Every finding on record at Solon Pointe at Emerald Ridge

Based on observation, medical record review, resident and staff interview, review of a menu, and facility policy review, the facility failed to ensure food was palatable and served at acceptable temperatures. This affected directly affected (#61 and #88) of two residents reviewed for food concerns and had the potential to affect all residents receiving meals from the kitchen. The facility indicated there were three (#44, #66, and #102) residents who received nothing by mouth. The facility census was 92.Findings include:1. Review of the medical record for Resident #61 revealed an admission date of 12/11/25. Diagnoses included but were not limited to hypokalemia, ulcerative colitis, and gastro-esophageal reflux disease.Review of the 12/18/25 admission Minimum Data Set (MDS) assessment for Resident #61 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. Resident #61 was noted to require set up for meals and receive a regular diet.Review of the physician orders for Resident #61 revealed an order dated 12/13/25 for a regular diet.Interview on 01/06/26 at 3:21 P.M. with Resident #61 revealed she felt there were not a lot of alternate choices for meals and she did not always receive what she orders. Resident #61 stated she told staff she was tired of the alternate menu items, but was not offered any other additional options.Interview on 01/07/26 at 2:55 P.M. with Resident #61 revealed the pork chop she received was tough and dry and stated she could not eat it. Resident #61 stated it was not very warm; she was unable to cut to up, and tried to eat it with her hands, but stated it was tough and chose not to eat it.2. Review of the medical record for Resident #88 revealed an admission date of 06/08/24. Diagnoses included but were not limited to cerebral palsy, morbid obesity, Parkinson's disease, and schizoaffective disorder bipolar type.Review of the 10/04/25 quarterly MDS assessment for Resident #88 revealed a BIMS score of 15 which indicated the resident had intact cognition. Resident #88 was noted to be independent for eating and receive a regular diet.Review of the physician orders for Resident #88 revealed an order dated 07/04/24 for a regular diet with large portions.Interview on 01/06/26 at 10:11 A.M. with Resident #88 revealed he felt the facility needed better food and felt it was low quality and deserved better options.Review of the facility menu for the week one, day four (Wednesday) lunch meal revealed baked pork chop, collard greens, black-eyed peas, cornbread, and whipped Jello parfait were on the menu.Observation of meal tray line temperatures on 01/07/26 at 11:50 A.M. with [NAME] #756 revealed the pork chop was 173 degrees Fahrenheit (F), black-eyed peas were 173 degrees F, collard greens were 179 degrees F, pureed pork was 173 degrees F, pureed greens were 179 degrees F, pureed black-eyed peas were 178 degrees F, mechanical soft pork was 166 degrees F, mashed potatoes were 180 degrees F, and chicken noodle soup was 200 degrees F.Observation revealed meal tray line started on 01/07/26 at 12:00 P.M. Meal tray line finished serving in the kitchen at 12:45 P.M. with the last cart going to the 800 unit (Chestnut unit). At 1:00 P.M., staff indicated the last tray had been passed on the 800 unit.A test tray was completed on 01/07/26 with Dietary Manager #796 at 1:02 P.M. on the Chestnut unit and the following temperatures were observed using Dietary Manager #796's thermometer: pork was 122.5 degrees F, black-eyed peas were 120 degrees F, and collard greens were 111.7 degrees F.Interview directly following the tasting of the meal test tray with Dietary Manager #796 taking temperatures revealed the items were not as warm as she would prefer and confirmed she probably would have heated the items in the microwave before eating them.Interview on 01/08/26 at 10:40 A.M. with Registered Dietitian (RD) #995 revealed she has spoken to corporate about expanding the options on the alternate menu and felt they were somewhat limited for residents to choose from. RD #995 stated she used to do a meal test tray but was unsure how long it had been and stated it was at least six months.Review of the facility policy titled, Food and Nutrition Services, revised October 2017, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, medical record review, staff interview, review of facility menus, review of facility production sheets, review of food substitution logs, and review of facility policies, the facility failed to ensure all menu items were provided for all residents, specifically residents with an order for a pureed diet. This directly affected one (#41) of four residents reviewed for food and nutrition with potential to affect seven (#9, #16, #55, #59, #68, #81, and #100) additional residents who received a pureed diet. The facility census was 92.Findings include:Review of the medical record for Resident #41 revealed an admission date of 09/05/24. Diagnoses included but were not limited to polyneuropathy, hyperlipidemia, noninfective gastroenteritis and colitis, and sarcoidosis. Review of the 11/14/25 significant change Minimum Data Set (MDS) assessment for Resident #41 revealed a Brief Interview of Mental Status (BIMS) score of four which indicated the resident had severe cognitive impairment. Review of activities of daily living (ADLs) for Resident #41 revealed she required supervision for eating and was also noted to receive a mechanically altered diet.Review of the 11/07/25 diet order for Resident #41 revealed she was on a regular pureed diet with nectar thickened liquids.Review of the facility menu for the week one, day four (Wednesday) lunch revealed food items included baked pork chop, collard greens, black-eyed peas, cornbread, and whipped Jello parfait.Review of the menu production sheet for the above listed meal, for puree textured meals, revealed residents with a pureed diet were to receive a #10 scoop (three and a quarter ounces) of pureed pork with two ounces of gravy on top, a #8 serving (four ounces) of collard greens, a #8 serving of refried beans, a #16 scoop of pureed cornbread, and six ounces of pureed Jello with whipped topping. Observation on 01/07/26 at 11:50 A.M. of kitchen tray line temperatures with [NAME] #756 revealed all temperatures were within appropriate range and appropriate scoop sizes were used.Observation on 01/07/26 at 12:08 P.M. revealed Resident #41's meal tray at the end of the tray line about to be put in the delivery cart. Resident #41's tray had pureed pork, pureed collard greens, pureed black-eyed peas, and pureed peaches. There was no evidence of pureed cornbread. Interview at the time of observation with [NAME] #756 confirmed the tray was complete and there was no pureed cornbread as listed on the production sheet. [NAME] #756 confirmed she had forgotten to make the pureed cornbread for the pureed residents. Interview on 01/07/26 at 1:02 P.M. with Dietary Manager #796 confirmed the production sheet for the menu listed pureed cornbread and also listed pureed Jello with whipped topping for the dessert. Dietary Manager #796 confirmed pureed Jello with whipped topping was on the menu and they had used pureed peaches for dessert because pureed Jello does not puree well and hold form. Dietary Manager #796 stated she had not completed a substitution log for the change and did not realize she needed to record the change on the menu or a log. Dietary Manager #796 confirmed residents should receive all approved menu items with their meals.Interview on 01/08/26 at 10:40 A.M. with Registered Dietitian (RD) #995 confirmed she reviews the seasonal menus twice a year prior to being initiated. RD #995 stated staff are to follow the menu and provide each listed item per their physician ordered diet. RD #995 confirmed the Dietary Manager was supposed to send her a log of food substitutions for her approve. Review of the facility menu substitution log for January through December 2025 revealed four listed substitutions. Review of January 2026's substitution log revealed one substitution for 01/07/26 following surveyor questioning and intervention. Review of the revised October 2017 facility policy titled, Menus, revealed menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). Review of the April 2007 revised facility policy titled, Substitutions, revealed the food services manager, in conjunction with the Clinical Dietitian, may make food substitutions as appropriate or necessary. The Food Services Shift Supervisor on duty will only make substitutions only when unavoidable. The Food Services Manager will maintain an exchange list identifying the seven exchanges of food groups. When in doubt about an appropriate substitution, the Food Services Manger will consult with the dietitian prior to making the substitution. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for substitutions.

Based on resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure residents advance directives were accurately documented in the resident medical record. This affected one (#88) of one resident reviewed for advanced directives. The facility census was 92. Findings include:Review of the electronic medical record (EMR) for Resident #88 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, dysarthria and anarthria, and ataxia. Review of the EMR revealed Resident #88 was a full code status (cardiopulmonary resuscitation (CPR) would be initiated in an event of cardiac or respiratory arrest). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 15, indicting the resident was cognitively intact. Review of the MDS assessment revealed Resident #88 required some assistance for activities of daily living (ADLs).Review of the care plan dated [DATE] revealed an advanced directive, revised [DATE], of full code status and to effectively communicate wishes by placing in the medical chart and/or when a resident must be transferred outside of the facility.Review of Resident #88's paper medical chart revealed a Do Not Resuscitate (DNR) form dated [DATE] that indicated Resident #88 elected to have a DNR Comfort Care (DNRCC) code status protocol to be implemented, meaning only comfort measures would be initiated in the event of a medical emergency.Interview on [DATE] at 11:34 A.M. with Licensed Practical Nurse (LPN) #786 revealed she was familiar with Resident #88 and was currently his nurse. During interview, a review of Resident #88 paper medical chart revealed a DNRCC code status and the EMR revealed a full code status. LPN #786 confirmed and verified Resident #88's advanced directives did not match and at that time changed the EMR advanced directives to match the paper medical chart. LPN #786 updated Resident #88's advanced directives without verification of code status, without consulting with Resident #88 and/or his Power of Attorney of Care (POAC). LPN #786 confirmed and verified the updated change to Resident #88's advanced directives.Review of the physician note dated [DATE] at 11:38 P.M., located in the EMR, revealed Resident #88 had an advanced directive of full code, discontinued.Review of the physician note dated [DATE] at 11:38 P.M. revealed Resident #88 had an advanced directive of DNRCC documented in the EMR.Interview on [DATE] at 11:45 A.M. with Resident #88 revealed he wanted to be a full code status and wanted the facility staff to perform CPR, but did not want to be put on a medical machine to keep him alive. Resident #88 revealed no staff spoke to him or approached him about his advanced directives.Review of the physician note dated [DATE] at 12:00 P.M., located in the EMR, revealed Resident #88 had an advanced directive of full code status. Review of the physician order revealed LPN #786 updated Resident #88's advance directives.Interview on [DATE] at 12:30 P.M. with Corporate Director of Nursing (CDON) #900 verified and confirmed the above information.Review of the facility document titled, Advanced Directives, revised [DATE], revealed the facility had a policy in place that revealed a resident advanced directive and/or changes would be documented in the care plan, medical record and obtained and maintained in the same section of the medical record and readily retrievable by the facility staff.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASRR) accurately reflected current mental health conditions. This affected one (#8) of three residents reviewed for PASRR. The facility census was 92.Findings include:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required assistance of one staff person for completing her activities of daily living.Review of the Preadmission Screening and Resident Review (PASRR) document dated 01/19/24, under section E titled, Indications of Serious Mental Illness, revealed the facility did not provide/document indications that the resident had a diagnosis of post-traumatic stress disorder.Social Service Director (SSD) #701 verified Resident #8's PASRR did not address Resident #8's PTSD diagnoses in an interview on 01/07/25 at 2:00 P.M.Review of the undated policy titled, admission Criteria PASARR_OH, revealed the facility must follow federal and state regulations for the PASRR process.

