he transferred to another facility because he had a lot of problems at the facility, most of the problems were with LPN #204, he told the Administrator but nothing went anywhere. Resident #88 stated he had many arguments with LPN #204, confirmed he had an argument with LPN #204 on 10/07/24, and said she recorded me and I did not say she could record me. Resident #88 indicated there were witnesses who saw LPN #204 recording him, and CNA #205 stuck up for me and they fired her. The DON told Resident #88 nothing was found to be true. Resident #88 stated this whole situation caused him to be very upset, overwhelmed, stressed and he could not sleep, and this was all because of the way he was treated and yelled at while he was at the facility, and he never had problems sleeping before. Interview on 01/13/25 at 10:32 A.M. with the Director of Nursing (DON) confirmed on 10/07/24 there was a situation between Resident #88 and LPN #204 was voice recording the altercation. The DON stated LPN #204 was reprimanded for recording Resident #88. The DON indicated it was not okay for staff to yell at residents and no staff were yelling at Resident #88, but Resident #88 was yelling at the staff. The DON stated CNA #205 heard Resident #88 yelling, and CNA #205 was not fired and chose to leave her position. The DON indicated CNA #205 did not observe or hear anything because she was standing at the top of the hall by the nurses station. The DON stated LPN #204 was suspended and staff were educated about cell phone use. Review of a witness statement dated 10/11/24 written by LPN #204 revealed LPN #204 entered Resident #88's room to provide a treatment and Resident #88 yelled for about ten minutes. When Resident #88 began yelling LPN #204 asked him if she could record him and he said I don't care. LPN #204 had a CNA in the room with her as a witness. Review of a witness statement undated written by CNA #209 revealed CNA #205 said she was going to file abuse claims on all of us. CNA #209's statement stated LPN #204 voice recorded all of this when Resident #88 started yelling at her. CNA #209 stated she never had her phone out recording. Review of LPN #204's Review Discussion Form created on 10/16/24 revealed the date of the conversation was 10/11/24. LPN #204 had her phone out in a resident room and call lights were on too long. LPN #204 would not have her phone out in any resident area at anytime. LPN #204 would ensure resident call lights were answered in a timely manner. Additional customer service education to be completed. LPN #204 responded that she took her phone out of her pocket to use as a flashlight to meet resident needs. LPN #204 stated sometimes she needed to pick something up for a resident and additional light was needed, and sometimes need a better look at a wound, and sometimes residents ask for phone number to a restaurant etcetera. Further violations of policy might lead to disciplinary action up to and including termination. Review of the facility policy titled Use of Cellular Phones, Cameras and Other Similar Devices undated included cellular telephones including smart phones such as iphones, blackberries etcetera, cameras, tablets, and similar devices such as audio or video recorders (Personal Handheld Device) may not be worn, carried or used during working time unless the device was used for the business purposes of the facility. You may not carry a Personal Handheld Device during working time unless you receive specific authorization from your facility administrator or corporate human resources. You must report to your supervisor any improper usage of a Personal Handheld Device in the workplace or on work time. Taking, viewing, showing, or otherwise distributing photographs, videos or other content of a lewd, indecent, or discriminatory nature during working time or on the facility property was strictly prohibited. All other company policies, including anti-harassment and violence in the workplace policies apply to use of Personal Handheld Devices on working time and on the facility premises. The deficient practice was corrected on 10/16/24 when the facility implemented the following corrective actions: On 10/09/24 staff were educated that cell phone use while on company time was for emergency use only. The education was provided by the DON and signed by all staff members. On 10/09/24 staff were educated that call lights were to be answered in a timely manner. The education was provided by the DON and signed by all staff members including nurses and aides. On 10/16/24 staff were educated on the facility abuse policy, cell phone use policy and call light policy. The education was provided by the DON and signed by all staff members. Interview on 01/13/25 at 10:32 A.M. of the DON revealed she did random audits on all three shifts and found no concerns related to cell phone use, abuse, or call lights being answered. This deficiency represents non-compliance investigated under Master Complaint Number OH00160965, Complaint Number OH00160980, and Complaint Number OH00160438.

Based on interview, record review and review of the facility policy the facility failed to ensure Resident #86 directed his own medical care. This affected one resident (Resident #86) out of three residents reviewed for resident rights. The facility census was 85. Findings include: Review of Resident #86's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included pneumonia, acute respiratory failure with hypoxia and hypercapnia, morbid obesity, bacteremia and type two diabetes mellitus with hyperglycemia. Review of Resident #86's care plan dated 12/01/24 included Resident #86 had the potential for altered respiratory status related to pneumonia, acute respiratory failure with hypoxia and hypercapnia history of PE (pulmonary embolus) and other diagnoses. Resident #86 would have breathing comfort with no dyspnea. Interventions included to assess respiratory status, assess breath sounds, position to facilitate breathing and comfort, suction as needed, administer oxygen as ordered; report difficulty breathing to charge nurse. Resident #86 had an infection related to sepsis and pneumonia. Resident #86 would be free of signs and symptoms of infection with no complications. Interventions included to report any abnormalities to the physician; administer medications as ordered, monitor for side effects and effectiveness, monitor for adverse reactions. Review of Resident #86's Admission Minimum Data Set assessment dated [DATE] revealed Resident #86 was cognitively intact. Resident #86 was dependent for toileting, upper and lower body dressing, and the ability to bathe self was not attempted due to medical condition or safety concerns. Resident #86 received oxygen therapy and used a non-invasive mechanical ventilator. Review of Resident #86's History and Physical dated 12/06/24 and completed by Physician #202 included Resident #86 was admitted to the facility for acute, chronic hypoxic and hypercapnic respiratory failure, pneumonia and other diagnoses. Resident #86 had a cough, dyspnea (difficult or labored breathing) and was on oxygen therapy. Review of Resident #86's progress notes including physician notes dated 12/06/24 through 12/15/24 did not reveal evidence Resident #86 was examined and evaluated by Physician #202. Review of Resident #86's progress notes dated 12/11/24 at 9:07 P.M. included Resident #86 used six liters of oxygen per minute and his breath sounds were cta (clear throughout). Review of Resident #86's progress notes dated 12/12/24 at 10:40 A.M. included Resident #86 stated I feel like my pneumonia is back, I was running a fever off and on, pulse ox was 88 percent with my CPAP on. Lab results from today compared to previous results, and oxygen saturation was 92 to 93 percent on CPAP. Lung sounds clear with diminished bases. Temperature 99.1 degrees Fahrenheit. Physician #202 was notified of today's lab results and past CO2 and WBC results, lung sounds, oxygen saturation reading and Resident #86's complaints. Physician #202 was notified of Resident #86 requesting chest x-ray, but portable not able to be performed due to resident size. The physician replied no to hospital x-ray and to use CPAP during the day. Review of Resident #86's progress notes dated 12/12/24 at 6:29 P.M. included Resident #86's oxygen saturation was monitored throughout the day and readings were 90 to 93 percent with oxygen on at six liters via nasal cannula or 10 liters while on CPAP. Resident #86 continued to report his oxygen saturation was 88 to 90 percent. Resident #86's respirations were even and unlabored, with no respiratory distress noted. Resident #86's skin was pink, warm and dry. Review of Resident #86's progress notes dated 12/13/24 at 8:32 A.M. included assessment completed due to Resident #86 continued to state I know I have pneumonia. Resident #86's skin color was pink, warm and dry, respirations were even and unlabored. CPAP in place as ordered and oxygen saturations was 96 percent. Resident #86's physician was in the facility and updated on Resident #86's vital signs. Review of Resident #86's progress notes dated 12/13/24 at 3:13 P.M. included the nurse was called to Resident #86's room to evaluate and speak to him. Resident #86 inquired what could be done in the facility versus what was done in the hospital for treatment of pneumonia. Resident #86 was told the facility could administer all the same medications that were ordered as in the hospital setting if they were ordered by the physician. Resident #86 stated he got aerosols around the clock in the hospital. The nurse explained the facility could do the same if the aerosols were ordered. Resident #86 was not short of breath during the conversation, did not have to stop talking to breathe, nor was he sitting straight up at the time. Resident #86 was advised if he felt shortness of breath, the nurse could see what medications were available. The nurse also suggested Resident #86 sit upright and use proper body alignment. The nurse offered to get assistance to help Resident #86 properly align self. Resident #86 refused the medication check, but did raise the head of the bed and straighten self in alignment with the bed without assistance. Resident #86 was not using accessory muscles when breathing. Review of Resident #86's late entry progress note dated 12/15/24 at 9:06 A.M. revealed on 12/13/24 at 4:55 P.M. the DON had a discussion with Resident #86's primary care provider and it was okay to start an antibiotic (Levaquin) as a precaution to pneumonia. It was explained to Resident #86 that if he had pneumonia the antibiotic was the appropriate treatment. Resident #86 stated he lived three hours from the nearest hospital and he wanted the chest x-ray to make sure he was getting better, not that he felt like he had pneumonia currently. It was explained to Resident #86 that he would need to be sent through the ED and then admitted per the hospital protocol, and that a preventive x-ray was not really an emergency so would have to schedule transport via non emergency transportation. Resident #86 became angry and started swearing, and Resident #86 was given his space. Resident #86's wife called and stated the antibiotic was fine and Resident #86 was worried for when he returned home. Review of Resident #86's progress notes dated 12/15/24 at 2:13 A.M. included Resident #86 had a cough and wanted to go to the hospital for a chest x-ray (could not be done at the facility due to body habitus). Resident #86 was started on Levaquin and was unhappy about not being evaluated at the hospital. When his pin care was completed at 1:00 A.M. Resident #86 noted redness around the pins and wanted to go to the hospital right then. Review of Resident #86's progress notes dated 12/15/24 at 7:21 A.M. included around 1:00 A.M. Resident #86 verbalized dissatisfaction that he had not gone to the hospital for a chest x-ray. Resident #86 was reminded he was on Levaquin just in case and he took his first dose. Resident #86 had his mind set that he should have gone out for an x-ray and wanted the facility to call the physician and go to the hospital for an evaluation at this time. Resident #86 was sent to the ER per his request and his physician, wife and on-call nurse were notified. Interview on 01/09/25 at 11:09 A.M. of Resident #86 and Family Member (FM) #200 revealed Resident #86 developed a respiratory infection that started about a week after he was admitted to the facility. Resident #86 stated staff came in the room without face masks and had hoarse, deep coughs, and after that he developed a cough. FM #200 stated facility staff argued with her and said they could not do a portable chest x-ray at the facility because Resident #86 was too big, and they would not even try. FM #200 stated she did not know if an x-ray was ever ordered. Resident #86 and FM #200 stated Resident #86 definitely asked for a chest x-ray because he had a respiratory infection. Resident #86 stated he did not talk to and was not examined by a physician or nurse practitioner after he thought he had pneumonia was definitely upset about the situation. Interview on 01/13/25 at 3:44 P.M. of the Director of Nursing (DON) revealed Resident #86 was unable to have a portable chest x-ray at the facility due to body habitus, and was not sent to the hospital for a chest x-ray. The DON confirmed Physician #202 did not order a chest x-ray for Resident #86 and told the nurses not to send him to the hospital where he could have a chest x-ray. The DON indicated even if Resident #86 had a chest x-ray at the hospital and it showed he had pneumonia, the treatment with the antibiotic Levaquin would be the same as what he was already receiving at the facility. The DON confirmed Physician #202 did not examine Resident #86 or talk to him from 12/06/24 until he went to the hospital on 12/15/24 and stated she could not make Physician #202 see Resident #86. The DON indicated she had a discussion with Resident #86 and told him the hospital protocol was he could not have a chest x-ray if he went to the ER, and he would have to be admitted if a chest x-ray was ordered. Review of the Ohio Health Care Association policy titled Resident Rights and Facility Responsibilities included the facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The resident had the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including the resident had a right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part. This deficiency represents non-compliance investigated under Complaint Number OH00160965.