Based on medical record review and staff interview, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's healthcare needs. This affected one (#8) of one residents reviewed for post-traumatic stress disorder. The facility census was 92.Findings include:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required assistance of one staff person for completing her activities of daily living.Review of the current comprehensive care plan for Resident #8 revealed no problems, goals, or interventions related to Resident #8's PTSD.Social Service Director (SSD) #701 verified in an interview on 01/08/26 at 8:45 A.M. that Resident #8's care plan did not address Resident #8's PTSD diagnoses in an interview on 01/07/25 at 2:00 P.M. SSD #701 further stated Resident #8 suffered from PTSD related to a gun fight between Resident #8 and her best friend.Review of the policy titled, Care Plans, Comprehensive Person Centered, dated 03/01/22, revealed the comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, medical record review, hospital document review, review of fall investigations, resident representative interview, staff interview, and policy review, the facility failed to ensure resident care plans were revised to reflect residents' current medical and psychological status and resident representatives were provided the option to chose care and treatment interventions during care plan development. This affected two (#22 and #82) of twenty-two sampled residents. The facility census was 92.Findings include:1. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type; dementia with psychotic disturbance; and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact, required hands-on assistance for activities of daily living, and had no documented behaviors. Review of Resident #22's care plan dated 07/05/24 revealed the resident had behavior problems as evidenced by: traveling to vending machines and purchasing items regardless of diet; smearing feces in his room and throughout the facility; preferring to wear women's clothing and have nails painted; refusing to allow staff to organize personal items; hanging soiled clothing on heaters, in the shower, and over his wheelchair; refusing housekeeping services; embellishing stories about money and credit cards; and stating he carries ten credit cards at all times. Review of Resident #22's January 2026 physician orders revealed an order dated 06/10/24 to monitor behaviors every shift. Review of Resident #22's medication administration record (MAR) revealed Resident #22 had zero documented behaviors during November and December 2025 and January 2026. Despite the absence of any documented behaviors for at least three months, Resident #22's care plan continued to list extensive behavioral concerns without revision or reassessment. Social Service Director (SSD) #701 confirmed during an interview on 01/08/26 at 8:45 A.M. that Resident #22's care plan had not been updated to reflect his current behavioral status. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 03/01/22, revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 2. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, intracranial injury, post traumatic seizures, and spastic quadriplegic cerebral palsy. Review of the MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 00, that indicated Resident #82 had severe cognition impairment. Review of the MDS assessment revealed Resident #82 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 05/19/25 revealed Resident #82 had increased risk for falls and an actual fall related to brain injury with interventions that included ensure a safe environment and anticipation to meet the needs of the resident. Further review of the care plan included additional interventions in keeping call light within reach, handrails on the wall, and bed in lowest position at night. Review of the admission hospital paperwork dated 05/12/25 revealed Resident #82 had a history of traumatic brain injury secondary to a gunshot wound, status post right hemicraniectomy with elective right cranioplasty. The resident was wheelchair bound with a seizure disorder and weak in all extremities. Review of the hospital paperwork revealed Resident #82 was a fall risk and required a bed alarm. Review of the fall risk assessment dated [DATE] revealed Resident #82 was a high risk for falls. Review of the admission care conference dated 05/21/25 at 11:00 A.M. revealed Resident #82 had poor safety awareness related to falls and/or fall risk and was dependent for all care. Review of the care conference dated 07/01/25 at 11:13 A.M. revealed Resident #82 was dependent on staff for ADLs. Review of the care conference revealed Resident #82's fall risk was not discussed. Review of the fall risk assessment dated [DATE] revealed Resident #82 had a history of one to two falls within the last six months. Review of the progress notes dated 08/14/25 at 12:31 A.M. revealed Resident #82 had an unwitnessed fall around 12:30 A.M. Registered Nurse (RN) #925 heard a sound that led to Resident #82's room, where he was found with his head down on the right side of his bed with his legs still in the bed. Resident #82 was repositioned in bed and placed back on the ventilator with his oxygen level at 55 percent (%) that increased to 95% less than a minute after. Resident #82, at approximately 12:45 A.M., had an episode of projectile vomiting and was subsequently sent out to the hospital via emergency medical services (EMS) due to his history of right intracranial surgery and presenting symptoms. Review of the fall follow-up assessment dated [DATE] at 12:38 A.M. revealed Resident #82 had a fall with no signs and/or symptoms of bleeding or bruising and fall mats put into place as the new intervention and was effective. Review of the hospital after-visit summary, dated 08/14/25 at 5:39 A.M., revealed Resident #82 was seen in the emergency department for a fall and was subsequently diagnosed with a fall with a head injury (struck left side of the head). Review of the after-visit summary revealed Resident #82 was a high risk for falling upon discharge. Review of the progress note dated 08/14/25 at 8:32 A.M. revealed Resident #82 experienced an unwitnessed fall. Resident #82 fall interventions were put into place. Review of the post fall/incident investigation summary dated 08/14/25, with no time indicated, revealed Resident #82 was observed at bedside, was assessed for range of motion and vital signs were within normal limits. Resident #82's physician and Power of Attorney (POA) were notified, and the fall protocol was followed. Review of the document revealed prior interventions were in place and current interventions consisted of repositioning, neurological checks, and put in place extended bed and extended air mattress. Further review of the document revealed Resident #82 contributing factors leading to the fall included poor bed mobility, decreased safety, and epilepsy. Review of the document revealed Resident #82 had a history of seizure activity, loss of trunk control, impaired posture stability, decreased safety awareness resulting in him sliding out of bed and inability to self-correct or recognize the need for assistance. Review of the document revealed no prior or subsequent implementation of floor mats. Observation on 01/05/26 at 8:30 A.M., 10:45 A.M., 12:15 P.M., and 2:00 P.M. revealed Resident #82 in bed with no fall mats observed in place. Resident #82 was observed to only be able to follow the surveyor with his eyes and slightly shift position of his head. Resident #82 appeared to lack voluntary control of his body. Observation and interview on 01/06/26 at 9:03 A.M. revealed Resident #82 lying in bed with no floor mats in place. Licensed Practical Nurse (LPN) #839 stated Resident #82 was fully dependent on staff for ADLs, was a fall risk, and was required to be checked on every two hours. LPN #839 stated Resident #82 never had fall mats in place as a fall intervention. LPN #839 revealed Resident #82's POA visited frequently and spoke to staff about his care needs. LPN #839 revealed the resident's POA asked about fall mats, but LPN #839 stated, Fall mats are not needed because he cannot move on his own. LPN #839 confirmed and verified the above findings at the time of the interview. Interview on 01/06/26 at 9:10 A.M. with Certified Nurse Aide (CNA) #745 revealed Resident #82 was a fall risk. CNA #745 revealed Resident #82 utilized a special high-back wheelchair to decrease his risk of falls while out of bed. CNA #745 revealed Resident #82 did not have floor mats in place to decrease the risk of injury if he fell out of bed. CNA #745 revealed Resident #82's POA visited him in the facility, wanted fall mats implemented, and had plans on discharging him home. CNA #745 revealed Resident #82's bed, during the day, was in the highest position, but she had never seen it in the lowest position. CNA #745 revealed Resident #82 had a history of seizures that could result in uncontrollable body movements. CNA #745 confirmed and verified Resident #82 did not have floor mats in place and was still a fall risk despite being unable to control his body movements. Interview on 01/07/26 at 1:54 P.M. with Medical Doctor (MD) #926 revealed Resident #82 was at high risk for falls due to his history of rolling out of bed. MD #926 revealed Resident #82 did not communicate well, had severe cognition deficits, and if he was high risk for falls, floor mats were typically an option for intervention. Interview on 01/08/26 at 10:47 A.M. with the Director of Nursing (DON) revealed Resident #82 was admitted to the hospital after a fall and identified as a fall risk due to his medical diagnoses. The DON revealed all residents were assessed for fall risk upon admission and information provided from other sources was taken into consideration. The DON revealed prior to Resident #82's fall, there were no fall mats in place, and after his fall, she implemented an extended bed as a result of the fall. The DON revealed she did not put floor mats in place as she felt it was not needed as a result of her assessment. Interview on 01/08/26 at 3:08 P.M. with Resident #82's POA revealed the resident was completely dependent on staff for all ADLs. The POA revealed Resident #82 was unable to care for himself and had a history of seizures which resulted in him being a high fall risk. The POA revealed prior to admission to the facility, Resident #82 had a history of sliding out of bed, seizures, and that she informed the facility staff upon admission. The POA revealed she requested fall mats to be placed down as a safety precaution due to his history of a gunshot wound to the head, traumatic brain surgery, and his falls out of bed. The POA revealed Resident #82 sustained a fall out of bed and hit his head that resulted in swelling, bruising, and scratches to his face. The POA revealed after multiple requests, the facility staff refused to put fall mats in place. The POA revealed she was currently planning to discharge Resident #82 home. Review of the facility policy titled, Comprehensive Person-Centered Care Plans, revised March 2022, revealed the interdisciplinary team in conjunction with the resident and/or his family or legal representative developed and implemented a care plan for each resident. Review of the policy revealed each resident and/or representative had a right to participate and request meetings and revisions to the plan of care. This deficiency represents non-compliance investigated under Complaint Number 2597600.

Based on observation, medical record review, review of shower sheets and schedules, resident interview, resident representative interview, staff interview, and facility policy review, the facility failed to ensure residents were provided with appropriate care and assistance with their activities of daily living. This affected three (#10, #25, and #73) of three residents reviewed for activities of daily living. The census was 92. Findings include:1. Review of the medical record for Resident #73 revealed an admission date of 07/11/25. Diagnoses included Parkinsonism, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact. She required supervision/touching assistance for eating. Review of the January 2026 physician orders revealed orders for a divided plate, weight utensils, and a sippy cup with lid and straw. Review of the care plan initiated on 07/23/25 revealed Resident #73 had a goal to maintain activities of daily living (ADLs). Interventions included supervision/set-up by one staff to eat, revised on 11/06/25, and Resident #73's usual performance was partial assistance with meals which was initiated on 11/14/25. Review of the progress note dated 01/02/26 and timed for 12:11 P.M. revealed Resident #73 was placed in the dining area for close watch. Meals were served and fed. Observation on 01/08/25 at 12:25 P.M. revealed a certified nurse aide (CNA) placed a plate in front of Resident #73 who was sitting at a table across from the nursing station. Both CNA #736 and CNA #763 continued to pass lunch to the rest of the residents in the dining room for approximately eight residents. Continued observation revealed both CNAs left the dining room. At approximately 12:29 P.M., the surveyor heard a continuous banging and looked up to see Resident #73 holding her weighted spoon in her right hand and it was striking her divided plate as she tried to scoop her food onto her spoon. She continued to attempt to get food onto her spoon by using her left hand to push the food without success. At 12:40 P.M., Resident #73 was observed holding her plate with her left hand and the plate was held with her right hand, but was halfway off the table at an angle. Staff members were observed passing in the hallway behind the nursing station. At 12:41 P.M., Resident #73 nearly dropped her plate with food falling to the ground at 12:42 P.M. Agency Registered Nurse (ARN) #870 came to the dining room just as this happened. ARN #870 helped push the resident closer to the table and picked up her plate. ARN #870 put on gloves and pulled up a seat to assist. ARN #870 cleaned off Resident #73's lap. ARN #870 observed Resident #73 for a few minutes and encouraged her to eat, turning the plate. ARN #870 picked up the spoon at 12:45 P.M. to start feeding the resident. Resident #73 ate approximately six bites of food and no additional food was offered to replace what fell on the floor. CNA #736 came into the dining room and swept up the food on the floor. Interview on 01/07/26 at 12:52 P.M. with ARN #870 stated she was from a staffing agency and had not been to the facility in months. She was not aware of Resident #73's assistance needs; however, she saw the plate falling and went to assist her. She was not certain of the policy on staff supervising in the dining room, but verified no one had been in there assisting Resident #73 with eating prior to her. Interview on 01/07/26 at 2:40 P.M. the Corporate Nurse revealed her response when told about no supervision or assistance for Resident #73 at lunch was asking if staff were loosely supervising and, Did the resident want to eat?. Interview on 01/07/26 at 3:20 P.M., with the Director of Nursing (DON) revealed the facility used acuity as far as supervision in dining room and verified 15 minutes without assistance was not acceptable. Interview on 01/08/26 at 11:45 A.M. with Licensed Practical Nurse (LPN) #793, a nurse familiar with Resident #73, stated the resident required assistance with eating and the CNAs knew they had to help her. Review of facility policy titled, Food and Nutrition Services, last revised October 2017, revealed nurse aides will provide support to enhance resident experience. 2. Review of the medical record for Resident #10 revealed and admission date of 02/09/21. Diagnoses included but were not limited to hemiplegia and hemiparesis, neuromuscular dysfunction of bladder, and chronic kidney disease. Review of the MDS assessment dated [DATE] for Resident #10 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated the resident had intact cognition. Resident #10 was noted to required maximum assistance of staff for bathing. Review of the care plan for Resident #10, last reviewed on 01/02/26, revealed a performance deficit related to disease process. Resident #10 was noted to require staff assistance to complete ADLs including bathing. Review of Resident #10's nursing progress notes for the past from August 2025 to January 2026 did not reveal any notes related to refusal of bathing. Interview on 01/06/26 at 10:52 A.M. with Resident #10 revealed she was not always bathed and stated sometimes the staff give excuses why they are unable to bathe her. Interview on 01/07/26 at 9:59 A.M. with CNA #742 revealed Resident #10 was scheduled for bathing on Wednesdays and Saturdays and stated she does not usually refuse bathing. Review of the facility shower schedule for Resident #10 revealed bathing was to be provided on Wednesdays and Saturdays between 7:00 A.M. and 3:00 P.M. Review of the October 2025 calendar revealed eight opportunities for Resident #10 to be bathed on Wednesdays and Saturdays (10/01/25, 10/04/25, 10/08/25 (the resident was in the hospital), 10/11/25, 10/15/25, 10/18/25, 10/22/25, 10/25/25, and 10/29/25). Review of the facility provided shower sheets for October 2025 for Resident #10 revealed an incomplete form was provided for 10/04/25, a shower was provided on 10/15/25, and 10/18/25. No additional evidence of bathing sheets was provided. Evidence of bathing was provided two times out of eight opportunities in October 2025. Review of the November 2025 calendar provided nine opportunities for Resident #10 to be bathed on Wednesdays and Saturdays (11/01/25, 11/05/25, 11/08/25, 11/12/25, 11/15/25,11/19/25, 11/22/25, 11/26/25, and 11/29/25). Review of the facility provided shower sheets for November 2025 for Resident #10 revealed an incomplete form was provided for 11/02/25, a shower on 11/05/25, a shower on 11/08/25, a shower on 11/12/25, a shower on 11/15/25 and a bed bath on 11/19/25. Evidence of bathing was provided five times out of nine opportunities for November 2025. Review of the December 2025 calendar revealed seven opportunities for Resident #10 to be bathed (12/03/25, 12/06/25, 12/10/25 (the resident was in the hospital), 12/13/25 (the resident was in the hospital), 12/17/25, 12/20/25, 12/24/25, 12/27/25, and 12/31/25). Review of the facility provided shower sheets for December 2025 for Resident #10 revealed a shower was given on 12/03/25, an incomplete shower form for 12/06/25, a bed bath was given on 12/17/25, a shower was given on 12/20/25, an incomplete form on 12/24/25, a shower was given on 12/27/25, and a shower was given on 12/31/25. Evidence of bathing was provided for five out of seven opportunities. 3. Review of the medical record for Resident #25 revealed an admission date of 12/27/19. Diagnoses included but were not limited to severe dementia with behaviors, vascular dementia and generalized anxiety disorder. Review of the MDS assessment dated [DATE] for Resident #25 revealed a BIMS score of three which indicated the resident had severe cognitive impairment. Resident #25 was noted to required moderate assistance of staff for bathing and rejection of care was not indicated. Review of Resident #25's nursing progress notes from August 2025 to January 2026 did not indicate any noted bathing refusals. Review of the bathing care plan for Resident #25 revealed it was last revised on 07/22/25. Resident #25 was noted to have a self-care performance deficit related to the aging process and required staff assistance to complete ADLs. Resident #25 was noted to require moderate assistance for bathing routinely and as necessary. Interview on 01/06/26 at 12:35 P.M. with Resident #25's daughter revealed her mother needed assistance at times with bathing. She stated she frequently visited the facility and Resident #25 was still in her pajamas and felt she was not getting bathed at least twice a week. Review of the facility bathing schedule revealed Resident #25 was scheduled for bathing on Tuesdays and Fridays between 7:00 A.M. and 3:00 P.M. Review of the October 2025 calendar revealed nine bathing opportunities (10/03/25, 10/07/25, 10/10/25, 10/14/25, 10/17/25, 10/21/25, 10/24/25, 10/28/25, and 10/31/25) for Resident #25. Review of the facility provided bathing sheets for Resident #25 revealed a refusal on 10/03/25 but did not indicate if resident was reapproached at a later time, a shower was given on 10/10/25, a refusal on 10/17/25 but did not indicate she was reapproached at a later time, and a refusal on 10/24/25 which also did not indicate she was approached at a later time for a second attempt. Evidence provided by the facility indicated Resident #25 was offered bathing four out of nine opportunities. Review of the November 2025 calendar revealed eight bathing opportunities (11/04/25, 11/07/25, 11/11/25, 11/14/25, 11/18/25, 11/21/25, 11/25/25 and 11/28/25) for Resident #25. Review of the facility provided bathing sheets for November 2025 for Resident #25 revealed an incomplete form for 11/04/25, a shower was given on 11/07/25, a shower on 11/18/25, a refusal on 11/21/25 which did not indicate a second attempt for bathing was made, and a bed bath was given on 11/28/25. Evidence provided by the facility indicated Resident #25 was offered bathing four out of eight opportunities. Review of the December 2025 calendar for Resident #25 revealed nine bathing opportunities (12/02/25, 12/05/25, 12/09/25, 12/12/25, 12/16/25, 12/19/25, 12/23/25, 12/26/25, 12/30/25). Review of the facility provided bathing sheets for December 2025 for Resident #25 revealed a bed bath was given on 12/02/25, a shower was given on 12/05/25, a refusal on 12/12/25 which did not indicate an additional attempt being made, a refusal on 12/19/25 which also did not indicate an additional attempt being made, and a form dated 12/26/25 which had a nurse signature but no additional information. The facility provided evidence for four of nine bathing opportunities. Interview on 01/07/26 at 6:40 A.M. with LPN #772 revealed Resident #25 will sometimes refuse bathing and it should be documented. Interview on 01/07/26 at 4:18 P.M. with the DON revealed residents are scheduled to be bathed twice a week and if a resident refused, staff are to ask several times and document the refusals. If they still refuse after a couple days, they are supposed to notify the family and physician to encourage them to shower. The CNAs are to complete the shower sheets and supposed to notify the nurse when they are providing bathing so the nurse can do a skin check. Both the nurse and the nurse aide are to sign the form once it is complete. Interview on 01/08/26 at 2:22 P.M. with Assistant Director of Nursing (ADON) #727 confirmed she provided additional shower sheets, but the information that was added was because she had called some of the staff after the fact to add information to the incomplete shower sheets. ADON #727 confirmed the shower sheets for Resident #10 and Resident #25 originally provided by the facility were not completed twice weekly as required. Review of the facility policy titled, Shower/Tub Bath, dated October 2010, revealed the following documentation should be recorded on the resident's ADLs record and/or in the resident's medical record: the date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, the signature and title of the person recording the data.

Based on observation, medical record review, hospital document review, review of fall investigations, resident representative interview, staff interview, and policy review, the facility failed to ensure appropriate fall interventions were implemented and consistently in place to prevent falls. This affected one (#82) of three residents reviewed for falls. The facility census was 92.Findings include:Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, intracranial injury, post traumatic seizures, and spastic quadriplegic cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 00, that indicated Resident #82 had severe cognition impairment. Review of the MDS assessment revealed Resident #82 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 05/19/25 revealed Resident #82 had increased risk for falls and an actual fall related to brain injury with interventions that included ensure a safe environment and anticipation to meet the needs of the resident. Further review of the care plan included additional interventions in keeping call light within reach, handrails on the wall, and bed in lowest position at night. Review of the admission hospital paperwork dated 05/12/25 revealed Resident #82 had a history of traumatic brain injury secondary to a gunshot wound, status post right hemicraniectomy with elective right cranioplasty. The resident was wheelchair bound with a seizure disorder and weak in all extremities. Review of the hospital paperwork revealed Resident #82 was a fall risk and required a bed alarm. Review of the fall risk assessment dated [DATE] revealed Resident #82 was a high risk for falls. Review of the admission care conference dated 05/21/25 at 11:00 A.M. revealed Resident #82 had poor safety awareness related to falls and/or fall risk and was dependent for all care. Review of the fall risk assessment dated [DATE] revealed Resident #82 had a history of one to two falls within the last six months. Review of the progress notes dated 08/14/25 at 12:31 A.M. revealed Resident #82 had an unwitnessed fall around 12:30 A.M. Registered Nurse (RN) #925 heard a sound that led to Resident #82's room, where he was found with his head down on the right side of his bed with his legs still in the bed. Resident #82 was repositioned in bed and placed back on the ventilator with his oxygen level at 55 percent (%) that increased to 95% less than a minute after. Resident #82, at approximately 12:45 A.M., had an episode of projectile vomiting and was subsequently sent out to the hospital via emergency medical services (EMS) due to his history of right intracranial surgery and presenting symptoms. Review of the fall follow-up assessment dated [DATE] at 12:38 A.M. revealed Resident #82 had a fall with no signs and/or symptoms of bleeding or bruising and fall mats put into place as the new intervention and was effective. Review of the hospital after-visit summary, dated 08/14/25 at 5:39 A.M., revealed Resident #82 was seen in the emergency department for a fall and was subsequently diagnosed with a fall with a head injury (struck left side of the head). Review of the after-visit summary revealed Resident #82 was a high risk for falling upon discharge. Review of the progress note dated 08/14/25 at 8:32 A.M. revealed Resident #82 experienced an unwitnessed fall. Resident #82 fall interventions were put into place. Review of the post fall/incident investigation summary dated 08/14/25, with no time indicated, revealed Resident #82 was observed at bedside, was assessed for range of motion and vital signs were within normal limits. Resident #82's physician and Power of Attorney (POA) were notified, and the fall protocol was followed. Review of the document revealed prior interventions were in place and current interventions consisted of repositioning, neurological checks, and put in place extended bed and extended air mattress. Further review of the document revealed Resident #82 contributing factors leading to the fall included poor bed mobility, decreased safety, and epilepsy. Review of the document revealed Resident #82 had a history of seizure activity, loss of trunk control, impaired posture stability, decreased safety awareness resulting in him sliding out of bed and inability to self-correct or recognize the need for assistance. Review of the document revealed no prior or subsequent implementation of floor mats. Observation on 01/05/26 at 8:30 A.M., 10:45 A.M., 12:15 P.M., and 2:00 P.M. revealed Resident #82 in bed with no fall mats observed in place. Resident #82 was observed to only be able to follow the surveyor with his eyes and slightly shift position of his head. Resident #82 appeared to lack voluntary control of his body. Observation and interview on 01/06/26 at 9:03 A.M. revealed Resident #82 lying in bed with no floor mats in place. Licensed Practical Nurse (LPN) #839 stated Resident #82 was fully dependent on staff for ADLs, was a fall risk, and was required to be checked on every two hours. LPN #839 stated Resident #82 never had fall mats in place as a fall intervention and confirmed the above findings at the time of the interview. Interview on 01/06/26 at 9:10 A.M. with Certified Nurse Aide (CNA) #745 revealed Resident #82 was a fall risk. CNA #745 revealed Resident #82 utilized a special high-back wheelchair to decrease his risk of falls while out of bed. CNA #745 revealed Resident #82 did not have floor mats in place to decrease the risk of injury if he fell out of bed. CNA #745 revealed Resident #82's bed, during the day, was in the highest position, but she had never seen it in the lowest position. CNA #745 revealed Resident #82 had a history of seizures that could result in uncontrollable body movements. CNA #745 confirmed and verified Resident #82 did not have floor mats in place and was still a fall risk despite being unable to control his body movements. Interview on 01/08/26 at 10:47 A.M. with the Director of Nursing (DON) revealed Resident #82 was admitted to the hospital after a fall and identified as a fall risk due to his medical diagnoses. The DON revealed all residents were assessed for fall risk upon admission and information provided from other sources was taken into consideration. The DON revealed prior to Resident #82's fall, there were no fall mats in place, and after his fall, she implemented an extended bed as a result of the fall. The DON revealed she did not put floor mats in place as she felt it was not needed as a result of her assessment. Review of the facility document titled, Managing Falls and Fall Risk, revised December 2007, revealed that based on previous evaluations and current data staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and minimize complications from falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling. This deficiency represents non-compliance investigated under Complaint Number 2597600.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered to prevent a medication error rate of less than five (5) percent (%). A total of two medication errors were observed out of 29 opportunities for a medication error rate of 6.9%. This affected one (#57) of four residents observed for medication administration. The census was 92. Findings include:Review of Resident #57's medical record revealed he was admitted [DATE] and had diagnoses including unspecified dementia, paranoid schizophrenia, and chronic gout. Review of Resident #57's physician orders revealed the resident was ordered fish oil 1200 milligrams (mg) once daily on 10/20/23, and was ordered vitamin D3 on 06/07/23 with instructions to give one tablet daily but had no dosage specified. Observation of a medication administration for Resident #57 by Licensed Practical Nurse (LPN) #840 on 01/07/25 at 9:02 A.M. revealed she administered one 1000 unit pill of vitamin D3 and one 1000 mg pill of fish oil. Interview with LPN #840 on 01/07/25 at 10:07 A.M. confirmed she administered 1000 mg of fish oil to Resident #57 and the order indicated to give 1200 mg, and confirmed she administered 1000 units of vitamin D3 to Resident #57 without clarify what dosage was to be given. Following surveyor intervention, the facility took steps to obtain the correct dosage of fish oil and obtained a new order with clarification of the vitamin D3 dosage. Record review of the facility's medication administration policy, dated 04/2019, revealed the individual giving the medication was to verify the correct medication and dosage before giving the medication.