Based on observation, open and closed medical record review, fax sheet review, policy review, and interview, the facility failed to ensure all residents received adequate, timely and necessary care and treatment. The facility failed to ensure Resident #78 received timely and adequate treatment and care and medical intervention to treat a change in condition. Resident #78 was admitted to the facility on [DATE] following a hospitalization for acute ischemia (reduced blood flow) of small intestine with perforation status post right hemicolectomy (removal of part of the large intestine), septic shock and gastroenteritis (inflammation of the lining of the stomach). Between 09/05/24 and 09/18/24 Resident #78 exhibited increased nausea/vomiting, diarrhea and abdominal pain. In addition, Resident #78 had orders for levothyroxine (used to treat thyroid disorders) with concerns the medication was not ordered/provided at an appropriate dose to meet the resident's needs. During this time, the facility failed to take appropriate action by updating the physician on a change of condition which included abnormal laboratory values and meal refusals for Resident #78. On 09/18/24, Resident #78's thyroid stimulating hormone (TSH) level was elevated at 44.9 (0.358 to 3.740 normal). Upon notification of the abnormal TSH level, the physician, who was unaware Resident #78 was already receiving levothyroxine, ordered levothyroxine at a lower dose. This resulted in Immediate Jeopardy and actual harm with the potential for serious impairment and/or death beginning on 09/24/24 when Resident #78's laboratory testing obtained on this date was abnormal with sodium of 127 (normal 136-145), potassium 3.3 (normal 3.5-5.1) and creatinine 2.09 (normal for woman 0.55 -1.02) without evidence the physician was notified. From 09/24/24 through 10/09/24, Resident #78 continued to have nausea, vomiting, diarrhea, abdominal pain, decreased appetite with refusal of meals and supplements, weight loss and weakness. On 10/09/24, Resident #78 presented with coffee ground emesis, exhibited (abdominal) pain rated a 10 out of 10 and low blood pressure (hypotension) and was transferred to the emergency room . Resident #78 was subsequently admitted to the hospital with severe dehydration, severe malnutrition and abnormal TSH which was noted to possibly be a contributing factor of the resident's gastrointestinal (GI) issues. The resident's sodium was noted to be abnormally low at 120, blood urea nitrogen (BUN) was abnormally high at 70 (normal 7-18) and her TSH level was abnormally high at 85.7 (normal 0.358 -3.740). The resident required intravenous fluids and intravenous levothyroxine. In addition, a concern that did not rise to Immediate Jeopardy occurred when the facility failed to ensure Resident #25 was transported to scheduled appointments to ensure continuity care and failed to assess Resident #71 timely related to an elevated blood sugar. This affected three residents (#78, #25 and #71) of 12 residents reviewed for change in condition and/or continuity of care/transportation. The facility census was 77. On 10/28/24 at 5:27 P.M., the Administrator, Director of Nursing (DON), Regional Clinical Registered Nurse (RCRN) #605, Regional Director of Operations (RDO) #606 and [NAME] President of Operations (VPO) #612 were notified Immediate Jeopardy began on 09/24/24 when the facility failed to identify a change in Resident #78's condition and provide physician notification of continued abnormal laboratory testing. Between 09/24/24 and 10/09/24 the facility failed to provide adequate medical/nursing intervention to ensure the resident received timely and necessary treatment. On 10/09/24, Resident #78 was admitted to the hospital intensive care unit (ICU) with severe dehydration, severe malnutrition and abnormal TSH level. The resident was hospitalized until 10/16/24 and did not return to the facility. Prior to the hospitalization , the resident exhibited increased nausea/vomiting, diarrhea, abdominal pain and weight loss without evidence of adequate intervention or communication to the physician for necessary and adequate treatment. The Immediate Jeopardy was removed on 10/29/24 when the facility implemented the following corrective actions. On 10/09/24 Resident #78 was transferred to the emergency room and did not return to the facility. On 10/28/24 by approximately 3:00 P.M., the DON conducted a whole house audit to ensure all resident labs in the last 30 days had documented evidence of physician notification. On 10/28/24 by approximately 7:00 P.M., the DON conducted a whole house audit to ensure any resident who refused meals in the last 72 hours had physician and registered dietitian (RD) notification and documentation. On 10/28/24 at approximately 8:00 P.M., the DON educated Registered Dietitian (RD) #613 on communicating meal refusals with the facility nursing management. On 10/28/24 by approximately 7:30 P.M., Licensed Practical Nurse (LPN) #578/Unit Manager conducted a whole house audit for all resident's nursing progress notes from the previous 72 hours (since 10/26/24) to ensure any change in condition had proper notification and documentation. On 10/28/24 by approximately 8:15 P.M., the DON educated all nurses on the proper process for reporting labs, observing new orders and ensuring appropriate documentation of all notifications and new orders. The education also included current medications related to lab values should be relayed to the physician at the time of notification. On 10/28/23 by approximately 8:30 P.M., the DON completed verbal education to all facility physicians and nurse practitioners regarding verifying the current dose of any medication related to a lab value before changing the dose. On 10/28/24 by approximately 8:30 P.M., the DON completed education for all nurses on notification of change in condition policy and recognizing signs and symptoms of a change in condition. On 10/28/24 by approximately 8:30 P.M., Registered Nurse (RN) #583/Unit Manager conducted a whole house audit for all residents ordered levothyroxine to ensure labs within the last 30 days were managed appropriately. All orders were verified for accuracy. Any concerns were addressed and documented. On 10/28/24 at approximately 8:30 P.M., Physician #600, who was the Medical Director, was notified of the concern related to Resident #78 and notified of the facility current corrective action plan. On 10/28/24 at approximately 8:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, RDO #606, VPO #612, RCRN #605, LPN #593/Minimum Data Set Nurse, RN #583/Unit Manager, LPN #578/Unit Manager, and with Physician #600 via telephone. Discussion included requirements of visits, labs, notifications, communication, current orders, and resident conditions. Beginning on 10/29/24, the DON/designee would audit all labs for results, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly. Beginning on 10/29/24, the DON/designee would audit all nurses' notes for a change in condition and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly. Beginning on 10/29/24, the DON/designee would audit meal intakes on five residents each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly. Beginning on 10/29/24, the DON/designee would audit four residents on Levothyroxine each week to check for notification of physician as warranted, if new orders were reviewed and were appropriate, documentation of labs, new order notification to family, and if any needed follow up was completed immediately for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly. Although the Immediate Jeopardy was removed on 10/29/24, the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action and monitoring for effectiveness and on-going compliance. Findings include: 1. Review of the closed medical record for Resident #78 revealed the resident was admitted to the facility on [DATE] with diagnoses of acute ischemia of small intestine, status post right hemicolectomy, infectious gastroenteritis, acute respiratory failure with hypoxia, diastolic heart failure, hypothyroidism, and need for personal care. The resident was transferred/discharged to the hospital on 10/09/24 and did not return to the facility. Review of the physician/nurse practitioner progress note dated 08/29/24 authored by Nurse Practitioner (NP) #603 revealed Resident #78 was admitted to the facility on [DATE] from the hospital where she was treated for ischemic small bowel perforation, septic shock, acute kidney injury and acute hypoxemic respiratory failure. Resident #78 had gone to the emergency department on 08/20/24 complaining of severe abdominal pain and nausea and was found to have small bowel ischemia with perforation and was taken to the operating room for right hemicolectomy with re-anastomosis. On 08/21/24, Resident #78 experienced hypotensive shock requiring pressors (medication). There was concern for further bowel ischemia and Resident #78 was transferred to a larger hospital. Labs from 08/27/24 to 08/28/24 included sodium 131 (low), potassium 4.0 (normal), BUN 7 (normal) and creatinine 0.66 (normal). Review of symptoms revealed Resident #78 was eating well and anxious. A physical exam indicated Resident #78 was ambulatory with assist and walker since hospitalization and alert and oriented to person, place, time and situation. The assessment/plan indicated infectious gastroenteritis and colitis status post right hemicolectomy. Follow up with surgeon (Physician #608) on 09/06/24 as scheduled. Regarding hypothyroidism the note indicated to continue levothyroxine and monitor labs. Recheck basic metabolic panel (BMP) in one week. Review of the physician orders from August 2024 revealed Resident #78 was ordered potassium chloride extended-release oral tablet 20 milliequivalent (mEq) one tablet by mouth two times a day for hypokalemia, spironolactone (a diuretic) oral tablet 50 milligrams (mg) by mouth in the morning for hypertension, meclizine HCl oral tablet 25 mg give one tablet by mouth every six hours as needed for dizziness, levothyroxine sodium oral tablet 75 micrograms (mcg) give one tablet by mouth in the morning evening Monday, Tuesday, Wednesday and Thursday and levothyroxine sodium oral tablet 75 mcg give 1.5 tablets by mouth in the morning on Friday, Saturday and Sunday for hypothyroidism. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #78 was cognitively intact, required setup or clean-up assistance with eating, needed partial/moderate assistance with toileting, and was always continent of bowel. Review of a fax sheet from the facility to Physician #600's office dated 09/04/24 authored by RN #581 revealed Resident #78 had complaints of nausea most of the day and had dry heaved off and on. The fax noted the resident was here (at the facility) after bowel surgery. Abdomen was soft, nondistended and not painful. Bowel sounds active throughout. She also had a soft/loose stool this evening. On 09/05/24, the resident refused all medications due to nausea. The NP wrote on the fax sheet dated 09/05/24 to complete a Kidney, Ureter and Bowel (KUB) x-ray. Review of the health status note dated 09/05/24 timed 6:54 A.M. revealed Resident #78 had complaints of nausea off and on all night. Staff documented the resident's abdomen was soft, not distended, and not painful. Bowel sounds were active throughout. Resident #78 also had a single loose stool. Labs were drawn. The note further indicated the nurse practitioner was aware and would assess that day. Review of the results of the BMP dated 09/05/24 revealed Resident #78's sodium was 129 (low), potassium 3.7 (normal), (BUN) was 5 (low) and creatinine was 0.79 (normal). Review of the nurse's note dated 09/05/24 revealed Resident #78 continued to complain of nausea. The nurse practitioner was in for a visit and gave order for Zofran (anti-nausea medication) and KUB x-ray. Review of the physician orders dated 09/05/24 revealed Resident #78 was ordered ondansetron (Zofran) oral tablet disintegrating four mg one table by mouth every six hours as needed for nausea and vomiting, Stat (immediate) KUB x-ray and BMP on 09/09/24. Review of the nutritional status care plan dated 09/05/24 revealed Resident #78 was at risk for decreased nutritional status and dehydration due to septic shock, required pressors, ischemic bowel status post right hemicolectomy, colitis, acute kidney injury, respiratory failure, morbid obesity. The care plan included nausea was currently affecting intakes and Resident #78 was at risk for malnutrition. Interventions included monitor for signs and symptoms of dehydration and monitor oral intakes. Review of the surgical physician, Physician #608's progress note dated 09/06/24 revealed Resident #78 had a laparotomy (an incision into the abdominal cavity performed to examine the abdominal organs and aid diagnosis of any problems) on 08/20/24. Resident #78 reported nausea and not tolerating much of a diet. She was having liquid stool. The progress note indicated Resident #78 could return in two weeks for a follow-up. Review of the fluid volume deficit care plan updated 09/10/24 revealed Resident #78 had potential for fluid volume deficit with an intervention to monitor labs as ordered. Review of the altered comfort level care plan updated 09/10/24 revealed Resident #78 had potential for altered comfort level related to gastrointestinal discomfort, hemicolectomy related to ischemic necrosis of small bowel and colitis with interventions to report abdominal pain, report episodes of diarrhea and vomiting and report complaints of nausea. Review of the BMP lab result dated 09/09/24 revealed Resident #78's sodium was 128 (low) and creatinine was 1.16 (high). Review of the physician order dated 09/10/24 revealed Resident #78 was ordered a 2000 milliliter (mL) fluid restriction, to encourage salt intake and BMP in one week. Review of the BMP lab dated 09/17/24 revealed Resident #78's sodium was 128 (low) and creatinine was 2.19 (high). Review of a fax sheet from the facility to Physician #608 dated 09/17/24 revealed Resident #78 continued to have frequent nausea and vomiting. Currently ordered Zofran as needed and effective short term. Recent KUB negative. Please advise. Physician #608's office responded with, Resident #78 to follow up next with Physician #608. If worsening symptoms, patient will need to go to the emergency room . Appointment on 09/23/24 at 3:00 P.M. Review of Resident #78's physician orders dated 09/17/24 revealed orders to discontinue fluid restriction and administer two liters of sodium chloride 0.9% at 75 mL/hour intravenously, recheck BMP in one week, and if resident's nausea and vomiting continue to worsen, may send to emergency department. Review of the TSH lab result dated 09/18/24 revealed Resident #78's TSH was 44.9 (high). Physician #600 wrote on the lab sheet, start Synthroid 50 micrograms (mcg) by mouth one a day in the morning by itself for one hour (no other food or pills). Review of Surgical Physician #608's progress notes dated 09/23/24 revealed Resident #78 was still complaining of nausea, vomiting and diarrhea. The assessment and plan indicated diarrhea. The note further indicated unsure as to the reason for the vomiting, but Resident #78 would require a CAT scan which the physician would rather have done at the emergency room if the resident was having acute vomiting. The resident's abdomen was not distended, and it was soft. The physician wanted to check/test the resident for Clostridium difficile (a bacterium that can cause diarrhea). Review of the nursing progress notes from 09/23/24 to 09/24/24 revealed there was no evidence of an order to obtain a Clostridium