Based on observations, medical record review, staff interview, family interview, review of the facility resident census, review of staff schedules, review of police records, review of the facility policy on Wandering, Unsafe Residents, review of the facility's investigation, review of information on the Weather Underground computerized environmental temperatures website, review of Google Maps, and review of the facility's elopement book, the facility failed to prevent the elopement of a cognitively impaired resident (Resident #70), with a history of attempted elopement and who was assessed to be at risk for elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death, when Resident #70 left the facility through an alarmed elevator (that did not alarm/sound), without staff knowledge, and was found by a tenant at a previous residence, 1.4 miles from the facility which was down a two-lane road with a center turn lane and no sidewalk. The road had a speed limit of 35 miles-per-hour. In addition, concerns were identified that did not rise to an Immediate Jeopardy level when Resident #41, who was cognitively impaired and assessed at risk for elopement was observed not to have an electronic monitoring bracelet per physician's order and Resident #10 who was cognitively impaired was found to have an electronic monitoring bracelet that did not properly function/would not register as designed due to the bracelet being expired. The facility failed to ensure fall interventions were appropriate for two cognitively impaired resident (#18 and #85), who was assessed at risk for falls and care planned fall interventions were in place. This affected five residents (#10, #18, #41, #70 and #85) of five residents reviewed for exit seeking behaviors from the facility and/or at assessed at risk for falls. The facility identified 14 residents (#10, #13, #14, #22, #38, #41, #52, #53, #54, #58, #70, #77, #88, and #90) at risk for elopement. The facility census was 88. On [DATE] at 3:30 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services #677, and Regional Director of Operations #676 were notified Immediate Jeopardy began on [DATE] when Resident #70, a cognitively impaired resident at risk for elopement walked out off the unit she resided on located on the second floor of the facility, took the elevator to the first floor without staff knowledge. Resident #70 then walked past the receptionist who thought she was a visitor, left the facility and was subsequently found 1.4 miles away from the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 3:09 P.M., a resident head count was completed by facility staff to ensure that all current residents were accounted for. All residents were accounted for. On [DATE] at 3:59 P.M., Resident #70 was returned by the [NAME] Police department and daughter. On [DATE] at 3:59 P.M., Resident #70 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #672 on 5.5.24, including visual assessment and physical assessment, and including but not limited to heat related issues. All results were unremarkable for significant negative effects. On [DATE], assessments were completed on residents at risk for elopement by DON and Licensed Practical Nurse (LPN) #615. At risk residents were determined by the most recently completed wander assessment. On [DATE], Resident #70 was immediately placed on a 1:1 supervision by State tested Nursing Assistant (STNA) #678 upon return to the facility, until 4:44 P.M., at which point the one on one was discontinued by the DON and STNA #678 was reassigned at the elevator to ensure safety for all residents at risk for wandering. On [DATE], the facility implemented a plan for a designated staff member to remain in place at elevator door 24 hours/7 days per week, to ensure residents at risk of wandering did not exit. This would remain in place until root cause of functioning concern is identified and corrected. On [DATE] at 4:15 P.M., Resident #70's physician was notified of Resident #70's return to the facility and assessment findings by ADON #343. On [DATE], all staff members present were interviewed by ADON #343. On [DATE], all stairwell and exit door alarms were checked for functioning by DON. The facility indicated there were no concerns noted. On [DATE], all residents with an order for a monitoring device (wander guards bracelets) were assessed to ensure placement of the wander guard and proper functioning of wander guard by DON and ADON #343. The facility indicated any wander guard that was not functioning properly was replaced by DON/designee. On [DATE] at 4:16 P.M., Resident #70's previous wander guard was removed, and a new wander guard was placed on Resident #70 by the DON. On [DATE] at 6:30 P.M., elopement drills for staff were conducted by the DON. On [DATE] at 4:25 P.M., an elopement drill was conducted for all staff by DON. On [DATE] at 2:00 A. M., an elopement drill for all staff was conducted by Registered Nurse (RN) #563. On [DATE], all staff in-service related to elopement protocols began by the DON and/or designee, including but not limited to ensuring that wander guards are in place and functioning as ordered, how to engage wander guard bracelets prior to applying, how to check for functioning of the wander guard bracelet and wander guard system, wandering residents' policy, elopement policy, pictures to be obtained and uploaded to EHR upon admission to the facility, the elopement binder, and notification protocols by the Administrative Team, completed by [DATE]. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed. On [DATE], all nursing staff in service on correct input of wander guard orders by the DON and/or designee (check placement and check function every shift) upon placement of wander guard by DON/designee and will be completed on or before [DATE]. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed. On [DATE], all nursing staff was to begin ensuring an order is in place to check wander guard placement and function every shift daily, ongoing. On [DATE], all wandering device orders were to be transcribed into point click care (PCC) the day of implementation by nursing audit began by the DON/designee daily for 2 weeks then weekly at RISK for 3 month and present to Quality Assurance Performance Improvement (QAPI). On [DATE], the profile pictures of all residents at risk for wandering were audited for accurate profile pictures in the electronic health record (EHR) by Medical Records/Central Supply #524. DON /designee began to audit profile pictures for all new admissions, five residents a week for two weeks then weekly for three months. Results would be presented to the facility Quality Assessment and Performance Improvement (QAPI). On [DATE], Resident #70's profile picture was uploaded to the EHR and was placed in the wander guard book by Medical Records/Central Supply #524. On [DATE], the elopement binder was audited for accuracy by Medical Records/Central Supply #524. No other discrepancies were identified. The elopement binder is to be audited for accuracy by DON/ designee five times a week for 2 weeks then weekly for 3 months. Results will be presented to QAPI. On [DATE], the DON and Administrator met with Alta Contractor (electronic monitoring company) regarding wander guard alert system to ensure the system was functioning per manufacturer's guidelines. No concerns were identified. On [DATE], all residents with wander guard bracelet orders were clarified to ensure an order to check placement and check function is placed in the HER and care planned by DON and LPN Supervisor #455. On [DATE], wandering risk assessments were completed on all census active residents by DON and LPN Supervisor #455. All residents identified at risk for wandering were given a wander guard placed on their person, an order written for wander guard and the Provider/resident representative was notified. Additionally, the care plan was updated. On [DATE], Resident #14 was identified to be at risk of wandering. Her physician was notified, and an order was given for a wander guard. A wander guard was placed on her, checked for placement/function, and her care plan was updated by Registered Nurse (RN) #443. Effective [DATE], all new employees hired by the facility would receive education on residents at risk for wandering policy by the DON /designee. On [DATE], the Minimum Data Set (MDS) nurse was educated by the DON, on ensuring that all residents who have an order for wander guard have a care plan in place for the wander guard. The education included ensuring that an intervention for checking the function and checking the placement of the wander guard are in the plan of care by DON/designee. On [DATE], all staffing agencies utilized by the facility were provided education for their employees by the DON and a copy of this training was placed in the agency education binder by the Administrator. On [DATE], all activities department and front desk staff were in serviced on PCC profile picture uploading upon admission by Administrator/ designee. Staff who were absent or PRN (pro re nata) would not be permitted to return to the floor and resident care until this in-servicing /education was completed. On [DATE], all receptionists were in service on the elopement binder review and updating the binder weekly and with any new admission by the Administrative Team. Staff who were absent or PRN (pro re nata) would not be permitted to return to the floor and resident care until this in-servicing /education was completed. On [DATE], the Admissions Director was in serviced on posting new admissions room number and expected date of admission by time clock daily (which is a secured area), by Administrator/designee. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1.Review of Resident #70's medical record revealed an admitted [DATE] with diagnoses including dementia, muscle weakness, and hypertension. Review of the Brief Interview for Mental Status (BIMS) dated [DATE] completed by Social Service Director (SSD) #301 for Resident #70 revealed a score of four, indicating the resident had severe cognitive impairment. Review of the Behavior Assessment and Data Collection dated [DATE] at 4:24 P.M., completed by Licensed Practical Nurse (LPN) #457 revealed Resident #70 had dementia related elopement attempts. Resident #70 wandered and was at risk for potentially getting to dangerous area, stairs or out of the facility unassisted. Resident #70 displayed exit seeking behaviors. Review of the Wandering Risk assessment dated [DATE] at 4:30 P.M., completed by LPN #457 revealed Resident #70 had wandered before, at home or in the previous living setting, the family/significant other voiced concerns. The wandering placed Resident #70 at significant risk of getting to a potentially dangerous place including stairs or outside the facility. Resident #70 was a new admission, cognitively impaired with poor decision-making skills, and ambulated independently. Resident #70 talked about her desire to go home and was seeking to find her spouse/family. Review of the baseline care plan for Resident #70 dated [DATE] at 8:56 A.M., revealed Resident #70 was alert but cognitively impaired, did not require any mobility devices. Resident #70 had a left ankle wander guard (electronic monitoring bracelet/device) placement used for safety. Resident #70 was an elopement risk. Interventions included checking placement and function of safety monitoring device every shift. Review of the physician orders for Resident #70 revealed an order dated [DATE], for skin checks biweekly on shower days, document observation in skin assessment every evening shift every Wednesday and Saturday, and new note wander guard placement/ function start date [DATE] at 3:00 P.M. Review of the Treatment Administration Record (TAR) for Resident #70 revealed an order for the wander guard placement/ function start date [DATE] at 3:00 P.M. and skin checks biweekly on the 3:00 P.M. to the 11:00 P.M. shift only. The wander guard placement checks and skin checks were one combined entry on the TAR. Documentation revealed Resident #70's wander guard was not assessed for placement or function on [DATE] on the 11:00 P.M. to 7:00 A.M. shift or [DATE] on the 7:00 A.M. to the 3:00 P.M. shift. Review of the physician order for Resident #70 dated [DATE] revealed an order for routine resident checks to help maintain resident safety and well-being at least every two hours every shift. Review of the Medication Administration Record (MAR) and TAR for Resident #70 for [DATE] revealed the resident checks to help maintain resident safety and well-being at least every two hours every shift was documented by shifts 7:00 A.M to 3:00 P.M., 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. Review of the progress note dated [DATE] at 6:00 A.M., completed by LPN #671, included Resident #70 slept well thought the night. Review of the progress note dated [DATE] at 4:24 P.M., completed by LPN #672 revealed Resident #70 had a new wander guard in place on left ankle. Review of the progress note dated [DATE] at 6:58 P.M., completed by the DON, revealed incident noted at 2:30 P.M., doctor notified, Assistant Director of Nursing (ADON) notified, Power of Attorney (POA) notified. Resident #70 returned to facility at 3:49 P.M., POA present. No concerns voiced. Resident #70 was assessed. Wander guard present. Care plan (CP) reviewed. Risk management completed. Review of the form titled Call for Service report dated [DATE] at 3:04 P.M., completed by Police Department (PD) #1 located in [NAME] Heights revealed they received a call from [NAME] #673, that a female was confused and doesn't know where her apartment was. The female was identified as Resident #70. Dispatch contacted the daughter of Resident #70 who advised that Resident #70 was to be at the nursing home in [NAME]. On [DATE] at 3:55 P.M., Resident #70 was returned to the nursing home per the [NAME] Heights Police Department. Review of the [NAME] Police Department (PD) report created [DATE] at 4:00 P.M. and completed by Police Officer #674 revealed on [DATE], [NAME] PD was contacted by [NAME] Heights officers in regard to a confused female that was found wandering around an apartment building located at (given address) in [NAME] Heights. [NAME] dispatch advised them that there were no recent missing persons reported. [NAME] Heights officers learned the elderly females name was Resident #70. They found a phone number for her daughter and made contact with her. The daughter advised that her mother (Resident #70) was admitted to the nursing home in [NAME] the past Friday, on [DATE], due to her suffering from dementia and wasn't supposed to have left. [NAME] Heights Officer assisted in transporting (Resident #70) back to the nursing home in [NAME]. When Police Officer #674 spoke with the daughter on the phone, the daughter said her mother had a bracelet on her ankle that was supposed to omit a loud sound, should she walk past a certain door and alert staff. She also said that her mother was getting a new bracelet put on her that would work. It was unknown when (Resident #70) left the facility except it would have had to happen sometime after Friday. The nursing home (Resident #70) resided in did not contact [NAME] Police at any time to advise them of a missing person. The report included the distance from where Resident #70 resided at the nursing home to where she was located by the PD was 1.4 miles. Review of Google Maps confirmed the distance from the facility Resident #70 resided and the location Resident #70 was found was 1.4 miles. Observation of the route revealed it included a two-lane highway with a middle turn lane and no sidewalks. Review of Weather Underground computerized environmental temperatures website revealed on [DATE], the temperature ranged from 59 to 75 degrees. From 12:00 P.M. through 3:00 P.M., the temperature ranged from 70 to 75 degrees. Review of the daily schedule dated [DATE] revealed the 7:00 A.M to 3:00 P.M. shift, (Resident #70's hall) staff consisted of LPN #615, State tested Nursing Assistant (STNA) #437, and STNA #355. Observation on [DATE] at 11:30 A.M., revealed on the second floor of the facility was a central hall. Located in the central hall was an elevator. On each end of the hall was a set of unsecured double doors that were closed. Behind each set of unsecured double doors was the residential living areas. Nursing Assistant Trainee #578 was observed sitting near the elevator and revealed he was monitoring the elevator to make sure residents did not leave. Review of the facility census revealed 47 residents resided on the second floor. Interview on [DATE] at 1:17 P.M., with LPN #526, revealed the unit Resident #70 resided on, located on the second floor, was not secured. LPN #526 revealed Resident #70 was at risk for elopement, but stated she was the only resident at risk for elopement on her unit. LPN #526 revealed the doors have an electronic monitoring system, every resident on her unit had an electronic monitoring bracelet on them. LPN #526 revealed she did not know how to check the alarm system to see if it was working but stated the 11:00 P.M. to 7:00 A.M. nurse checked it. Observation on [DATE] at 1:20 P.M., with LPN #526 of the facility list of residents at risk for elopement revealed 14 residents (#10, #13, #14, #22, #38, #41, #52, #53, #54, #58, #70, #77, #88, and #90) of 47 residents who were at risk for elopement, and all resided on the second floor of the facility. During the observation, interview with LPN #526 revealed she did not check any residents for bracelet placement this shift. When requested by the surveyor to check the electronic bracelets for function, LPN #526 revealed she did not know how, stating she had never done that before. LPN #526 revealed she would ask someone how to do it and return. Observation and interview on [DATE] between 1:43 P.M. and 5:00 P.M., revealed Resident #70 was pleasantly confused, smiled frequently and revealed the month was September, the year was October and confirmed she did not know where she was. Resident #70 ambulated with a slow steady gait. Interview on [DATE] at 4:38 P.M. with Resident #70's daughter revealed Resident #70 was admitted to the facility on Friday ([DATE]). On Sunday ([DATE]) at three something, [NAME] Heights police department called her and said a lady (her mom) was at her old apartment wandering around. Resident #70's daughter revealed she didn't know how her mom (Resident #70) got there, but stated the maintenance man at the apartment building, let her in her old apartment. Resident #70's daughter revealed someone at the apartment building called the police, they knew her because she lived there since 1981. Resident #70's daughter revealed her mom was known as the walking lady because she loved to walk. Resident #70's daughter revealed Resident #70 was diagnosed with dementia a few years ago. She and her sister took turns staying with her 24 hours a day for the past few years because she was no longer safe to stay by herself. She was very confused, her conversations no longer made sense. Resident #70's daughter revealed her sister became ill and they could no longer care for her by themselves and that was why they needed help to keep her safe and admitted her to the facility. Resident #70's daughter revealed she met the police at the apartment, she called the facility to let them know her mom was in her old apartment with the police. The police then returned her to the facility. Interview on [DATE] at 5:12 P.M., with the Administrator confirmed on [DATE] Resident #70 left the facility unattended. The facility did not complete a self-reported incident (SRI) of the situation because they determined the situation did not constitute neglect but was a result of a malfunctioning system. Resident #70 had a wander guard which should have alarmed to alert the staff when she went to the elevator to leave. The facility determined the elevator alarm was malfunctioning, it did not alert. The Administrator revealed residents were assessed on admission and if it was determined they were at risk for elopement a wander guard would be placed on them, which was done for Resident #70. The second floor was considered a memory care, not a locked unit. If a resident with a wander guard got close to the elevator it should sound and prevent the elevator from going down. When Resident #70 returned to the facility, a staff member was assigned to monitor the elevator because sometimes it worked, sometimes it did not. The Administrator revealed the company who placed the alarm system came to look at it on [DATE] and determined it was functioning correctly, but it was a hit and miss. The Administrator revealed the facility would have a monitor at the elevator until the alarm system was fixed or replaced. Interview on [DATE] at 5:20 P.M., with Maintenance Director #470 revealed the wander guard system only hooked up to the elevator, no doors. If any resident with a wander guard bracelet got within 10 feet of the elevator, the parameter monitor on the wall would reflect they were near the elevator. The alarm sounded when the elevator door opens. The elevator would not move until the resident was removed from the area and a code was put in to shut the alarm off. Maintenance Director #470 revealed he checked the monitor on the wall for the elevator about once a month, but he never documented it. He stated the last time he checked was about the middle of last month. An attempted follow-up interview on [DATE] at 8:35 A.M., with Resident #70 revealed the resident stated her sister picked her up and took her home. Resident #70 then began rambling and talking about hot flashes. A follow-up interview with Resident #70's daughter on [DATE] at 8:42 A.M. revealed Resident #70's sister lived out of state, was older than her and could not drive. Resident #70's daughter revealed she still did not know how Resident #70 got to her old apartment so far away, no one knew, either she walked, or someone picked her up, but confirmed she did not know. Interview on [DATE] between 10:03 A.M., with [NAME] #673 revealed she called the police on [DATE] when she saw Resident #70 outside wandering around the apartment building alone and looked confused. [NAME] #673 revealed she first called the maintenance man at the apartment; he knew her from when she lived there before, he let her in the building then she called the police. Interview on [DATE] at 10:05 A.M., with the Administrator revealed the facility did have cameras but she did not look at the footage related to the incident with Resident #70. The Administrator revealed possibly someone looked at the footage of when Resident #70 left the facility, but she did not know. The Administrator denied the surveyor the opportunity to view the camera footage. Interview on [DATE] at 11:35 A.M., with Repair Man #675 from the Alarm System Company revealed he found the alarm on the elevator working but stated the facility was using expired bracelets. He stated the plan was to replace all bracelets per the DON and plan to eventually change out whole system. Repair Man #675 revealed Resident #70's bracelet was one of the expired bracelets and did not work. The DON was present and revealed the facility purchased the alarm system in [DATE] and stated the bracelets should have been good for one year. The DON confirmed the bracelets should have been checked every shift for functioning. Interview on [DATE] at 11:39 A.M., with LPN #615 revealed she was the charge nurse on [DATE] for Resident #70 when Resident #70 left the facility unattended. LPN #615 revealed on [DATE] at about 2:00 P.M., she did Resident #70's vital signs, then left Resident #70 to check on other residents. LPN #615 revealed she did not recall what time it was when they noticed Resident #70 missing and started looking for her. LPN #615 revealed she went to a nearby apartment building, and someone said he did see a lady with that description walking down the street. Her and the man drove to a nearby plaza, then someone from the facility called and said they found her. Resident #70 still had her ankle bracelet on when she returned to the facility, the DON put a new one on. LPN #615 revealed the alarm system did not go off or sound when Resident #70 left the facility unattended. Interview on [DATE] at 11:51 A.M., with State tested Nurse Assistant (STNA) #437 confirmed she worked with Resident #70 on [DATE] when she was found missing. STNA #437 revealed no alarm sounded when Resident #70 left. When she returned to the facility, her ankle monitor was still on. STNA #437 revealed on [DATE], she last saw Resident #70 around lunch time which was around 1:00 P.M. Resident #70 did not eat her lunch, she frequently walked around looking for her daughter and saying she was just there to visit. The STNA indicated the resident was wearing a jean blazer, black and white shirt, blue jeans, and black shoes. Interview on [DATE] at 12:01 P.M., with Administrator (Repair Man #675 also present) revealed she needed to clarify what Repair Man #675 said. Repair Man #675 said the bracelet was expired but we don't know that. Repair Man #675 then stated he no longer had time to speak with the surveyor. Interview and record review on [DATE] at 12:40 P.M., with the DON revealed the facility timeline for [DATE] included the following: The DON confirmed she viewed the camera footage of Resident #70 leaving the facility unattended. Per the DON, on [DATE] at 2:13 P.M., Resident #70 was noted leaving the unit. At 2:25 P.M., Resident #70 was seen leaving the facility by the front desk. Receptionist #307 was present. The DON revealed Receptionist #307 thought Resident #70 was a visitor. The DON confirmed the facility had an elopement book located at the front desk. The elopement book had pictures and information of all residents in it who were at risk for elopement. The book was to be used by the staff to confirm residents at risk for elopement. The DON revealed Resident #70's picture was not yet put in the elopement book on [DATE] when Resident #70 left the facility. The DON revealed on [DATE] at 2:30 P.M., the facility began searching for Resident #70. At 3:21 P.M., the facility was notified Resident #70 was found. The facility had not yet notified the police or family (as the timeline stated). When Resident #70 was found, the facility was notified by Resident #70's daughter that Resident #70 was found 1.4 miles from the facility at her previous apartment she resided at. Review of the undated written statement, completed by Receptionist #307 included, they came to the front desk and asked if I had seen the new lady around 2:30 P.M.; I remembered seeing a short lady with white hair, but I thought she was visiting. She was outside in front talking to the cable/internet guy. I thought she was a visitor. Interview on [DATE] at 10:30 A.M., with Regional Director of Operations (RDO) #676 confirmed the system used for elopement was not a WanderGuard system (trade name for a certain electronic monitoring system). The system was a wander preventative system in place. The facility referred to as a wander guard system although it was not a brand name WanderGuard. Review of the policy titled, Wandering, Unsafe Residents, revised [DATE], revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement. 2. Review for Resident #10's medical record revealed an admitted [DATE] with diagnoses including dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbances. Review of the BIMS for Resident #10 completed [DATE] revealed a score of zero indicating (severe cognitive impairment). Review of the Nursing Admission assessment dated [DATE], for Resident #10 completed by LPN #615, revealed Resident #10 was admitted to the facility due to dementia. Resident #10 required extensive assistants with bed mobility and transfers. Resident #10 was alert to person only and was appropriate for verbal expression. Resident #10 used a wheelchair and was able to propel herself off the unit. Review of the Wandering Risk Assessment for Resident #10 dated [DATE] completed by LPN #615 revealed Resident #10 was cognitively impaired with poor decision-making skills, was a new admission, and talked about her desire to go home. Review of the baseline care plan for Resident #10 dated [DATE] revealed the initial goal was for Resident #10 to remain in the facility. Resident #10 was not an elopement risk. Review of care plan for Resident #10 initiated [DATE], revealed the resident is an elopement risk/ wanderer and has been known to make unsafe transfers. Interventions included to check placement and functioning of safety monitoring device every shift. Reorient/validate and redirect resident as needed. Review of the physician order dated [DATE] at 11:00 P.M., revealed an order to check placement of wander guard to left lower extremity every shift for wandering. Review of the progress note dated [DATE] at 5:58 P.M., completed by LPN #615 revealed wander guard placed on left lower extremity power of attorney was aware. Review of Resident #10's medical record revealed no explanation of the reason for the new order for the wander guard. Record review of the Wandering Risk assessment dated [DATE] initiated by LPN Supervisor #455 was incomplete. Review of the care plan dated [DATE] revealed Resident #10 was an elopement risk/ wanderer, wander guard. Interventions included check placement and function of safety monitoring device every shift. Observation on [DATE] at 11:30 A.M., revealed on the second floor of the facility was a central hall. Located in the central hall was an elevator. On each end of the hall was a set of unsecured double doors that were closed. Behind each set of unsecured double doors was the residential living areas. Nursing Assistant Trainee #578 was observed sitting near the elevator and revealed he was monitoring the elevator to make sure residents did not leave. Review of the facility census revealed 47 residents resided on the second floor. Interview on [DATE] at 1:17 P.M., with LPN #526, revealed Resident #10 tried to leave once, and she was told to keep an eye on her. LPN #526 revealed the doors have an electronic monitoring system, every resident on her unit had an electronic monitoring bracelet on them. LPN #526 revealed she did not know how to check the alarm system to see if it was working but stated the 11:00 P.M.

Based on observation, staff interview, and record review, the facility failed to ensure a resident's call light was accessible to request assistance as needed. This affected one (#28) of four resident's observed for accommodation of needs. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, hemiplegia affecting left nondominant side, morbid severe obesity, major depressive disorder, anxiety, tracheostomy, and dependence on respirator. Review of the Annual MDS assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 had no impairment of the upper or lower extremities. Resident #28 used no mobility devices. Resident #28 required assistants with activities of daily living. Review of the care plan for Resident #28 dated 02/15/24 revealed Resident #28 was at risk for falls related to deconditioning, confusion, gait/balance problems, and incontinence. Interventions included to be sure the residents call light was within reach and encourage the resident to use it for assistants as needed. Observation and interview on 05/08/24 at 3:22 P.M., with Resident #28 revealed the call light was wrapped around the lamp above her head out of reach. Resident #28 verified she could not reach the call light. Resident #28 revealed she liked the call light hanging above her head where she could reach up to get it but this time the State tested Nursing Assistant (STNA) placed it out of her reach. Observation and interview on 05/08/24 at 3:30 P.M., with Licensed Practical Nurse (LPN) #370 verified Resident #28's call light was out of reach. LPN #370 revealed Resident #28 used her call light frequently.

Based on observation, resident interview, family interview, staff interview, record review, and review of policy, the facility failed to timely implement measure to promote mobility of a resident, who required a specialized wheelchair to be evaluated by therapy services to obtain a customized wheelchair. This affected one (#28) of three residents reviewed for mobility. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, hemiplegia affecting left nondominant side, morbid severe obesity, major depressive disorder, anxiety, tracheostomy, and dependence on respirator. Resident #28 had a payer source of Medicaid. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 had no impairment of the upper or lower extremities. Resident #28 used no mobility devices. Resident #28 was set up or clean up assist with eating and oral hygiene, and dependent with toileting, bathing, dressing, personal hygiene, bed mobility, lying to sitting, and transfers. No wheelchair or scooter was used. Resident #28 had no behaviors exhibited and no rejections of care. Review of the care plan for Resident #28 dated 02/15/24 revealed Resident #28 had an activity of daily living (ADL) self-care performance deficit related to disease process. Resident requires staff assist to complete activities of daily living (ADL) tasks daily. Fluctuations are expected related to diagnosis. Interventions included the resident is bedfast all or most of the time. Monitor, document, as needed any changes. Physical and Occupational Therapy evaluation and treat per physician orders. Review of the Occupational Therapy Evaluation and Plan of Treatment with a Certification Period of 01/05/24 through 02/01/24 for Resident #28 completed by Occupational Therapist (OT) #685, revealed Clinical Impressions/Reason for skilled services included Resident #25 presented with impairments in balance, gross motor coordination, mobility, attention and strength resulting in limitations and or participation restrictions in the areas of mobility, self-care and functional tasks of choice, assess safety and independence with Activities of Daily Living (ADL's), increase functional activity tolerance, develop and instruct on adaptation techniques and develop and instruct on compensatory strategies in order to facilitate ability to live in environment with least amount of supervision and assistants. Due to documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for further decline in function, falls, immobility and compromised general health. Continued review of the OT progress notes revealed OT continued care through 02/27/24. Resident #25 actively participated with skilled interventions. Resident #28 demonstrated right lateral lean at edge of bed level, achieved midline, able to access bedside table and complete self-feeding. Head of bed elevated 35 degrees, no signs and symptoms of pain, discomfort, or shortness of breath. Review of the physician orders revealed Resident #28 received an order on 05/01/24, for OT eval completed, plan of care established to include therapeutic exercise, therapeutic activities to include self-care management, wheelchair management three times a week for four weeks. Interview on 05/08/24 at 3:22 P.M., with Resident #28 revealed she wanted to get out of bed. Resident #28 stated, They didn't have right size wheelchair for a long time so they couldn't get me up. Interview on 05/08/24 at 3:30 P.M., with Licensed Practical Nurse (LPN) #370 revealed Resident #28 recently received a bariatric wheelchair and had been getting up. Observation of the wheelchair for Resident #25 revealed a bariatric tilt-n-space chair. Interview on 05/15/24 at 9:50 A.M., with Occupational Therapist (OT) #685 revealed Resident #28 was currently on Occupational Therapy services to try the loaner chair. The loaner chair was a bariatric tilt-n-space chair. OT #685 revealed Resident #28 did not have a chair before receiving the loaner chair. Resident #28 was at the facility for about a year and was not getting out of bed because she did not have an option to get out of bed, there was no chair she could use. OT #685 revealed Resident #28 had low motivation to get out of bed, but she had no option. OT #685 revealed the chair got here for Resident #28 on 04/29/24, it was a trial wheelchair to eventually get her a custom wheelchair. OT #685 revealed Resident #25 was admitted to the facility on [DATE]. Resident #25 was picked up for the first time on 01/05/24 by OT for positioning in bed and to tolerate head of bed elevation. OT #685 revealed therapy never picked her up before because there was nothing to put her in. The insurance company wanted to see her tolerate getting up in order to order her a chair they would pay for. The facility did not have one to trial. OT #685 revealed it was mentioned to the Administrator in the past but was never approved. OT #685 revealed she finally went to a community vendor and received a loaner chair for Resident #25. Resident #25 was currently on case load beginning 05/01/23. Resident #25 sat up in the chair for an hour. OT #685 stated, It should have been attempted sooner, it's been a year, she is afraid now. It should have been done when she came, that's how it's usually done, they need to get out of bed. I finally went and got the chair myself, her needing to get out of bed is what kept me trying to find a chair we could use. Interview on 05/15/24 at 1023 A.M. with Resident #28's son revealed Resident #28 lived in Florida with her family and friends prior to the accident. She was at a hospital in Florida, they said she would need a nursing home that accepted bariatric and ventilator patients. The closest place was in Ohio. She had no family or friends in Ohio but had to go for care. Resident #28's son revealed prior to going to Ohio she did get out of bed, the facility used a mechanical lift, she got up all the time, every time he visited, she was up, she would go to the dining room to eat her meals and socialize. Resident #28's son revealed he hasn't been able to get to Ohio yet and didn't know why they were not getting her out of bed revealing, they should have been, that's their job. Observation and interview on 05/15/24 at 10:31 A.M. revealed Resident #28 were up in the chair in the dining area. Resident #28 was smiling and revealed it felt good to get up. Resident #28 confirmed she previously lived in Florida and was at a facility in Florida, in 2018. While she was at a church, she had a stroke and eventually needed to come to Ohio for care. Resident #28 revealed she was at another facility in Ohio for a year before transferring to the current facility, they never got her up either, they didn't even try. Resident #28 revealed she wanted to get up, when she lived in Florida, they got her up every day, they had patience; Resident #28 revealed she wanted to get up here also but sometimes with therapy, she refused, it is scary, but they never tried until now because they didn't have a chair to put her in. Interview on 05/15/24 at 10:40 A.M., with Administrator revealed Resident #28 never expressed she wanted to get out of bed until recently, she came with no motivation, she never expressed prior she wanted to get out of bed, she would not have been able to. Administrator stated no one asked her for a chair. Interview on 05/15/24 at 10:49 A.M., with OT #685 revealed since Resident #28 arrived she was dependent; she still was except she can feed herself; therapy did not evaluate her or pick her up until January which was nine months after she came. Interview on 05/16/24 at 2:00 P.M., with Physical Therapist (PT) #686 and Regional Director of Clinical Services (RDCS) #677 revealed Resident #28 was picked up in January 2024 for OT. Resident #28 was focusing on self-feeding and head of bed elevation. On 05/15/23, Resident #28 was screened by PT and OT and no evaluation was recommended by either therapy department because she could only tolerate 10 degrees up in bed and was too weak for therapy. PT #686 revealed Resident #28 was not assessed for a wheelchair either at that time because she was too weak to get up and could only tolerate 10 degrees up in bed. Interview on 05/20/24 at 2:44 P.M., with PT #686 revealed on 05/15/23, Resident #28 was not picked up for range of motion because that was not a skilled service, and the facility did not offer a Restorative Program. PT #686 confirmed Resident #28 was not screened again after 05/15/23 by therapy until January 2024, and revealed the therapy department only screened residents when they received a referral from the staff. Review of the policy titled, Rehab Services Policy titled Interdisciplinary Therapy Data Collection and Nursing to Therapy Communication Forms and Data Collection Log, revised 06/29/21, included the Interdisciplinary Therapy Data Collection form may be completed with specific information for nursing facility patients within - 72 hours of admission or readmission and or completed quarterly according to their care plan schedule and or upon referral/recommendation for a screen from facility staff. This deficiency represents the noncompliance investigated under Complaint Number OH00153124.

Based on record review and staff interview, the facility failed to ensure oxygen orders were obtained including the liters to be administered and the frequency of administration. This affected one (#18) of three residents reviewed for respiratory services. The facility census was 88. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease and unspecified glaucoma. Review of the significant change Minimum Data Set (MDS) dated [DATE] for Resident #18 revealed Resident 18 was moderately cognitively impaired. Resident #18 received oxygen therapy. Review of the care plan for Resident #18 dated 07/13/23 revealed Resident #18 was at risk for developing complications secondary to has oxygen therapy related to respiratory illness. Review of the physician order dated 02/22/24 for Resident #18 revealed an order Respiratory Therapy to evaluate and treat as indicated. Review of the Respiratory Therapy note dated 02/23/24 at 3:28 P.M., completed by Respiratory Therapist (RT) #688 for Resident #18 revealed patient evaluated by RT. Patient SPO2 (oxygen saturation) on four liters via nasal cannula 94%. Patients heart rate 101. Patients lung sounds markedly diminished on left side on auscultation. Review of the General Progress Note dated 02/27/24 at 8:46 A.M., completed by RT #688 for Resident #18 revealed SPO2 99% on two liters of oxygen per nasal cannula. Continue to monitor. Review of the physician order for oxygen therapy for Resident #18 revealed there was no physician order for oxygen therapy dated 02/23/24 or after until 03/03/24. Review of the physician order for oxygen therapy for Resident #18 dated 03/03/24 and discontinued 03/16/24 revealed an order for oxygen as needed (prn) to maintain SPO2 above 90 % every one hour as needed for shortness of breath (sob). Review of the Medication Administration Record (MAR) for Resident #18 for March 2024 revealed under the only oxygen ordered dated 03/03/24 and discontinued 03/16/24 (for oxygen as needed (prn) to maintain SPO2 above 90 % every one hour as needed for sob) revealed there was no documentation Resident #18 had the oxygen saturation assessed to assure it was above 90%, nor was there documentation on the MAR Resident #18 received any oxygen. Review of the Respiratory Therapy note dated 03/07/24 at 2:20 P.M., completed by RT #687 revealed Resident #18 was on four liters of oxygen via oxygen concentrator. There was no documentation of the oxygen saturation. Review of the physician order for oxygen therapy for Resident #18 dated 03/16/24 and discontinued 03/19/24 revealed an order for oxygen PRN for comfort care every one hour as needed for shortness of breath (sob). Review of the Medication Administration Record (MAR) for Resident #18 for March 2024 revealed under the only oxygen ordered dated 03/16/24 and discontinued 03/19/24 (for oxygen PRN for comfort care every one hour as needed for sob) revealed no documentation Resident #18 received any oxygen or had sob. Review of the nursing note dated 03/19/24 at 4:19 P.M., completed by Licensed Practical Nurse #542, revealed Resident #18 status post weaning with RT, orders clarified per RT, Resident #18 was on continuous oxygen at two liters per nasal cannula. Review of the physician order dated 03/19/24 for Resident #18 revealed an order two liters of oxygen via nasal cannula continuous. Interview on 05/15/24 at 9:00 A.M., with RT #683 revealed she started working with Resident #18 on 03/01/24. Resident #18 had received oxygen therapy daily. RT #683 confirmed Resident #18 was on two liters of oxygen. RT #683 revealed she was not aware of the physician order dated 03/03/24 for oxygen as needed (prn) to maintain SPO2 above 90 % every one hour as needed for sob or the order dated 03/16/24 and discontinued 03/19/24 for oxygen PRN for comfort care every one hour as needed for sob. RT #683 revealed she was unsure of the orders but there should have been an amount in liters of oxygen placed in the orders, she just went by whatever the resident was already on. RT #683 verified there were no physician orders for Resident #18 oxygen use from 02/27/24 through 03/03/24 and the orders were not complete with a liter amount from 03/03/24 through 03/19/24. This deficiency represents the noncompliance investigated under Complaint Number OH00153124.