difficile culture for Resident #78 and no evidence the testing was completed. Review of the health status note dated 09/23/24 timed 10:00 P.M. revealed Resident #78 complained of ongoing nausea with emesis of bile and saliva. Ginger ale and as needed Zofran administered at 7:40 P.M., not effective. On call physician notified and order given for an additional dose of Zofran 4 mg. Resident aware of order and medication administered. Resident #78 refused part of bedtime medications due to nausea. The primary care physician (PCP) was notified of continued nausea and medication refusal. Resident #78 with no diarrhea noted this shift. Review of the fax sheet from the facility to Physician #600/NP dated 09/23/24 revealed Resident #78 with complaints of frequent nausea with emesis of bile and saliva. Resident #78 was medicated with Zofran 4 mg at 7:40 P.M. without relief. On call physician notified and additional order given for repeat administration of Zofran 4 mg. Continued to complain of nausea. Refused medications due to nausea. Resident #78 had been having more frequent bouts of nausea. The fax indicated Resident #78 had an order for Zofran 4 mg every six hours and asked if the physician/nurse practitioner would consider increasing dose or frequency or additional medication. NP #603 responded on 09/24/24 with direction to start omeprazole (reduces the amount of acid the stomach makes) 20 mg once a day at night. Review of the physician order dated 09/24/24 revealed Resident #78 was ordered omeprazole oral tablet delayed release 20 mg once a day at bedtime for indigestion and if nausea and vomiting worsened could send to emergency room for CAT scan. Review of BMP lab results dated 09/24/24 revealed Resident #78's sodium was 127 (low), potassium 3.3 (normal 3.5-5.2) and creatinine was 2.09 (high). Review of the nursing progress notes and assessments from 09/24/24 to 10/09/24 revealed there was no evidence Resident #78's physician (Physician #600) and/or NP (NP #603) were notified of Resident #78's 09/24/24 abnormal lab results. In addition, there was no evidence Resident #78's physician and/or NP was notified from 09/26/24 to 10/07/24 regarding Resident #78's ongoing nausea, vomiting, diarrhea, refusal of meals and abdominal pain. Review of the health status note dated 09/25/24 timed 11:57 A.M. revealed Resident #78 refused to go to the dining room during the shift and refused to eat meals. Review of the nutrition progress note dated 09/25/24 timed 1:01 P.M. revealed Resident #78 had refused 24 meals and nausea and vomiting was noted in Resident #78's chart. Review of the pharmacy review note dated 09/25/24 authored by Pharmacist #611 revealed Pharmacist #611 reviewed Resident #78's medication regimen and noted any irregularities and/or observations on a separate report to the DON and prescriber. Review of the Consultant Pharmacist's Medication Regimen Review sheet dated 09/30/24 revealed Resident #78 was reviewed during the consultant pharmacist's visit between 09/01/24 and 09/30/24 with no irregularities noted and no pharmacist recommendations. Review of the late-entry Medicare Skilled Assessment note dated 09/27/24 timed 9:48 P.M. revealed Resident #78 had abdominal cramping with nausea and stomach cramping. Review of the Medicare Skilled Assessment note dated 09/28/24 timed 10:08 P.M. revealed Resident #78 complained of abdominal pain, nausea and stomach cramping. Review of the health status note dated 09/29/24 timed 8:47 P.M. revealed the author discussed with Resident #78 the importance of eating foods with medications due to frequent complaints of nausea, that food intake could help neutralize acids, and taking multiple medications could increase the chance of nausea. Review of the Medication Administration Record (MAR) from September 2024 revealed Resident #78 received the as needed Zofran 4 mg on 09/05/24 at 8:10 P.M., 09/06/24 at 1:19 P.M. and 8:45 P.M., 09/07/24 at 8:38 A.M., 09/08/24 at 10:04 P.M., 09/09/24 at 10:33 P.M., 09/10/24 at 7:14 A.M. and 8:05 P.M., 09/11/24 at 7:49 A.M., 09/12/24 at 7:42 A.M. and 8:28 P.M., 09/13/24 at 7:52 A.M. and 3:35 P.M., 09/14/24 at 7:48 A.M. and 5:37 P.M., 09/15/24 at 12:14 A.M., 9:06 A.M. and 4:54 P.M., 09/16/24 at 8:00 A.M. and 4:17 P.M., 09/17/24 at 5:21 A.M. and 4:21 P.M., 09/18/24 at 1:19 A.M., 7:41 A.M. and 4:40 P.M., 09/19/24 at 9:12 A.M. and 8:26 P.M., 09/20/24 at 5:51 P.M. and 8:55 P.M., 09/21/24 at 5:32 P.M. and 8:46 P.M.,09/22/24 at 6:01 A.M. and 7:55 P.M., 09/23/24 at 5:44 A.M., 7:44 P.M. and 10:00 P.M., 09/24/24 at 4:22 A.M. at 4:43 P.M., 09/25/24 at 2:50 A.M., 09/26/24 at 1:47 A.M. and 3:25 P.M., 09/27/24 at 8:39 A.M. and 9:09 P.M., 09/28/24 at 7:16 A.M. and 5:23 P.M.,09/29/24 at 6:17 A.M. and 8:14 P.M., and 09/30/24 at 7:28 A.M. and 10:24 P.M. Review of the MAR from September 2024 revealed Resident #78 received the as needed meclizine 25 mg on 09/04/24 at 8:11 P.M., 09/11/24 at 7:49 A.M., 09/14/24 at 9:13 P.M., 09/15/24 at 10:58 P.M., 09/18/24 at 11:51 A.M. and 9:13 P.M., 09/20/24 at 3:34 P.M., 09/21/24 at 7:15 P.M., 09/23/24 at 1:30 P.M. and 8:37 P.M., 09/25/24 at 5:49 A.M. and 7:34 P.M., 09/26/24 at 6:09 A.M. and 7:17 P.M., 09/27/24 at 5:20 A.M. and 4:38 P.M.,09/28/24 at 2:48 A.M., 11:48 A.M. and 9:26 P.M., 09/29/24 at 5:28 P.M., and 09/30/24 at 3:53 A.M. Review of the September 2024 meal intake documentation in the tasks tab of the electronic medical record (EMR) revealed Resident #78 refused meals on 09/07/24 at breakfast, 09/08/24 at breakfast, 09/09/24 at lunch, 09/10/24 at breakfast, lunch and dinner, 09/11/24 at breakfast and dinner, 09/12/24 at breakfast and dinner, 09/13/24 at breakfast and dinner, 09/14/24 at breakfast and dinner, 09/15/24 at breakfast and lunch, 09/16/24 at breakfast and lunch, 09/18/24 at breakfast, 09/19/24 at breakfast and lunch, 09/20/24 at breakfast and lunch, 09/21/24 at breakfast, 09/22/24 at breakfast and lunch, 09/23/24 at lunch, 09/24/24 at breakfast, lunch and dinner, 09/25/24 at breakfast and lunch, 09/26/24 at breakfast, lunch and dinner, 09/27/24 at breakfast, lunch and dinner, 09/28/24 at breakfast, 09/29/24 at breakfast and lunch, and 09/30/24 at breakfast. Review of the September 2024 bowel continence documentation in the tasks tab of the EMR revealed Resident #78 had loose stools or diarrhea on 09/05/24, 09/07/24, 09/09/24, 09/10/24, 09/11/24, 09/12/24, 09/13/24, 09/14/23, 09/15/24, 09/16/24 (two episodes), 09/17/24 (three episodes), 09/19/24, 09/22/24 (two episodes), 09/23/24, 09/24/24, 09/26/24 (two episodes), 09/27/24 (two episodes), 09/28/24, and 09/29/24. Review of the Medicare Skilled Assessment note dated 10/01/24 timed 9:26 P.M. revealed Resident #78 had mild abdominal pain and complaints of nausea frequently. Review of the nutrition progress note dated 10/03/24 timed 9:54 A.M. revealed Resident #78 had refused 27 meals, and nausea and vomiting continued with treatments in place. Resident #78 was independent to set up assistance with some increased assistance from helper at times. Resident #78 was still at risk for malnutrition. The goal indicated meal intakes greater than or equal to 50% once nausea was resolved. Review of the health status note dated 10/08/24 timed 6:11 P.M. revealed Resident #78 had a small coffee ground emesis this evening. The physician notified. The note further indicated to see new orders. Review of the health status note dated 10/09/24 timed 7:11 A.M. revealed Resident #78 was noted to have additional coffee ground emesis and complained of intense left upper quadrant and left lower quadrant abdominal pain. Resident #78 stated, worse than before I had my surgery. The note indicated Resident #78 had a bowel obstruction when she was hospitalized prior to the nursing home admission. Physician #600 was notified. Review of the eINTERACT Transfer Form assessment dated [DATE] timed 7:14 A.M. revealed Resident #78 had an unplanned transfer to the hospital for abdominal pain with a blood pressure of 95/66 (hypotensive) and a pain level rated a 10 out of 10 (with 10 being the most severe pain). Resident #78 had complaints of achy pain, stated constant for the last hour and also had coffee ground emesis. Review of the MAR from October 2024 revealed Resident #78 received as needed Zofran 4 mg on 10/01/24 at 4:53 A.M. and 8:07 P.M., 10/02/24 at 5:43 A.M. and 7:55 P.M., 10/03/24 at 5:10 P.M.,10/04/24 at 10:12 A.M. and 8:01 P.M., 10/05/24 at 3:08 A.M.,10/06/24 at 12:10 P.M. and 6:10 P.M., 10/07/24 at 1:16 A.M., 12:49 P.M. and 11:25 P.M.,10/08/24 at 9:59 A.M. and 4:44 P.M., and 10/09/24 at 4:38 A.M. Review of the MAR from October 2024 revealed Resident #78 received as needed meclizine 25 mg on 10/02/24 at 12:02 P.M., 10/03/24 at 3:00 A.M. and 12:44 P.M.,10/04/24 at 12:55 P.M. on 10:26 P.M.,10/05/24 at 2:29 P.M. and 8:46 P.M.,10/06/24 at 2:58 P.M.,10/07/24 at 5:10 A.M. and 7:44 P.M., and 10/08/24 at 5:38 A.M., 2:23 P.M. and 11:29 P.M. Review of the October 2024 meal documentation in the tasks tab in the EMR revealed Resident #78 refused meals on 10/01/24 at breakfast and lunch,10/02/24 at breakfast, lunch and dinner,10/03/24 at breakfast, 10/04/24 at breakfast, lunch and dinner,10/05/24 at breakfast, lunch and dinner,10/06/24 at breakfast, lunch and dinner,10/07/24 at breakfast and lunch, and 10/08/24 at breakfast and dinner Review of the October 2024 bowel continence documentation in the tasks tab of the EMR for Resident #78 revealed Resident #78 had loose stools or diarrhea on 10/02/24, 10/03/24 (two episodes), 10/05/24, and 10/07/24. Review of the weights in the weights/vitals tab of the EMR revealed Resident #78 sustained weight during her facility admission with the following weights obtained: On 09/03/24 the resident weighed 267.4 pounds, on 09/10/24 the resident weighed 255.4 pounds, on 09/17/24 the resident weighed 253.3 pounds, on 09/24/24 the resident weighed 246.8 pounds, on 10/01/24 the resident weighed 245.5 pounds and on 10/07/24 the resident weighed 239.1 pounds. From 09/03/24 to 10/07/24 the resident experienced a 28.3-pound weight loss. Review of the emergency department physician summary dated 10/09/24 revealed Resident #78 presented from a nursing home with dark brown coffee-ground emesis that she stated she had for the past week without any bloody or red discoloration and left-sided abdominal pain that started in the morning (10/09/24). She stated she had been vomiting like this for six weeks or so, but she had not had any abdominal pain until this morning. Labs showed acute renal failure .and with her BUN of almost 70 and actively vomiting intravenous fluids were warranted. The resident was noted to be hyperkalemic presumably from the acute renal failure .Labs from 10/09/29 at 8:36 A.M. showed BUN 68 and creatinine 4.78 (reflective of acute renal failure). Review of the hospitalist physician's history and physical exam dated 10/09/24 timed 11:45 A.M. revealed family assisted with Resident #78's history, and they told the hospitalist that she had a Pneumovax vaccine three weeks ago and since that point in the time she had nausea and vomiting, diarrhea and intermittent abdominal pain. Her oral intake had declined, and Resident #78 reported profuse watery diarrhea. Resident #78 stated she had been able to take her medicines, but she was unsure what was coming back up when she vomited and was not clear on absorption. Given her ongoing decline and ongoing issues with vomiting and concern or hematemesis (bloody emesis) she was sent to the emergency department. TSH was 85.7. The plan indicated abnormal TSH with history of hypothyroidism. TSH was markedly elevated. Paperwork from nursing facility noted the resident was on (levothyroxine) 50 mcg daily but per documentation she had been on 125 mcg daily. Hold home oral thyroid replacement therapy and give intravenous (thyroid replacement therapy) 75 mcg. The note indicated this could have been confounding the resident's digestive issues. The resident was admitted to the intensive care unit. Review of Physician #608's hospital progress note dated 10/10/24 revealed Resident #78 was having severe dehydration as she also had an elevated TSH. Resident #78 was receiving a low-dose of Synthroid at her nursing home so she was receiving intravenous to replete. Continue hydration and observation. Resident #78 had been very dehydrated and not eating or drinking at the nursing home. Resident #78 said she had been having a lot of nausea. Labs shown on 10/09/24 at 8:36 A.M. that TSH was 85.7 (0.358 to 3.740 normal). Review of a hospital discharge summary dated 10/16/24 revealed Resident #78 had acute gastroenteritis, acute cystitis (urinary tract infection that causes inflammation of the bladder), diffuse abdominal pain, acute kidney failure, and acidosis and severe malnutrition related to inadequate oral intake as evidenced by 10% unintentional weight loss in 1.5 months and oral intake meeting less than 50% of estimated needs for three weeks. Interview on 10/21/24 at 2:15 P.M. with LPN #536 revealed the evening of 10/08/24, Resident #78 had a small coffee ground emesis, so LPN #536 notified the on-call physician who ordered labs to be drawn the morning of 10/09/24. Interview on 10/21/24 at 2:40 P.M. with the DON verified Resident #78's labs were abnormal on 09/24/24 and verified there was no evidence Resident #78's physician and/or nurse practitioner was notified of the resident's 09/24/24 abnormal labs. Interview on 10/21/24 at 3:00 P.M. with RN #574 revealed Resident #78 had been at the facility for approximately a month and a half and stated she believed the resident was medically in poor condition when she arrived from the hospital as she was weak and not eating much. Resident #78 began to progress and get better; however, Resident #78 began to have nausea and vomiting and was not eating well. Resident #78 was given Zofran and meclizine. RN #574 stated she would question the day shift nurses about how the medication was not fixing Resident #78's nausea and vomiting. Interview on 10/22/24 at 7:15 A.M. with RN #581 revealed on the evening of 10/08/24, Resident #78 had nausea and vomiting and a coffee ground emesis during LPN #536's shift. The physician ordered labs for 10/09/24, and the nurses thought Resident #78 was possibly in lactic acidosis (a condition where there is too much lactic acid in the body). The RN stated Resident #78 was fine through the night of 10/08/24 into 10/09/24 then at 6:20 A.M., Resident #78 started complaining of abdominal pain. Interview on 10/22/24 at 9:45 A.M. with Physician #600 revealed Resident #78 was dehydrated on 09/17/24 resulting in the new order of two liters of intravenous fluids being administered. Physician #600 revealed he was not aware of Resident #78's abnormal labs on 09/24/24 and stated if he had been notified of the abnormal potassium and sodium values, Physician #600 would have likely ordered oral potassium and another round of intravenous fluids to correct the sodium value. Physician #600 also revealed he was not aware Resident #78 had consistently refused 27 meals during her stay in the facility. Interview on 10/22/24 at 10:10 A.M. with Physician #608's office representative revealed during Resident #78's office visit on 09/23/24, Resident #78 was sent back to the facility with orders to obtain a lab culture for Clostridium difficile and to send the resident to the emergency department if the vomiting continued. Physician #608's office representative stated the Clostridium difficile culture should have been obtained at the nursing home. Interview on 10/22/24 at 12:00 P.M. with the DON and RCRN #605 revealed the facility did not have a policy regarding meal refusals and notifying the physicia [TRUNCATED]