Based on record review, staff interview, and review of policy, the facility failed to monitor a resident's blood pressure prior to the administration of medication per physician orders. This affected one (#93) of three residents reviewed for assessment prior to medication administration. The facility census was 88. Findings include: Review of the medical record for Resident #93 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic combined systolic congestive and diastolic congestive heart failure (CHF), and essential primary hypertension. Review of the quarterly Minimum data set (MDS) dated [DATE] revealed Resident #93 required assistants with activities of daily living and had cardiorespiratory conditions. Review of the care plan for Resident #93 revealed Resident #93 was a full code. Resident #93 had hypertension interventions which included giving medications as ordered, monitoring side effects, and monitoring for signs and symptoms of hypertension. Review of the physician orders for Resident #93 revealed an order dated 09/13/23, for sacubitril valsartan oral tablet 24-26 milligrams (mg) give one tablet by mouth two times a day for COPD, hold if blood pressure is less than 120/60. Review of the Medication Administration Record (MAR) for March 2024 and April 2024 for Resident #93 revealed Resident #93's blood pressure was not documented on the MAR two times a day prior to giving the medication sacubitril valsartan oral tablet 24-26 mg. Review of the medical records including the progress notes and vital signs for Resident #93 revealed vital signs were not documented two times a day prior to giving the medication sacubitril valsartan oral tablet 24-26 mg. Interview on 05/13/24 between 3:51 P.M. and 4:08 P.M., with Licensed Practical Nurse (LPN) #486, #681, #457, and Registered Nurse (RN) #670 revealed if there was an order to check a blood pressure prior to giving a medication, the result of the blood pressure would be documented in the MAR after the blood pressure was taken. (LPN) #486, #681, #457, and Registered Nurse (RN) #670 confirmed if they assessed a resident's blood pressure, they would document it. LPN #457 revealed she worked with Resident #93 and revealed if the person placing the order in the electronical medical record does not place the vital sign in there also to pop-up when you're giving the medication like it is supposed to, it would be easy to miss the order to assess the blood pressure prior to giving the medication. LPN #457 confirmed she may have missed the portion of the order to assess Resident #93's blood pressure prior to giving the medication because it did not pop-up. Interview on 05/13/24 at 4:16 P.M., with Director of Nursing (DON) revealed she would expect the nurse to assess the blood pressure on any resident if it was in the physician orders and document the result. DON verified Resident #93 had an order for valsartan oral tablet 24-26 mg give one tablet by mouth two times a day for COPD, hold if blood pressure is less than 120/60. DON verified the blood pressure was not documented for Resident #93 prior to the medication being administered two times a day on the MAR or anywhere in the medical record. Interview via telephone, on 05/13/24 at 4:28 P.M., with Resident #93's Primary Care Physician/facility Medical Director, Physician #680 revealed if there were physician orders to check a resident's blood pressure prior to giving a medication, the nurse should be documenting the blood pressure in the medical record. Interview on 05/15/24 at 1:20 P.M., with DON and Physician #680 revealed one day Resident #93's blood pressure was low and Physician #680 was notified. Physician #680 suggested Resident #93 go to the hospital; the daughter refused and wanted Resident #93's blood pressure checked two times a day. Physician #680 agreed and gave the order to check Resident #93's blood pressure prior to giving the medication sacubitril valsartan oral tablet 24-26 mg and to hold the medication if the blood pressure was less than 120/60. DON revealed because it was the daughter's request to check the blood pressure, the nurses didn't need to document the results of the blood pressure, they would just notify the physician if it was too low. Physician #680 confirmed she gave the order, and it was a written physician order to hold the medication if the blood pressure was less than 120/60. DON confirmed she could not verify if Resident #93's blood pressure was assessed each time as per the physician's order. Review of the policy titled, Administering Medications, revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. As required or indicated for a medication, the individual administering the medication records in the resident's medical record any results achieved and when those results were observed. This deficiency represents the noncompliance investigated under Complaint Number OH00153220.

Based on record review, staff interview, transport timeline review and review of policy, the facility failed to ensure documentation was complete in the resident medical record. This affected one (#85) of three residents medical records reviewed for documentation. The facility census was 88. Findings include: Review of the medical record for Resident #85 revealed an admitted [DATE]. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, tracheostomy, and chronic respiratory failure. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #85 had severe cognitive impairment and was impaired on one side of the upper and lower extremity. Resident #85 was dependent for activities of daily living. Resident #85 had medically complex conditions, which included cerebral palsy, chronic respiratory failure with hypoxia, tracheostomy, oxygen therapy, and suctioning. Review of the care plan dated 01/29/24 revealed Resident #85 was at risk for alteration in code status, Resident #85 was a full code. Interventions included obtaining vital signs as ordered per doctor and as needed, notify doctor as indicated. Interventions included calling 911 immediately as indicated. Review of the care plan dated 02/12/24 revealed Resident #85 was at risk for developing complications secondary to tracheostomy related to impaired breathing mechanics. Interventions included ensure that trach ties are secured at all times. Monitor/document for restlessness, agitation, confusion, increased heart rate (tachycardia), and bradycardia. Monitor/document level of consciousness, mental status, and lethargy as needed (PRN). Monitor/document respiratory rate, depth, and quality. Check and document every shift/as ordered. Provide means of communication and procedural information. Reassure me that help is available immediately. Tube out procedures: Keep extra trach tube and obturator at bedside. If the tube is coughed out, open stoma with a hemostat. If the tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate the head of bed 45 degrees and stay with resident. Obtain medical help immediately. Review of the physician order dated 01/22/24 revealed Resident #85 was a full code. Additional orders included: Respiratory Therapy may evaluate and treat as needed dated 01/22/24. Spare trach (one size smaller, one size larger) and oxygen e tank at bedside dated 03/14/24. Trach care every shift and as needed dated 01/25/24. Trach assessment every four hours dated 01/24/24. Review of the progress note for Resident #85 dated 04/09/24 at 6:55 A.M., completed by Registered Nurse (RN) #433, revealed (Resident #85) decannulated herself. Unable to reinsert trach per respiratory. Patient was rounded on multiple times during the shift. Current pulse oximetry was 93% room air. Respiratory notified, doctor notified, patient currently receives hospice services. Patient will be sent out to emergency room (ER) for evaluation. Review of the respiratory therapy note dated 04/09/24 at 7:30 A.M., for Resident #85 completed by Respiratory Therapist (RT) #687 revealed the resident was assessed after self-decannulating her trach (removing the whole trach). Patient's assessment discovered by State tested Nursing Assistant (STNA) and Respiratory. RT #687 performed Full Assessment with no findings of Respiratory Distress. RT #687 is stable on room air via stoma. Respiratory attempted to replace trach, but Resident #85 became semi-violent and was actually almost able to phonate (speak). RT #687 notified Pulmonologist and described the situation. Although Patient is quite Stable, Respirations unlabored, oxygen saturation at 95% on room air. Heart rate 68 beats per minute., (Resident #85's) secretions and airway integrity are of concern, so we agree that (Resident #85) should be sent out to ER and further evaluated by ear, nose, and throat (ENT). A physician's ambulance has been called for pick-up (non - emergent transport). RT will follow-up. Review of the progress note for Resident #85 dated 04/09/24 at 11:39 A.M., completed by RT #687 revealed respiratory assessed, Resident #85 noting the need for small amounts of secretion to be suctioned. Pt. has the ability to expectorate secretions intermittently but does require suctioning. The nurse also assisted with suctioning throughout the shift. Resident was last seen around 3:00 A.M. and then discovered self-decannulation (trach removal) at 5:50 A.M. Review of the progress note for Resident #85 dated 04/09/24 at 8:37 P.M., completed by Licensed Practical Nurse (LPN) #689 revealed she spoke with nurse, Doctor #690 from Hospital #691 about update for (Resident #85), as stated she is tachycardia and hypertensive, and they are trying to get her vitals stable. Review of the Therapy Administration Record for April 2024 for Resident #85 revealed on 04/08/24 oral care every shift and as needed every day was not documented as completed for the 7:00 P.M. to the 7:00 A.M. shift or on 04/09/24 for the 7:00 A.M. to the 7:00 P.M. shift. The trach care orders each shift and as needed two times a day was not documented completed on 04/08/24 for the 7:00 P.M. to the 7:00 A.M. shift or on 04/09/24 for the 7:00 A.M. to the 7:00 P.M. shift. The order for the trach assessment every four hours timed to be completed at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M. 4:00 P.M. and 8:00 P.M. was not documented as completed on 04/08/24 at 4:00 P.M. and 8:00 P.M. and 04/09/24 at 12:00 A.M., 4:00 A.M. or 8:00 A.M. Record review of Resident # 85's medical record revealed there was no documentation of time of transport to the hospital. Record review of the transport timeline provided by Administrator obtained through an email dated 05/16/24 from Transport Company #692 revealed the call to the ambulance company for Resident #85 from the facility was placed on 04/09/24 at 7:21 A.M. The Ambulance arrived at the facility on site on 04/09/24 at 10:09 A.M. and transport arrived at the hospital at 10:49 A.M. Interview on 05/16/24 at 11:29 A.M., with Director of Nursing (DON) revealed she was unsure why Resident #85's Therapy Administration record for treatments was not documented as completed per orders. Review of the undated policy titled, Charting and Documentation revealed all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, may be documented in the resident's medical record. The medical record may facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. This deficiency represents the noncompliance investigated under Complaint Number OH00153124.

Based on observation and staff interview, resident interview, the facility failed to timely repair one resident's wall with several large visible holes, dents, and scrape markings on it. This affected one (#28) of three residents reviewed for the environment. The facility census was 88. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, hemiplegia affecting left nondominant side, morbid severe obesity, major depressive disorder, anxiety, tracheostomy, and dependence on respirator. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/14/24, revealed Resident #28 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident #28 had no impairment of the upper or lower extremities. Resident #28 used no mobility devices. Resident #28 had no behavior exhibited and no rejections of care. Observation on 05/08/24 at 3:22 P.M., revealed the wall behind Resident #28's headboard had three very large holes that reached from outside both sides of the headboard and continued behind the headboard from one end to the other. The wall also had multiple scrapes, dents, and black markings on it which were all visible while visiting with Resident #28. Interview at the time revealed Resident #28 stated she was unable to see the wall in her position in bed. Observation and interview on 05/08/24 at 3:30 P.M., with Licensed Practical Nurse (LPN) #370 confirmed the holes and markings on Resident #28's wall. LPN #370 revealed she was unsure how long it's been that way. Observation and interviews on 05/15/24 at 8:40 A.M., revealed Resident #28's wall had no repairs to the holes or markings on the wall were initiated. State tested Nursing Assistant (STNA) #302, Respiratory Therapist (RT) #682 and #683, and LPN #370 were present and confirmed they just repositioned Resident #28 as they have in the past several times and have never banged the wall. RT #683 revealed the wall had holes and was banged up in that same condition as long as she could remember. Interview on 05/15/24 at 9:47 A.M., with Housekeeper #303 confirmed she had seen the holes in Resident #28's wall. Housekeeper #303 revealed she reported it to Maintenance Director #470 weeks ago. Interview on 05/15/24 at 10:55 A.M., with Maintenance Director #470 confirmed he was aware of the holes in the wall in Resident #28's room. Maintenance Director #470 revealed he was unsure how long ago he was made aware and confirmed he did not repair it. This deficiency represents the noncompliance investigated under Complaint Number OH00153124.

Based on observation, interview, and record review, the facility failed to ensure a clean and sanitary shower room. This had the potential to affect all residents residing on Chestnut unit with shared shower room. The facility identified 22 residents (#3, #9, #15, #25, #26, #34, #44, #45, #46, #48, #49, #54, #59, #62, #66, #73, #78, #85, #88, #90, #92, and #93) as residing on Chestnut unit. The facility census was 93. Findings include: Interview on 05/24/23 at 11:19 A.M. with State tested Nursing Assistant (STNA) #804 revealed there was one community shower room on the Chestnut unit. STNA #804 noted someone must have used the bathroom in the shower room as she had noted there was bowel movement (BM) in the room. Observation on 05/24/23 at 11:22 A.M. of the second floor Chestnut unit shower room with STNA #804 revealed a shower room adjacent to the nurse's station with the door closed. Upon entry to the shower room with STNA #804 there was a strong odor of BM. Observation revealed a large, formed BM on a facility shower chair. There was also noted smearing of an unidentified brown substance on floor leading to door for shower room. Findings were confirmed with STNA #804. STNA #804 indicated she was unsure how long the BM had been there and who was responsible for cleaning up the BM. Interview on 05/24/23 at 12:02 P.M. with Housekeeper #807 revealed when a resident would toilet in an inappropriate area the nurses and aides usually left it until someone from housekeeping addressed it. Interview on 05/24/23 at 2:07 P.M. with Housekeeping Director #808 revealed STNAs or nurses would be expected to dispose of feces or urine and the housekeeping staff would clean and sanitize after. Interview on 05/24/23 at 3:35 P.M. with the Director of Nursing (DON) revealed STNAs would be responsible for cleaning up urine or feces and a housekeeper would be responsible for disinfecting the area. Review of the facility policy, Cleaning Spills or Splashes of Blood or Body Fluids, dated January 2012, revealed whoever witnessed bodily fluids anywhere in the facility would notify environmental services. An appropriately trained individual would clean and disinfect any surface or equipment contaminated as soon as practical to prevent exposure. This deficiency represents non-compliance investigated under Complaint Number OH00143122.

Based on observation, medical record review, policy review and interview, the facility failed to honor Residents #2's preferences. This affected one of three residents reviewed for transfer assistance. The census was 88. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses of multiple sclerosis, B-cell lymphoma, history of falling, seizures, need for personal assistance and major depressive disorder. Review of the activities of daily living (ADL) care plan, updated 05/10/22 revealed Resident #2 had an activities of daily living self-care performance deficit related to disease process. Resident #2 required staff assistance to complete ADL tasks daily. Resident #2 required extensive by one staff to move between surfaces daily and as necessary. Review of the nursing admission/readmission assessment dated [DATE] revealed Resident #2 usually woke up between 5:00 A.M. and 6:00 A.M. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #2 was cognitively intact, required extensive physical assistance of two-person for transferring and utilized a wheelchair for mobility. Review of the nutrition/hydration status assessment dated [DATE] revealed Resident #2 fed herself, used a wheelchair and had meals in the dining room. Observation on 05/02/23 at 8:48 A.M. revealed Resident #2 was lying in bed, wearing a hospital gown, with an untouched breakfast tray on her overbed table. Interview, during the observation, with Resident #2 revealed she woke up around 5:30 A.M. and liked to be out of bed by 9:00 A.M. but there were not enough aides to get her up on time. Observation on 05/02/23 at 8:50 A.M. revealed Agency State tested Nurse Aide (STNA) #6 was passing out breakfast trays while Registered Nurse (RN) #5 was sitting at the nursing station working on the computer on the Purple unit. Interview, during the observation, with RN #5 revealed Agency STNA #6 arrived late to work at 8:15 A.M. so RN #5 directed STNA #6 to pass breakfast trays then get Resident #2 out of bed. RN #5 stated she was passing medications. RN #5 verified Resident #2 was not out of bed and verified Resident #2 was supposed to be out of bed before breakfast as she liked to come to the dining room before breakfast. RN #5 also revealed Resident #2 would always complain that she was not out of bed on time then unable to eat in the dining room. RN #5 said Agency STNA #6's shift began at 7:00 A.M. and there was not a STNA on the unit with 15 residents from approximately 7:00 A.M. to 8:15 A.M. Interview on 05/02/23 at 8:55 A.M. with Agency STNA #6 revealed this day was her first time in the facility. Observation on 05/02/23 at 8:59 A.M. revealed Resident #2 continued to lay in bed and had eaten her cold cereal. At 9:02 A.M., STNA #6 entered Resident #2's room and asked RN #5 if she should get Resident #2 up and ready. RN #5 replied, yes and STNA #6 closed the door. At 9:36 A.M., STNA #6 exited Resident #2's room and Resident #2 was dressed in street clothes, self-propelling into her bathroom. Review of the facility's Quality of Life - Accommodation of Needs policy revised August 2009 revealed the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. This deficiency represents non-compliance investigated under Complaint Number OH00142180.

Based on observation and interview the facility failed to provide timely incontinence care. This affected one resident (#31) of two observed for incontinence care. The facility census was 88. Findings include: Review of Resident #31's medical records revealed an admitted [DATE]. Diagnoses included psoriasis and cellulitis (bacterial skin infection). Review of Resident #31's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 required extensive assistance with toileting and personal hygiene and was incontinent of bowel and bladder. Review of Resident #31's care plan dated 02/17/23 revealed Resident #31 had self care deficits. Interventions included staff to provide care daily. Observation on 05/04/23 at 7:51 A.M. revealed Resident #31's call light was on outside of her room. Upon entering Resident #31's room a strong pungent odor of urine was noted. Interview with Resident #31 at time of observation revealed she had been changed the previous evening prior to bedtime. Further observation revealed Resident #31 had been incontinent of urine with a large visible wet area underneath of the resident. Observation of incontinence care for Resident #31 on 05/04/23 at 8:00 A.M. with State tested Nursing Assistant (STNA) #105 revealed Resident #31 had been incontinent of a large amount of urine and liquid stool that had saturated through her incontinence brief and incontinence liner, two bath blankets and onto her mattress. STNA #105 stated she had started her shift at 7:00 A.M. and had not provided incontinence care to Resident #31 yet. STNA #105 stated she had not observed an STNA present on the unit when she arrived and did not know when not Resident #31 had last received incontinence care. This deficiency represents non-compliance investigated under Complaint Number OH00142180.

Based on observation, staff interview, and policy review the facility failed to ensure that all drugs and biologicals used in the facility were accurately labeled in accordance with professional standards to facilitate safe medication administration. This had the potential to affect all residents who reside in the facility. The facility census was 78. Findings include: Observation with the Director of Nursing (DON) on 01/10/23 at 12:05 P.M., of the medication storage room located on Rust unit, revealed the refrigerator contained one opened Novolog (insulin) flex pen mixed with other resident insulin pens, and without a resident identifier or date opened. Interview with the DON immediately following the observation, revealed the DON was unable to accurately identify the prescribed resident or date opened. The DON verified the medication was not labeled for safe medication administration per the facility policy. Observation with the DON on 01/10/23 at 12:35 P.M., of the medication storage room located on Maple unit, revealed the refrigerator contained a single one milliliter (ml) syringe that was filled with 0.1 ml of an unknown solution and placed in a plastic bin under resident vials of insulin. The syringe was not labeled with medication name, resident identifier, or date opened. Interview with the DON immediately following the observation, revealed the DON was unable to identify the medication solution or date the medication was drawn. The DON verified the medication was not labeled for safe medication administration per the facility policy. Interview on 01/12/23 at 10:28 A.M., The DON revealed all residents who reside at the facility require medication administration from staff. Review of the facility policy titled Storage of Medications, dated 04/2019, revealed the facility will store all drugs and biologicals in a safe, secure, and orderly manner. Review of the policy procedures revealed discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed; Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents; Medications requiring refrigeration are stored in a refrigerator or other secured location and are labeled accordingly.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 line list, review of facility policies, observations, interviews with the local health department (LHD), staff and residents and record review the facility failed to timely and appropriately exclude COVID-19 positive staff from working in the facility and failed to screen staff working the COVID-19 unit. This resulted in Immediate Jeopardy on 12/09/21 when State tested Nursing Assistant (STNA) #132 tested positive for COVID-19 on a rapid test at the facility. STNA #132 received a second COVID-19 rapid test by the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #112 which was negative, she continued to work the duration of her shift on the Maple unit. A polymerase chain reaction (PCR) COVID-19 test was not completed at this time. Through interview it was determined she obtained a PCR COVID-19 test in the community which was also positive yet returned to work at the facility on 12/16/21 on day seven of her infection. The lack of effective infection control practice placed all residents at the facility at risk for serious life-threatening harm, complications and/or death. The facility census was 68. On 12/28/21 at 4:58 P.M., the Regional Director of Operations (RDO) #190, the Director of Nursing (DON), Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #112 and Minimum Data Set (MDS)/LPN #143 were notified that Immediate Jeopardy began on 12/09/21 when STNA #132 tested positive for COVID-19 during outbreak testing that was initiated due to Resident #74 testing positive for COVID-19 at the hospital on 12/09/21. ADON/LPN #112 conducted a second rapid test on STNA #132 which was negative and STNA #132 continued to work the remainder of her shift providing resident care. STNA #132 obtained a PCR COVID-19 test in the community on 12/11/21 and received the results back on 12/13/21 indicating she was positive for COVID-19. STNA #132 came back to work on 12/16/21, day seven of being positive for COVID-19. The Immediate Jeopardy continued on 12/13/21 when STNA #115 tested positive for COVID-19 via rapid test on 12/13/21 but returned to work on 12/17/21, day four after testing positive for COVID-19. The Immediate Jeopardy was removed on 12/29/21 when the facility implemented the following corrective actions: · On 12/28/21, ADON/LPN #112, who served as the facility's Infection Preventionist, reviewed all staff members who tested positive for COVID-19 within the last 14 days to ensure those staff members had been removed from work duties. There were no COVID-19 positive employees working or scheduled. · On 12/28/21, Human Resources Staff (HRS) #127 emailed an updated line-listing to the Local Health Department (LHD). Another updated line-listing was emailed to the LHD on 12/29/21 by the DON. · On 12/28/21, ADON/LPN #112 placed screening protocol/documents at the entrance/exit of COVID-19 unit to ensure all staff members working the COVID-19 unit screened in and out. · From 12/28/21 at 6:00 P.M. to 12/29/21 at 6:00 P.M., DON/Designee in-serviced all staff members on adhering to protocol/policy of screening in/out of COVID unit. No staff who was absent or as needed (PRN) staff was permitted to return to the floor and provide resident care until in-servicing is completed. · On or before 12/29/21, RDO #190 educated the Administrator, DON, and ADON/LPN #112 on the following policy/protocols: 1) Conducting a PCR test upon receiving positive results from rapid test. ADON/LPN #112 will be responsible for ensuring this is done. The DON will be responsible as a back-up. 2) Following CDC/CMS recommendations for COVID-19 work restrictions. 3) Notification of local health department per protocol regarding COVID-19 positive test results within 24 hours of receiving the results. 4) Adhering to CDC/CMS/facility policy of return-to-work guidance, following contingency staffing guidelines, and then discussing our staffing with the LHD. 5) Ensuring all employees including agency staff screen in and out of COVID-19 unit. 6) Ensuring that an updated line listing is always kept by the Administrator with full access of the line listing given to DON and HRS #127 as a back-up. · DON/Designee will audit compliance daily for four weeks and then weekly for eight weeks to ensure no COVID-19 positive employee works outside of the parameters of the current CDC work restrictions for staff with COVID-19 infection and exposures. If a positive staff member is found to be working during our audit, the positive employee will immediately be removed from the unit and sent home. ADON/LPN #112/designee will initiate immediate re-education for all staff and the Administrator will ensure that a root cause analysis will be done within 24 hours to determine why this employee was working. · DON/Designee will audit daily for four weeks then weekly for eight weeks, five random employees across all shifts working on COVID-19 unit to ensure employees screen in and out per protocol/policy. · ADON/LPN #112/Designee shall conduct daily audit for four weeks then weekly for eight weeks to ensure LHD is notified with all new positive COVID-19 cases within 24 hours after results are received. · Audits will be presented and reviewed by quality assurance performance improvement (QAPI) committee monthly for three months. Audits would continue at direction of QAPI if appropriate. · On 01/03/22 from 9:29 A.M. to 9:47 A.M. interviews with Receptionist #124, Dining Services Director #105, Activity Director #107, STNA #146 and LPN #178 indicated they had received training on infection control including COVID-19 positive staff not returning to the facility too soon after infection and screening on and off the COVID-19 unit. Although the Immediate Jeopardy was removed on 12/29/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Interview during the entrance conference on 12/27/21 at 8:34 A.M. with HRS #127 confirmed the facility was allowing COVID-19 positive staff to work during the COVID-19 outbreak, but she did not know specifics. Infection control policies related to COVID-19 as well as a line list of staff and resident's positive for COVID-19 were requested during the interview. Interview on 12/27/21 at 9:07 A.M. with the DON indicated the facility was allowing COVID-19 positive staff to work on the COVID-19 unit. The DON indicated the facility's COVID-19 outbreak started on 12/09/21 when Resident #74 went to the hospital and tested positive for COVID-19. The facility's COVID-19 unit started with the first in-house resident COVID-19 cases on 12/15/21 and three COVID-19 positive residents were moved to the unit. Later that week, the facility allowed COVID-19 positive staff to work the COVID-19 unit per policy. The surveyor requested this policy during the interview. Review of facility contact tracing revealed Resident #74 was the first positive resident on the Chestnut unit on 12/09/21. She had had visitors for her birthday from out of town the weekend prior. Her neighboring residents (she was in a single room) Resident #74 and Resident #32 tested positive on 12/15/21. Additional residents on the unit tested positive on 12/15/21 (Resident #36, Resident #34), 12/18/21 (Resident #30) and 12/22/21 (Resident #31 and Resident #35). Review of additional contact tracing revealed on the Rust unit, Resident #29 tested positive on 12/19/21. Additional positives were on 12/19/21 (Resident #25), 12/22/21 (Resident #28), 12/26/21 (Resident #33. Resident #75 and Resident #76), 12/27/21 (Resident #27). Interview on 12/27/21 at 11:24 A.M. with the DON revealed all the facility policies were on an S-drive on the computer but the previous management company took that when they left the building on 10/29/21. The DON stated it had been a slow transition to the new company and verified no policy regarding allowing COVID-19 positive staff to work was available for review. The DON indicated the Purple unit was the facility's COVID-19 unit which currently had 12 positive residents (Residents #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35 and #36). Interview on 12/27/21 starting at 3:56 P.M. with the DON indicated a COVID-19-line list had just been obtained. STNA #132 was the first COVID-19 positive staff member of the outbreak on 12/09/21 and was the only COVID-19 positive staff working. The DON stated STNA #132 did not come back until 10 days after her positive test result and stated no other COVID-19 positive staff had worked under the 10-day work exclusion period. Further review of the COVID-19-line list provided on 12/27/21 revealed 17 residents (Residents #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #73, #74, #75, #76 and #77) and 12 staff starting with STNA #132 had tested positive for COVID-19 since 12/09/21. STNA #115 was not listed on the line list. Review of staff testing information revealed STNA #132 tested positive for COVID-19 on 12/09/21. A second rapid test was completed on 12/09/21 and was negative. Review of STNA #132's timecard revealed she worked the entire shift from 7:15 A.M. to 7:15 P.M. on 12/09/21 (Thursday) after the initial positive COVID-19 test. STNA #132 returned to work the COVID unit on 12/16/21 (Thursday), day seven after the initial positive test, 12/18/21 (Saturday), day nine after her initial positive test and 12/19/21 (Sunday) day ten after her initial positive test. STNA #132 was not vaccinated per facility documentation. Interview on 12/28/21 at 8:36 A.M. with STNA #132 revealed she had tested positive for COVID-19 on 12/09/21. STNA #132 stated she had symptoms while she was off work from 12/10/21 until 12/15/21 and came back to work the facility's COVID-19 unit on 12/16/21, day seven after her positive COVID-19 result. Phone interview on 12/28/21 at 8:43 A.M. with Local Health Department Cluster Investigator (LHDCI) #188 indicated they recommended staff with a positive COVID-19 test be excluded from work for 10 to 14 days depending on symptoms and to follow up with a PCR test to verify positive results. LHDCI #188 did not recommend COVID-19 positive staff work in the facility and denied contact from the facility requesting to do so due to staffing shortages. Review of staff testing information revealed STNA #115 tested positive for COVID-19 on 12/13/21 (Monday). STNA #115's timecard indicated she was sent home right after the positive test result. The timecard indicated STNA #115 returned to work the COVID unit on 12/17/21 (Friday), day four after testing positive for COVID-19. STNA #115 worked 12/18/21 (Saturday), day five after testing positive; 12/22/21 (Wednesday), day nine after testing positive and 12/23/21 (Thursday), day 10 after testing positive. STNA #115 was not vaccinated per facility documentation. Phone interview on 12/28/21 at 12:33 P.M. with STNA #115 revealed she had tested positive for COVID-19 on 12/13/21 (Monday) and returned to work the facility's COVID-19 unit on 12/17/21 (Friday), day four following her positive COVID-19 result. STNA #115 verified she was not vaccinated and stated she felt fine but thought there was a 10-day isolation period for COVID-19 positive individuals to return to work. Interview on 12/28/21 at 12:56 P.M. with the DON revealed STNA #115 tested positive for COVID-19 and returned to work on day four of her infection and their policy stated they would return to work after 10 days since STNA #115 was unvaccinated. The policy used for this guidance was again requested by the surveyor. Interview on 12/28/21 at 1:10 P.M. with the DON revealed per time punch data, STNA #132 worked her entire shift the day she tested positive for COVID-19. The DON indicated day shift testing would have ended by 4:00 P.M. and did not know why STNA #132 stayed at the facility to work out her shift. Interview on 12/28/21 at 1:13 P.M. with STNA #132 and ADON/LPN #112 revealed STNA #132 was unvaccinated. ADON/LPN #112 stated the first rapid test done on STNA #132 was positive, she did another rapid test and it was negative, so she had STNA #132 return to the floor to work. STNA #132 wanted to get vaccinated against COVID-19 so ADON/LPN #112 called the pharmacy who advised STNA #132 to get a PCR test. STNA #132 got a PCR test on 12/11/21 with positive COVID-19 results back on 12/13/21. ADON/LPN #112 verified STNA #132 came back to work on 12/16/21 and stated this was within guidelines. The policy the facility was using was again requested by the surveyor. Interview on 12/28/21 at 1:20 P.M. with ADON/LPN #112 revealed per the Administrator, the facility was in contingency status. Interview on 12/28/21 at 3:12 P.M. with the DON revealed the facility was following contingency staffing guidelines and verified this was not communicated to the local health department nor was there any documentation to show contingency staffing concerns for surveyor review. There was no documented evidence provided that showed the facility reached out to the state agency (SA), sister facilities or other emergency resources. Interview on 12/28/21 at 4:40 P.M. with the DON revealed the facility would have to be in crisis staffing to call the Ohio National Guard. The facility used agency staff to avoid going into crisis staffing and thus stayed in contingency levels of staffing. The DON indicated there was a period ending in December 2021 when agencies would not come to the facility since the previous management company did not pay the agency bill. The DON provided the policy that the facility was following for guidance. Review of the facility policy, Planning for Additional Staffing Needs, no date, revealed as part of the emergency preparedness process, the facility may establish relationships with other facilities that provide similar care to assess the possibility of cross-training staff from each facility. If staff is used from outside staffing agencies, the staff shall be oriented and trained to provide care for the residents as well as the emergency preparedness plan. The policy was silent to COVID-19 response and allowing staff to work while COVID-positive. Phone interview on 12/29/21 at 1:44 P.M. with Registered Nurse (RN) #123 revealed after testing positive for COVID-19, staff were to come back to work after 10 days. In an email on 12/29/21 at 1:55 P.M., RDO #190 stated the facility currently had two deaths as a result of their COVID-19 outbreak, Resident #74 at another facility and Resident #73 on 12/23/21. Phone interview on 12/29/21 at 4:08 P.M. with LPN #166 revealed it was known two COVID-19 positive staff, STNA #115 and STNA #132 had worked the COVID-19 unit while still positive. Review of the undated facility policy COVID-19 revealed symptomatic healthcare personnel (HCP) with suspected or confirmed COVID-19 shall be excluded from work until at least 72 hours had passed since resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms and at least 10 days had passed since symptoms first appeared. Unvaccinated HCP with laboratory-confirmed COVID-19 who have not had any symptoms shall be excluded from work until 10 days have passed since the date of their first positive COVID-19 test and assumed they have not developed symptoms; if symptoms developed then symptom-based protocol shall commence. Review of CMS memorandum, QSO-20-38-NH revised 09/10/21 revealed staff with symptoms or signs of COVID-19, vaccinated or not vaccinated, must be tested immediately and are expected to be restricted from the facility pending the results of testing. 2. Observations on 12/27/21 from 10:04 A.M. to 10:17 A.M. of the end of the COVID-19 unit also known as the facility's Purple unit revealed fire doors separated the Rust unit from the Purple unit with signage indicating to not enter. Observation of the front entrance to the COVID-19 unit on the other edge of the Purple unit indicated a key code was needed to enter the unit and signage indicated staff needed to stop and don personal protective equipment (PPE) for the COVID-19 unit. No screening area or documentation for staff was noted immediately outside of the COVID-19 unit. Observation on 12/27/21 from 4:40 P.M. to 5:26 P.M. of the interior of the COVID-19 unit revealed no screening area or screening documentation. Interview on 12/27/21 at 4:45 P.M. with STNA #186 indicated since she had not tested positive for COVID-19, she was able to screen in at the front reception area of the facility and then enter the COVID-19 unit at the designated entrance on the edge of the Purple unit. Interview on 12/27/21 at 4:50 P.M. with LPN #187 indicated since he had history of COVID-19 infection, he entered and exited the COVID-19 unit using a separate entrance at the back of the facility located off the Purple unit. LPN #187 denied any screening in place for those entering and exiting directly off the COVID-19 unit and verified he was not screened for signs and symptoms of COVID-19 infection. Interview on 12/28/21 at 8:36 A.M. with STNA #132 revealed no screening was in place for staff with a history of COVID-19 infection that utilized the back door to enter and exit the COVID-19 unit. Phone interview on 12/28/21 at 12:33 P.M. with STNA #115 indicated staff did not screen for COVID-19 signs and symptoms when working on the COVID-19 unit if they entered through the back door. Interview on 12/28/21 at 12:56 P.M. with the DON revealed staff that had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the COVID-19-unit staff were to be screening each other. The DON was made aware there was no mechanism in place for staff screening on the COVID-19 unit and that staff were not self-screening during the interview. Review of the undated facility policy COVID-19 revealed all people who entered the facility were to be screened for signs and symptoms of COVID-19 (temperature checks, questions about and observations of signs/symptoms such as fever, cough, shortness of breath, sore throat, nausea, vomiting, diarrhea, fatigue and malaise). Review of CMS memorandum, QSO-20-39-NH on nursing home visitation, revised 11/12/21 revealed the facility should screen all who enter for positive test for COVID-19, symptoms of COVID-19 or currently meeting the criteria for quarantine. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/21 revealed facilities were to establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: a positive COVID-19 test, symptoms of COVID-19 or who meets criteria for quarantine or exclusion from work Options could include but are not limited to: individual screening on arrival at the facility or implementing an electronic monitoring system which individuals can self-report any of the above before entering the facility. This deficiency substantiates Master Complaint Number OH 545.