Based on record review and interview, the facility failed to ensure residents were seen by their physician once at least every 30 days for the first 90 days after an admission. This affected four residents ( #9, #10, #78 and #84) of seven residents reviewed for physician visits. The facility census was 77. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including necrotizing fasciitis (a bacterial infection that results in the death of the body's soft tissue), sepsis, paraplegia and fracture of the left tibia. Review of the nursing progress notes (where the physician and nurse practitioner progress notes were also located) dated 08/24/24 through 10/29/24 revealed Resident #9 was not seen by his physician while at the facility. Resident #9 was seen by Nurse Practitioner (NP) #603 on 08/27/24, 09/19/24, 10/08/24 and 10/17/24. Interview on 10/29/24 at 1:55 P.M. with Resident #9 verified he had never seen Physician #600 while at the facility. He stated he had seen NP #603 and had also went out of the facility to see his surgeon and the wound clinic physician. Interview on 10/29/24 at 2:22 P.M. with Regional Clinical Registered Nurse (RCRN) #605 verified Resident #9 had not been seen by Physician #600 while at the facility. 2. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including aftercare following joint replacement surgery, diabetes mellitus and chronic kidney disease. Review of the nursing progress notes dated 08/30/24 through 10/29/24 revealed Resident #10 was not seen by her physician while at the facility. Resident #10 was seen by NP #603 on 09/05/24, 09/10/24 and 10/17/24. Interview on 10/29/24 at 2:22 P.M. with RCRN #605 verified Resident #10 had not been seen by Physician #600 while at the facility. 3. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including acute ischemia (decreased blood flow) of the small intestine, chronic obstructive pulmonary disease, acute respiratory failure, infectious gastroenteritis (inflammation of the stomach and intestines) and hypothyroidism (condition where the thyroid does not produce enough hormone). Resident #78 was discharged to the hospital on 10/09/24 for an emergent health condition. Review of the nursing progress notes dated 08/28/24 through 10/09/24 revealed Resident #78 was not seen by her physician while at the facility. She was seen by NP #603 on 08/29/24. Interview on 10/28/24 at 11:43 A.M. with RCRN #605 verified Resident #78 had not been seen by Physician #600 while at the facility. 4. Review of the medical record for Resident #84 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm (cancer) of the lung and heart failure. Resident #84 was discharged to the hospital on 08/26/24. Review of the nursing progress notes dated 07/03/24 through 08/26/24 revealed Resident #84 was seen by Physician #600 on 08/25/24. There was no other documentation that Resident #84 saw a physician at the facility prior to this date. Resident #84 was seen by NP #603 on 08/01/24 and 08/20/24. Interview on 10/29/24 at 10:40 A.M. with the Director of Nursing (DON) revealed Physician #600 had seen Resident #84 on 08/25/24. The DON provided a physician progress note for Resident #84 dated 08/25/24 that indicated late entry. However, the effective date indicated 08/25/24 and there were no other dates listed on the progress note. The DON verified Resident #84 had not been seen by a physician within 30 days of admission. The DON stated she had spoken to Physician #600 and he could not recall the date he had seen Resident #84 other than the indicated date on the progress note.

Based on closed medical record, interview, and policy review, the facility failed to notify the physician and/or nurse practitioner of abnormal lab results for Resident #78. This affected one resident (#78) of 17 residents reviewed for abnormal lab results. The census was 77. Findings include: Review of the closed medical record for Resident #78 revealed an admitted [DATE] with diagnoses of acute ischemia (reduced blood flow) of small intestine, status post right hemicolectomy (removal of part of the large intestine), infectious gastroenteritis (inflammation of the lining of the stomach), acute respiratory failure with hypoxia, diastolic heart failure, hypothyroidism, and need for personal care. Resident #78 was discharged to the hospital on 10/09/24. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #78 was cognitively intact, needed setup or clean-up assistance with eating, and needed partial/moderate assistance with toileting. Review of the physician/nurse practitioner progress note dated 08/29/24 authored by Nurse Practitioner (NP) #603 revealed Resident #78 was admitted to the facility on [DATE] from the hospital where she was treated for ischemic small bowel perforation, septic shock, acute kidney injury and acute hypoxemic respiratory failure. Resident #78 had gone to the emergency department on 08/20/24 complaining of severe abdominal pain and nausea and was found to have small bowel ischemia with perforation and was taken to the operating room for right hemicolectomy with re-anastomosis. On 08/21/24, Resident #78 experienced hypotensive shock requiring pressors (medication). There was concern for further bowel ischemia and Resident #78 was transferred to a larger hospital. Labs from 08/27/24 to 08/28/24 included sodium 131 (low), potassium 4.0 (normal), BUN 7 (normal) and creatinine 0.66 (normal). Review of symptoms revealed Resident #78 was eating well and anxious. A physical exam indicated Resident #78 was ambulatory with assist and walker since hospitalization and alert and oriented to person, place, time and situation. The assessment/plan indicated infectious gastroenteritis and colitis status post right hemicolectomy. Follow up with surgeon (Physician #608) on 09/06/24 as scheduled. Regarding hypothyroidism the note indicated to continue levothyroxine and monitor labs. Recheck basic metabolic panel (BMP) in one week. Review of the health status note dated 09/05/24 timed 6:54 A.M. revealed Resident #78 had complaints of nausea off and on all night. Abdomen was soft, not distended, and not painful. Bowel sounds were active throughout. Labs were drawn. Resident #78 also had a single loose stool. The note further indicated the nurse practitioner was aware and would assess that day. Review of the BMP lab result dated 09/05/24 revealed Resident #78's sodium was 129 (normal 136 to 145), potassium 3.7 (normal 3.5 to 5.1), blood urea nitrogen (BUN) was 5 (normal 7 to 18) and creatinine was 0.79 (normal 0.55 to 1.02). Review of the fluid volume deficit care plan updated 09/10/24 revealed Resident #78 had potential for fluid volume deficit with an intervention to monitor labs as ordered. Review of the BMP lab result dated 09/09/24 revealed Resident #78's sodium was 128 (low) and creatinine was 1.16 (high). Review of the physician order dated 09/10/24 revealed Resident #78 was ordered a 2000 milliliter (mL) fluid restriction, to encourage salt intake and BMP in one week. Review of the BMP lab result dated 09/17/24 revealed Resident #78's sodium was 128 (low) and creatinine was 2.19 (high). Review of the physician orders dated 09/17/24 revealed Resident #78's fluid restriction was discontinued, two liters of intravenous (IV) sodium chloride 0.9% at 75 mL/hour was ordered, a BMP was to be rechecked in one week, and if Resident #78's nausea and vomiting continued to worsen, could send to emergency department. Review of the health status note dated 09/23/24 timed 10:00 P.M. revealed Resident #78 complained of ongoing nausea with emesis of bile and saliva. Ginger ale and as needed Zofran (used to treat nausea and vomiting) was administered at 7:40 P.M. and was not effective. On call physician was notified and order given for an additional dose of Zofran 4 mg. Resident #78 was aware of order and medication administered. Resident #78 refused part of bedtime medications due to nausea. Primary care physician (PCP) notified of continued nausea and medication refusal. No diarrhea was noted that shift. Review of the physician order dated 09/24/24 revealed Resident #78 was ordered omeprazole oral tablet delayed release 20 mg once a day at bedtime for indigestion and if nausea and vomiting worsened could send to emergency room for CAT scan. Review of BMP lab results dated 09/24/24 revealed Resident #78's sodium was 127 (low), potassium 3.3 (low), and creatinine was 2.09 (high). Review of the nursing progress notes and assessments from 09/24/24 to 10/09/24 revealed there was no evidence Resident #78's physician (Physician #600) and/or NP (NP #603) was notified of Resident #78's 09/24/24 abnormal lab results. Interview on 10/21/24 at 2:40 P.M. with the Director of Nursing (DON) verified Resident #78's labs were abnormal on 09/24/24 and verified there was no evidence that Resident #78's physician and/or NP was notified of the resident's 09/24/24 abnormal labs. Interview on 10/22/24 at 9:45 A.M. with Physician #600 revealed Resident #78 was dehydrated on 09/17/24 resulting in the new order of the two liters of IV fluids being administered. Physician #600 verified he was not aware of Resident #78's abnormal labs on 09/24/24 and if he would have been notified of the abnormal potassium and sodium values, Physician #600 would have likely ordered oral potassium and another round of IV fluids to correct the sodium value. Interview on 10/22/24 at 3:15 P.M. with NP #603 for Physician #600 revealed she could not recall if she was notified of Resident #78's 09/24/24 abnormal labs. Normally when NP #603 received a lab, she reviewed the lab then wrote orders or consulted with Physician #600. Review of the facility's Notification of Change in Resident Condition policy updated January 2022 revealed the facility would ensure that the resident, physician, resident representative and/or the resident responsible party or family member (unless otherwise directed by resident, where the resident did not want family member informed) was notified when the following occurred, involving the resident: significant change in the resident's physical, mental or psychological status. This deficiency represents non-compliance investigated under Complaint Number OH00158806.

Based on observation, staff interview, review of pest control reports and review of facility policy, the facility failed to maintain a kitchen area free of pests. This had the potential to affect all 90 residents who received meals from the kitchen. The facility census was 90. Findings include: Observation on 06/24/24 at 8:22 A.M. of the kitchen, with Dining Services Director (DSD) #505, revealed large amounts of drain flies in the dish machine area. The drain flies were seen on the walls and equipment in the area and flying around the area. Interview on 06/24/24 at 9:12 A.M. with DSD #505 confirmed the findings of drain flies. DSD #505 indicated maintenance was aware of the drain flies and was supposed to have it treated. DSD #505 indicated it had been two weeks and nothing had been done yet. Interview on 06/27/24 at 11:07 A.M. with Maintenance Director (MD) #538 revealed he was unaware of the drain flies until 06/24/24, after the observation was made with DSD #505. Review of Pest Control Service Inspection Reports from 01/16/24, 02/09/24, 03/12/24, 04/08/24, 05/09/24, and 06/11/24 revealed the kitchen had not been treated for drain flies. Review of the facility policy titled Pest Control Policy, dated December 2024, revealed when an issue with pest control arises, the pest control company would be contacted and appropriate services would be provided.

Based on observation, staff interview and review of facility policy, the facility failed to ensure garbage was properly disposed of. This had the potential to affect all 90 residents of the facility. The facility census was 90. Findings include: Observation on 06/24/24 at 9:13 A.M. of the outside trash area, with Dining Services Director (DSD) #505, revealed two dumpsters. There were various plastic wrappers, gloves, plastic spoons and cigarette butts on the ground surrounding the dumpsters. Interview at the time of the observation with DSD #505 verified the findings. Review of the facility policy titled Dumpster/Trash Policy, dated January 2022, revealed the area around the dumpsters would be free from any debris and each employee was responsible for keeping the area clean and free of debris.

Based on observations, staff interview and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area and ensure foods were properly stored. This had the potential to affect all 90 residents who received meals from the kitchen. The facility census was 90. Findings include: Observation on 06/24/24 at 8:22 A.M. with Dining Services Director (DSD) #505 of the facility's kitchen revealed a plastic storage container with oats in the dry storage room. A scoop was resting on top of the oats inside the container. Continued observation of the walk-in refrigerator revealed a box of cucumbers, with two molded cucumbers touching non-molded cucumbers, a quarter-full pan of tomato soup covered with plastic wrap without label or date, a pitcher of red juice without label or date, a pitcher of grape juice dated 06/13/24 and a pitcher of sweet tea dated 06/13/24. Concurrent interview with DSD #505 indicated pitchers of juices should be kept for no more than seven days in the cooler (the pitchers of grape juice and sweet tea were on day 11). Further observation of the deep fryer revealed the oil was dark and had food debris floating in the oil. The floor around the deep fryer had significant oil build-up and food debris, including French fries. The front of the deep fryer had drips of oil build-up. There was a three-tiered cart next to the deep fryer that was coated in fryer oil and food debris. On the cart was a metal half pan with burned food debris, used tongs, and a used fryer scoop. Additional observations of the ovens revealed food build-up and crumbs on the front of each of the three double ovens and the flat top grill revealed dark grease build up on the grill top and surrounding guards. Observation of the dish machine area revealed food debris on the clean side of dish machine. The rubber mats and floors were greasy and slippery in the dish machine area. A fan, with a cart below the fan in the dish machine area, were covered in dust build-up. The three trash cans in the dish machine area had drips of an unidentified dried substance down sides and the lids had a layer of food build-up. Lastly, the ceilings in the kitchen area and dish machine area had dust build-up around lights and air vents. Interview on 06/24/24 at 9:12 A.M. with DSD #505 verified the above findings in kitchen areas. Observation on 06/25/24 at 2:58 P.M. of the kitchen revealed a hand sink next to the coffee machine with significant food debris in the sink. Concurrent interview with DSD #505 confirmed the finding. Review of the facility policy titled Sanitation and Food Handling Policy, dated January 2021, revealed sanitary conditions would be maintained in the storage, preparation, and distribution of food. The Dietary Manager was responsible for ensuring cleaning assignments were carried out. Review of the facility policy titled Food Stock Rotation Policy, dated January 2021, revealed any item in a pan or open item would be covered and dated with current date and use by date.

Based on observation and staff interview, the facility failed to ensure residents rooms were maintained in a clean/sanitary manner and were in good repair. This affected 10 (#16, #17, #20, #21, #23, #33, #36, #39, #66, and #85) of 10 residents reviewed for physical environment. The facility census was 90. Findings include: Observation on 06/24/24 at 11:24 A.M. of Residents #33 and #66's room revealed the closet doors were hanging at a slant and off the track. Observation on 06/24/24 at 11:40 A.M. of Residents #17 and #39's room revealed several black markings and gashes across wall between the two residents' beds. Further observation of Resident #39's bed remote revealed the wiring was exposed and the bottom drawer of the resident's nightstand was off the track. Observation on 06/24/24 at 12:15 P.M. of Resident #85's room revealed several gashes and black marking along the wall that extended to bed two, which was unoccupied. Observation on 06/24/24 at 2:13 P.M. of Residents #16 and #23's room revealed the cover of the heating unit was missing, exposing the heating element. Continued observation on 06/24/24 at 2:40 P.M. of Residents #17 and #39's room revealed the light fixture above each bed was covered with heavy dust with what appeared to be dead bugs inside the fixture. Additionally, the closet doors were off the track and the call light panels were not affixed to wall. Observation on 06/24/24 at 02:43 P.M. of Residents #20 and #36's room revealed a large gash in wall to the right side of Resident #36's bed. Continued observation revealed several black markings and gashes in wall between the residents' beds and Resident #20's bed remote had exposed wiring. Interview on 6/25/24 from 11:38 A.M. through 11:55 A.M. with Director of Maintenance (DOM) #538 verified the above identified finding. Concurrent observations with DOM #538 revealed the exposed wiring on Resident #39's bed remote had been covered with a material that was similar to black electrical tape. At the time of the observation, Resident #39 stated her roommate had fixed it. DOM #538 indicated the repair was okay. Further observation of Residents #16 and #23's room revealed the heating unit now had a cover. DOM #538 verified it had been off and he put a cover on the heating unit this morning. The cover had an unknown dried substance on it. DOM #538 verified the observation and stated it needed to be cleaned. During the observation of Resident #85's room with DOM #538, the resident's bathroom was observed to have an unknown dried substance on the floor and along the baseboard, two floor tiles were cracked and there was an odor of urine. DOM #538 verified the findings and stated the bathroom needed cleaned and he would get the floor tiles fixed. Additional observations with DOM #538 revealed in Resident #21's bathroom, the light over the sink was missing the light cover, the baseboard was coming off the wall behind the toilet, the wall behind toilet appeared stained, the floor and baseboard were dirty and the wall around the soap dispenser was dirty and needed painting. DOM #538 verified the findings.

Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to store medications in a safe manner. This affected one (#79) resident, with the potential to affect nine additional residents (#14, #28, #41, #52, #54, #62, #89, #197, and #198) who were identified by the facility as being independently mobile and cognitively impaired residing on the memory care unit. The facility census was 90. Findings include: Record review for Resident #79 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, altered mental status, depression, alcohol dependence and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was severely cognitively impaired. Resident #79 had no impairment to the upper or lower extremities. Resident#79 used a walker/wheelchair for mobility. Observation on 06/25/24 at 11:26 A.M. of medication administration on the secured memory care unit with Registered Nurse (RN) #569 revealed the nurse placed Resident #22's medications in a medication cup and sat the cup on the medication cart. The medications in the cup included aspirin 81 milligrams (mg), benztropine (used to treat involuntary movements) 0.5 mg, duloxetine (anti-depressant) 30 mg, and omeprazole 20 mg. Resident #79 was observed to be within a few feet of the medication cart, observing RN #569. RN #569 left the medications in the cup, unsupervised, on the medication cart and entered Resident #22's room. While RN #569 assessed Resident #22's blood sugar in the resident's room, the medication cart was out of RN #569's view and no other staff were present to monitor Resident #79, who was still standing next to the cart and observing the items on the cart. Interview on 06/25/24 at 11:31 A.M. with RN #569 verified she left the medication cup containing Resident #22's medications on top of the medication cart, unsupervised. RN #569 confirmed Resident #79 was standing near the cart when she left the medications. RN #569 stated, Oh yea, he could have taken them. I thought about taking them in, but I didn't. Review of the facility policy titled Medication Storage Policy, revised August 2021. revealed medication and other supplies are received by the facility and are either stored in a locked medication cart or in the locked overflow area until those items are ready for use.

Based on medical record review, resident interview and staff interview, the facility failed to ensure residents were free of unnecessary medication increases. This affected one (#74) of six residents reviewed for unnecessary medications. The facility census was 90. Findings include: Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included end stage renal disease, depression, insomnia and anxiety disorder. Further review of census information revealed Resident #74 was moved to a new room on 03/19/24. Review of the plan of care revised 01/04/24 revealed Resident #74 had altered sleep pattern and difficulty falling asleep. Interventions included identifying regular sleep schedule, give measures of comfort including turn out lights, provide quiet and darkness and turn off television, give hypnotics per orders, and report complaints of sleeplessness to the charge nurse. Review of a physician's order dated 03/18/24 revealed Resident #74 had an order for Trazodone (an anti-depressant medication that can be used off-label for patients with insomnia) 50 milligram (mg) by mouth at bedtime for sleep aid. Review of a Psychiatric Nurse Practitioner (PNP) note dated 05/14/24 revealed Resident #74 reported feeling frustrated at times. It was quoted Resident #74 reported I can not sleep due to my roommate making noise. Resident #74 reported a hard time sleeping on most nights. It was noted staff were aware of Resident #74's concerns. PNP gave a new order to increase Resident #74's Trazodone 75 milligrams by mouth at bedtime. Review of a nurses note dated 05/15/24 at 10:19 P.M. revealed staff were called to Resident #74's room. Resident #74 asked the staff to turn down his roommate's television. Resident #74's roommate indicated I don't care if you don't like it. Resident #74 was noted to kick over the wheelchair and dart out of bed. Staff attempted to de-escalate the situation and encouraged Resident #74's roommate to turn down the television. It was noted the problem would be addressed in the morning. Further review of Resident #74's medical record revealed no evidence of follow-up to the nursing note on 05/15/24. Review of a PNP note dated 06/03/24 revealed Resident #74 continued to report issues with sleep. Resident #74 reported having a hard time staying asleep. PNP gave an order to increase Resident #74's Trazodone to 100 milligrams by mouth at bedtime. Interview on 06/24/24 at 11:40 A.M. with Resident #74 revealed he was moved to his current room following a hospitalization . Resident #74 indicated his roommate kept the television on all night, was constantly making noises and moving the bed up and down, preventing him from sleeping. Resident #74 reported dissatisfaction with current roommate. Interview on 06/26/24 at 3:45 P.M. with Registered Nurse (RN) #564 revealed she was aware Resident #74 was not getting along with his roommate. RN #564 indicated there were open rooms and a room move could easily be made. RN #564 indicated she should notify the Unit Manager (UM) or Director of Nursing (DON) of the concern. Interview on 06/26/24 at 3:50 P.M. with the Administrator revealed she was unaware Resident #74 was not getting along with his roommate. Interview on 06/26/24 at 3:57 P.M. with the DON and RN #562 revealed RN #562 was the UM for Resident #74's hallway. RN #562 indicated she was aware of a situation of tension between Resident #74 and his roommate regarding television volume; however, she believed the situation to be resolved. Trazodone medication increases in Resident #74's medical record were reviewed with the DON and RN #562. The DON and RN #562 stated they were unaware of the reasoning for medication increases for Resident #74. While the DON stated she was aware the medication was increased, she had not read the PNP notes.

Based on observation, medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure all fall interventions were implemented. This affected two (#41 and #45) of three residents reviewed for falls. In addition, the facility failed to follow procedures following a fall to prevent further injury. This affected one (#41) of three residents reviewed for falls. The facility census was 90. Findings include: 1. Record review for Resident #41 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, subsequent encounter epilepsy, and epilepticus pseudobulbar affect vascular dementia. An additional diagnosis of displaced simple supracondylar fracture of right the humerus was added on 05/16/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely cognitively impaired. Resident #41 had no impairment to the upper or lower extremities, required supervision or touch assistance with transfers and the resident was frequently incontinent of urine and always incontinent of bowels. Review of the Fall Risk Assessment, dated 05/04/24 at 6:17 P.M. and completed by Restorative Registered Nurse (RRN) #562, revealed Resident #41 was at risk for falls. Review of a Change in Function Assessment, dated 05/12/24 at 12:55 P.M. and completed by RRN #562, revealed Resident #41 was more unsteady when ambulating and had an increase in confusion. Review of an updated Fall Risk assessment dated [DATE] at 1:45 P.M. and completed by RRN #562 revealed Resident #41 was alert and oriented times two, was continent, had unsteady gait and transferred with no assistance. Resident #41 was identified as higher risk for falls and two assist/handheld for transfers was implemented. Review of a safety note, dated 05/15/24 at 9:25 P.M. and completed by RRN #562 revealed on 05/15/24 at 1:45 P.M., Resident #41 was in the dining room eating lunch and the activity aide was in the dining room with her. Resident #41 had a fall while in the dining room at 1:45 P.M. Resident #41 indicated she tripped over her wheelchair and stated her right shoulder hurt and she was lifted into the wheelchair. Resident #41 had pain in the right elbow with range of motion. Resident #41's physician was notified at 3:30 P.M. and it was recommended Resident #41 be sent to the emergency room (ER). A new fall intervention was implemented for two person assist/handheld and for Occupational Therapy (OT) to evaluate and treat. Review of hospital records, dated 05/16/24, revealed Resident #41 had x-rays completed to include the right forearm and right humerus. The x-ray results revealed Resident #41 had an acute fracture of the distal humerus, displacement of the fat pads of the elbow, indicating an elbow effusion (build up of fluid)/hemarthrosis (joint bleeding) and soft tissue swelling around the elbow. Resident #41 discharged back to the facility with an order for oxycodone five milligrams (mg) by mouth every six hours for 12 doses. Review of the care plan dated 06/11/24 for Resident #41 revealed Resident #41 had an activity of daily living self-care deficit. Interventions included a wheelchair for mobility and two person assist/handheld assist for transfers. During observation on 06/25/24 at 11:41 A.M. of medication administration with Registered Nurse (RN) #569, Resident #41 was observed to propel herself up the hallway in her wheelchair, towards her room (medication administration occurred directly across from the resident's room). Continued observation revealed Resident #41 entered her room, stood up from the wheelchair, independently ambulated into the bathroom and shut the bathroom door. Concurrent interview with RN #569 confirmed Resident #41 had a recent fall, resulting in an arm fracture. RN #569 verified the observation of Resident #41 ambulating independently into the bathroom and closing the door. As RN #569 watched Resident #41 ambulating independently, she stated She takes herself to the bathroom all the time. She's not supposed to, but she does it anyway. RN #569 did not intervene or ask any staff to assist Resident #41. RN #569 continued her task and did not monitor or address the safety of Resident #41. Interview on 06/26/24 at 3:38 P.M. with the Director of Nursing (DON) and RRN #562 confirmed Resident #41 had a fall with a fracture on 05/15/24 while in the dining room. The DON confirmed Resident #41 complained of pain to the right arm immediately following the fall and staff proceeded to pick Resident #41 up and transfer her to a wheelchair. The DON verified if a resident experienced a fall and had complaints of pain, the resident should not be moved, the physician should be notified immediately and the resident sent to the hospital to prevent further injury. Interview on 06/27/24 at 4:19 P.M. with Physical Therapist (PT) #926 confirmed Resident #41 continued to be unsteady and required two persons to assist with ambulation to prevent falls. 39333 2. Review of the medical record for Resident #45 revealed an admitted [DATE]. Diagnoses included, but not limited to, epilepsy, anxiety disorder and muscle weakness. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #45 had intact cognition and required maximal assistance with activities of daily living. (ADLs). No Falls were noted on the MDS. Review of the progress note dated 05/08/24 at 9:45 P.M. revealed the aide was assisting Resident #45 to bed when the resident requested another pillow and towel. The staff member reached for the pillow and towel and threw them on the bed, while still having a hand on the resident. Resident #45 lost his balance and started to fall. The staff member tried to break the fall and obtained scratched on her right arm. Resident #45 fell back on the bedside table and hit the trash can. Resident #45 did not hit his head but obtained two large abrasions on his back and a bruise to his right elbow. Review of the facility's fall investigation dated 05/08/24 revealed the current intervention of nonskid footwear was in place and the new immediate intervention for Resident #45 would be a two person assist with a front wheeled walker (FWW) for stand pivot transfer only. There was no statement from the aide on duty the night of the fall. Review of the statement dated 05/09/24 by RRN #562 revealed the fall investigation was completed this day and the Interdisciplinary Team (IDT) agreed to the intervention of two person assist with FWW for stand pivot transfer only. Review of the progress note dated 05/13/24 at 9:15 P.M. revealed the aide alerted the nurse that Resident #45 had fallen while she was transferring him into bed. Both the aide and the resident stated the resident did not hit his head. Resident #45 stated he had lost his balance. Resident #45 was assessed for range of motion at which time resident complained of left hip pain. The nurse obtained orders to have a portable x-ray of the resident's left hip. The DON and physician were notified. Review of the facility's fall investigation dated 05/13/24 revealed no notation of whether the fall intervention of two staff for transfers was in place. The new immediate intervention was for OT to evaluate Resident #45. There was no statement from the aide on duty the night of the fall. Review of the statement dated 05/14/24 by RRN #562 revealed the fall investigation was completed this day, and the Interdisciplinary Team (IDT) agreed to the intervention of OT to evaluate and treat. Interview on 06/25/24 at 4:53 P.M. with RRN #562 revealed she completed the fall investigations for Resident #45's falls on 05/08/24 and 05/13/24. RRN #562 stated that the new intervention that was put in place for 05/08/24 was transfers would be done with two staff with a FWW. The fall on 05/13/24 occurred while being transferred to bed and documentation was verified by RRN #562 that there was only reference to one aide being in the room during the transfer. RRN #562 could not state who the aide was on duty was. Further review of Resident #45's medical record revealed the x-ray came back negative for a hip fracture. Review of the facility policy titled, Fall Management and Incident Intervention Protocol, updated July 2022, revealed any new interventions would be communicated to the relevant nursing staff. In addition, movement of the resident from the original site and position of the fall should only take place after assessment finding reveal that it will not cause further injury to do so. The physician and family will be made aware of the incident as soon as possible.

Based on medical record review, observation and staff interview, the facility failed to ensure dependent residents received nail care. This affected one resident (#89) of three residents reviewed for podiatry care. The facility census was 90. Findings include: Record review for Resident #89 revealed an admitted [DATE]. Diagnoses included unspecified dementia, muscle weakness and need for assistance with personal care. Review of the Admission Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was severely cognitively impaired. Resident #89 had impairment to one side of the upper extremity and required substantial maximum assistants with personal hygiene. Further review of Resident #89's medical record revealed no evidence of an identified need for toenail care or that the resident received toenail care. Observation on 06/24/24 at 9:49 A.M. revealed Resident #89 was lying in bed. Resident #89's feet were sticking out from under the blanket at the end of the bed. Further observation revealed Resident #89's toenails on both feet were very long, thick and curling under his toes. Interview on 06/27/24 at 1:01 P.M. with the Director of Nursing (DON) confirmed Resident #89's toenails were very long, thick and curling under his toes. The DON revealed Resident #89's toenails were too thick and long for staff to trim them. The DON confirmed there was no documentation in Resident #89's medical record pertaining to the resident's toenails or need for care. Additionally, the DON stated staff should notify Social Services if podiatry care was needed and they would arrange a podiatry visit. The DON verified there was no evidence Resident #89 had been assessed for toenail care or referred for podiatry services. Interview on 06/27/24 at 1:06 P.M. with Registered Nurse (RN) #562 confirmed podiatry was not notified until 06/26/24 of Resident #89's need for toenail care. RN #562 confirmed there were no previous podiatry visits scheduled for Resident #89.

Based on medical record review and staff interview, the facility failed to ensure residents and/or resident representatives received written transfer notices when transferring to the hospital. This affected two residents (#11 and #51) of three residents reviewed for hospitalization . The facility census was 90. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required substantial/maximum assistance from staff for bed mobility and was dependent on staff for transfers. Review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Forms dated 03/27/24, 05/13/24, and 06/04/24 revealed Resident #11 was transferred to the hospital on those dates. Review of the Transfer/Discharge Notices dated 03/27/24, 05/13/24, and 06/04/24 revealed the notices were reviewed by phone with Resident #11's responsible party. Interview on 06/27/24 at 10:35 A.M. with the Administrator verified the transfer notices were reviewed with Resident #11's responsible party over the phone. The Administrator stated social services was responsible for the transfer and discharge notices and she was unsure if written notices were provided to the resident and/or the resident's responsible party. Telephone interview on 06/27/24 at 10:58 A.M. with Social Services Designee )SSD) #611 revealed she was responsible for providing transfer/discharge notices. SSD #611 verified she did not provide the transfer/discharge notice forms in writing to Resident #11 or the resident's responsible party. 44457 2. Review of the medical record for Resident #51 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included diabetes mellitus, end stage renal disease, atrial fibrillation, hypoxemia, metabolic encephalopathy, and lobar pneumonia. Review of Transfer Form dated 06/10/24 revealed Resident #51 was transferred to the hospital for shortness of breath and generalized discomfort. Review of the medical record revealed no evidence Resident #51 was given a written transfer notice upon transfer to the hospital on 06/10/24. Interview on 06/27/24 at 11:13 A.M. with Administrator confirmed Resident #51 was not given a written transfer notice. The Administrator indicated transfer notices were reviewed over the phone and residents were not provided with a copy in writing.

Based on medical record review, review of resident fund records and staff interview, the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (#148) of one resident reviewed for funds conveyance. The facility census was 90. Findings include: Resident #148 was admitted to the facility on [DATE] with a readmitted [DATE]. Resident #148 was discharged [DATE]. Review of a progress note dated [DATE] revealed Resident #148 was transferred to the hospital. Review of a progress note dated [DATE] revealed the hospital informed the facility that Resident #148 expired. Review of Resident #148's resident funds records revealed on [DATE], a check in the amount of $1193.46 was dispersed to the state and one for $527.18 was dispersed to the funeral home handling Resident #148's arrangements. Interview on [DATE] at 7:17 A.M. with Business Office Manager (BOM) #522 verified Resident #148's funds were not conveyed within the required timeframe of 30 days post discharge.

Based on record review and interview, the facility failed to apply a personal alarm as ordered and adequate supervision in order to prevent Resident #1 from falling from her wheelchair. This resulted in Actual Harm as Resident #1 hit her head and sustained a cut to her forehead and subsequent brain bleed requiring transfer to the hospital for emergent treatment. This affected one (Resident #1) of three residents reviewed for falls. The facility identified 32 residents who were at risk for falls. The facility census was 115 residents. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Order dated 01/16/17 revealed Resident #1 was on the Guardian Angel (falls risk) program. A falls risk assessment dated [DATE] revealed Resident #1 had an unsteady gait, required assistance for transfers and had a history of [REDACTED]. Resident #1 had a score of 13.0 on her falls assessment which meant she was at higher risk for falls. A physician's orders [REDACTED].#1 was to have a personal alarm to her wheelchair to alert staff of attempts to self transfer. Review of the physical restraint decision making tree dated 10/11/17 revealed Resident #1 was to continue using the personal alarm and bed alarm for safety due to attempts at independent ambulation, weakness, unaware of safety concerns, and attempts to independently transfer. The care plan dated 01/17/17 revealed Resident #1 was to remain in common areas while up in her wheelchair for safety, use a tilt and space wheelchair for positioning, and required a two person assist for transfers. The care plan further revealed Resident #1 was supposed to be in the upright position in her tilt and space wheelchair for all meals. Review of the transfer task from 10/31/17 to 11/20/17 revealed Resident #1 required assistance to transfer. A progress note dated 11/14/17 revealed Resident #1 fell out of her wheelchair in the dining room at 6:25 P.M. and sustained a laceration to her left forehead. Vital signs were within normal limits, Resident #1's head was stabilized, and pressure was applied to the cut on her forehead. Emergency services were notified and Resident #1 was sent to the hospital for treatment. The fall investigation dated 11/14/17 revealed Resident #1 had a fall with injury on 11/14/17 at 6:25 P.M. Resident #1 sustained a laceration to her left forehead. The written statement by Registered Nurse (RN) #11 revealed she did not witness Resident #1's fall on 11/14/17. The written statement by Licensed Practical Nurse (LPN) #12 revealed she had witnessed Resident #1 attempting to self transfer from her tilt-in-space wheelchair and falling to the floor on 11/14/17. LPN#12's statement further revealed Resident #1 landed face down on the floor on her left side and blood was pooling under her head. Review of the hospital record dated 11/14/17 revealed Resident #1 was diagnosed with [REDACTED]. The physician at the hospital closed the laceration to Resident #1's forehead with three sutures (stitches). The family was consulted and Resident #1 was referred to Hospice. Review of the progress note dated 11/14/17 at 7:28 P.M. revealed Resident #1 was readmitted to the facility. A physician's orders [REDACTED].#1 was admitted to Hospice due to a cerebral brain hemorrhage with a poor prognosis. Safety Follow Ups done PRN (as needed ) at the facility (dated 11/15/17, 11/16/17, and 11/17/17) revealed Resident #1 had discomfort related to her fall on 11/14/17. A verbal warning conference dated 11/17/17 revealed State tested Nurse Aide (STNA) #10 was called and reprimanded for not following nursing policy/procedure, including leaving her shift without giving report and verifying safety measures were in place for Resident #1. Interview on 11/28/17 at 11:39 A.M. with Director of Nursing (DON) and Administrator revealed STNA #10 was given a verbal warning for not attaching the personal alarm to Resident #1 prior to the fall and leaving Resident #1 unsupervised in the dining room. Interview on 11/28/17 at 12:22 P.M. with LPN #12 revealed she was at the nurse's station when Resident #1 had a fall in the dining room on 11/14/17. Resident #1 attempted to stand up and get out of her wheelchair. Resident #1 was not able to stand on her own and fell to the ground hitting her head. LPN #12 responded immediately to Resident #1 and assessed her, noticing that she had a laceration on her left forehead. Another staff member called emergency services and Resident #1 was taken to the hospital. There was no staff in the dining room at the time of the fall, and Resident #1's chair alarm was not sounding. All other fall precautions including nonskid footwear and Dycem (nonskid surface) was applied to wheelchair, and were in place during the fall. Interview on 11/29/17 at 9:36 A.M. with STNA #17 revealed she had attempted to feed Resident #1 on 11/14/17 immediately prior to the fall incident. Resident #1 was unresponsive and not agitated at that time and refused the meal. Resident #1 was in the tilt-in-space wheelchair in an upright position as care planned for meals and made no attempts to self transfer at that time. STNA #17 had to take another resident to her room due to an episode of incontinence. STNA #17 did not reposition Resident #1 before leaving the dining room. In the ten minutes STNA #17 was out of the dining room Resident #1 had fallen out of her wheelchair. This deficiency substantiates Complaint Number OH 774.

Based on record review and staff interview, the facility failed to provide services to prevent skin breakdown under a removable cast boot for Resident #1, which resulted in development of a pressure ulcer on the resident's heel. This affected one of seven sampled residents (#1). the facility census was 103 residents. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] for long term placement, with a plan that included rehabilitation and supportive care. Admission [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 2.0 assessment, dated 10/22/99, revealed the resident was ambulatory; had an unsteady gait; and required one person assist with ADLs, bed mobility, and transfers. Review of the physician progress notes [REDACTED]. The annual MDS dated [DATE] revealed the resident required two person assist with bed mobility and transfers, and a MDS dated [DATE] revealed the resident had a significant change in cognition with increased behaviors of verbal and physical abuse. Review of the facility incident investigation initiated on 06/22/10 revealed that on 06/19/10 at 11:45 A.M., Resident #1 was transferred by a nurse aide via her wheelchair to the dining area and the resident's left foot had slipped from her right foot resulting it in being hyperextended under the wheelchair. Additional record review revealed that during the incident, Resident #1 had sustained a fractured distal left tibia confirmed by X-ray, resulting in an orthopedic physician consult, treatment that included the application of a cast boot, and follow-up visits to the orthopedic physician. Nurses notes dated 06/22/10 at 12:58 A.M. documented the result of the X-ray, confirming the ankle fracture and the presence of a plantar heel spur on the resident's left heel was called to the physician and family. An initial orthopedic examination occurred on 06/23/10 in the physician's office where a cast boot was applied to the left ankle, and physician orders [REDACTED]. Follow-up orthopedic physician notes dated 07/07/10 revealed the resident had been in an Aircast boot at the nursing home and had an obvious pressure ulcer over her heel that was completely covered. The physician discussed with the family that the pressure from being in bed with the boot on had likely caused her to have the pressure sore. Review of the wound nurse documentation dated 07/08/10 revealed the resident had a Stage IV in house acquired unstageable wound, measuring 3.0 centimeters (cm) by 3.5 cm in the left heel further described as dry boggy, black, and purple that was new. Review of nurses notes dated 06/23/10 revealed the resident returned from the physician office visit at 10:30 A.M. with no documentation of a resident assessment present identifying a cast boot or other device was in place on the resident's ankle. Review of the care plan between the dates of 06/23/10 and 07/07/10 revealed no update indicating the increased potential for skin breakdown due to the presence of a heel spur or the presence of a boot cast to be kept on at all times except when bathing or inspecting the skin. Review of skin check documentation dated 06/13/10 through 07/05/10 with Corporate Nurse #5 revealed documentation that showers were refused and bed baths were given, and the resident's skin was intact. There was no documented evidence indicating the cast boot was removed during the bath. Interview with Corporate Nurse #5 revealed the skin check documentation provided was data input into the computer by the nurse from the shower sheet completed by the state tested nurse aide, and not from licensed nurse assessment data. Review of documentation by the wound nurse of weekly skin checks dated 06/24/10 revealed that skin was intact, with no detailed documentation that the left ankle cast boot was in place or removed for the inspection. There was no evidence of nursing notes that documented the boot was removed for skin inspection by the nurse. Review of the treatment documentation and nurses notes dated 06/23/10 and 07/07/10 revealed numerous entries that an ongoing skin treatment ordered previously to protect the resident's left ankle bone with a padded 4x4 gauze pad was completed by the nurse due to a boot to the left ankle. Nurses notes dated 06/24/10 at 3:08 A.M. revealed circulation checks to the left lower extremity ordered each shift was done with the boot on. Additional nursing documentation of circulation checks between those same dates mentioned that the capillary refill was brisk and toes were pink and warm to touch. No nursing notes that documented circulation checks between those dates contained information that the boot was removed or the foot was examined during circulation checks. Review of nurses notes dated 06/23/10 through 06/30/10 revealed the resident was medicated two to three times a day for complaints of severe ankle pain. Documentation in the nurses notes 07/01/10 through 07/07/10 revealed the resident was medicated for complaint of pain described as in the left foot rather than the ankle, and a documented episode when the resident frequently requested the staff take her splint off and the staff explained the consequences to the resident if it was taken off. No documentation was present that indicated the foot was inspected with the resident complaints of foot pain rather than ankle pain. This deficiency substantiates Complaint Number OH 757.