Based on observation, record review, and interviews, the facility failed to identify a right heel pressure ulcer until it progressed to being unstageable. The facility also failed to ensure effective pressure reduction measures and techniques were implemented after discovery of a wound on Resident #63's left ischium that was classified as an abrasion. Harm occurred when the abrasion deteriorated to a Stage 3 pressure ulcer. This affected one (Resident #63) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a care plan dated 03/18/17 that addressed the identified concern of activities of daily living deficit with assistance required. Interventions listed included inspect skin condition daily during personal care and report any impaired areas to the charge nurse, and the resident requiring assistance of one person for bed mobility. The care plan interventions included inspect for any reddened areas during daily care, and encourage to turn and reposition every one and one-half hours and as needed. There was no documentation Resident #63 refused to turn and reposition. There was no care plan for an identified concern that Resident #63 was non-compliant with turning and repositioning. There was a care plan dated 04/05/17 for Resident #63's potential for alteration in skin integrity related to poor intake, incontinence and decreased mobility. The care plan interventions included inspect for any reddened areas during daily care, and encourage to turn and reposition every one and one-half hours and as needed. Review of the facility Skin/Wound Tracking Log revealed a deep tissue injury to the right heel on 04/27/17. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as an area that may be intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure at the bone/muscle interface. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, Stage 3 or Stage 4). Review of the wound physician's (Podiatrist #1's) note dated 05/04/17 revealed the right heel wound was necrotic (dead tissue which usually results from inadequate blood supply), and measured 6 centimeters (cm) by 9.5 cm. Weekly wound notes by Podiatrist #1 documented the wound was improving and the resident had good compliance. Podiatrist #1's note dated 07/06/17 documented the wound measured 3.5 cm by 3.3 cm by 0.2 cm and was improved. Review of the facility Skin/Wound Tracking Log revealed an unstageable pressure ulcer to the left ischium dated 05/30/17. The national Pressure Ulcer Advisory Panel defines an unstageable wound as a wound with full thickness skin and tissue loss in which the extent of the damage within the ulcer cannot be confirmed because it is obscured by slough (necrotic/avascular tissue in the process of separating from the viable portions of the body), or eschar (thick, leathery, frequently black or brown tissue that has lost its usual properties and biological activities). Review of the facility Non-pressure Skin Condition Report dated 05/28/17 revealed an abrasion/excoriation to the left buttock. A note dated 06/05/17 documented the wound declined and the physician was notified and was to see the resident on 06/08/17. Review of the Physician #2's note, dated 06/08/17, revealed the physician classified the left ischium as unstageable. The facility Wound/Skin Healing Record dated 06/08/17 revealed the wound was a Stage 3 that measured 4.0 cm by 3.0 cm by 0.5 cm. On 06/15/17 the wound was classified as a Stage 4. On 07/06/16 the wound was classified a Stage 4 and measured 4 cm by 2.0 cm by 2.0 cm. On 07/11/17 at 11:45 A.M., interview with State tested Nursing (STNA) #1, revealed Resident #63 was not able to turn and position herself in bed and required extensive staff assistance to do so. On 07/11/17 at 12:10 P.M., the assistant director of nursing (ADON) who was also the facility wound nurse, verified the above information. The ADON also verified the wound on the left ischium was initially classified as an abrasion and progressed to an unstageable area. On 07/11/17 at 3:10 P.M. the surveyor observed Resident #63's ischium wound with the ADON. The wound measured 4.0 cm by 2.0 cm by 2.0 cm deep. Resident #63 was not able to turn herself without staff assistance. Resident #63 was pleasant and cooperative with the treatment and dressing change. This deficiency substantiates Complaint Number OH 146.

Based on observation, record review and interview, the facility failed to assess a pressure ulcer upon discovery, failed to provide treatments to a wound as ordered by the physician and failed to implement new interventions to prevent a further decline in a pressure ulcer. This resulted in actual harm to Resident #1 who developed avoidable Stage Four (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) pressure ulcers to the sacrum and fourth and fifth toes on the left foot. Harm also occured to Resident #36 who developed avoidable pressure ulcers to both heels that declined to unstageable. The deficient practice affected two (Resident #1 and Resident #36) of four residents reviewed for pressure ulcers. The facility census was 82. Findings Include: 1. Review of the medical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for Resident #1 dated 09/03/14 revealed a problem of potential for skin alteration with interventions including to initiate and continue wound treatments as ordered by the physician and to monitor and document character of wound weekly. Review of a patient wound assessment dated [DATE] revealed Resident #1 was assessed to have a new Stage Four pressure ulcer to the sacrum and left ishium. Review of the medical record for Resident #1 revealed no documentation of an assessment of this wound at the time of the discovery. Review of Treatment Administration Records (TAR) dated September 2014 revealed an order for [REDACTED]. This treatment was discontinued on 10/13/14 and a new order written on 10/14/14 to cleanse the sacral/ishial and the posterior thigh wounds with normal saline/sterile water, pat dry, apply silver alginate, a foam dressing and change daily and as needed. Review of the October 2014 TAR revealed this treatment was not documented as completed on 10/21/14 and 10/26/14. This order was discontinued on 10/28/14 and a new order written to cleanse the sacral/ishial/ left posterior thigh wounds with normal saline/sterile water, apply silver alginate, four by fours and a foam dressing and to change this daily and as needed. Review of the TAR dated October 2014 revealed this dressing was not documented as completed on 10/28/14, 10/29/14, 10/30/14, and 10/31/14. Review of a physician order [REDACTED]. Review a patient wound assessment dated [DATE] revealed Resident #1 was assessed to have wounds (type of wound not described) to the fourth and fifth toes. Review of the October 2014 TAR revealed an order dated 10/28/14 to cleanse the fourth toe of the left foot with normal saline/ sterile water, apply santyl/ silver alginate, a four by four gauze dressing and a foam dressing and to change this dressing daily and as needed. Review of the October 2014 TAR revealed an order dated 10/28/14 to cleanse the fifth toe of the left foot with normal saline/ sterile water, apply silver alginate, a four by four gauze and then a foam dressing and to change this dressing daily and as needed. Review of the October 2014 TAR revealed the treatments to the left fourth and fifth toes were not documented as completed on 10/28/14, 10/29/14, 10/30/14 and, 10/31/14. Interview with LPN #102 on 12/01/14 at 9:26 A.M. verified there was no documentation in the medical record that the treatments to the toes were completed on 10/28/14, 10/29/14, 10/30/14 and 10/31/14 as ordered by the physician. Interview also verified there was no documentation in the medical record to indicate the sacrum and left ischium wound treatments were completed on 10/03/14, 10/21/14, 10/26/14, 10/28/14, 10/29/14, 10/30/14, and 10/31/14. Interview with Licensed Practical Nurse (LPN) #102 on 12/01/14 at 2:34 P.M. verified there was no documentation in the medical record for Resident #1 of an assessment of the wound to the left rear thigh at the time of discovery. Review of a weekly wound report dated 11/10/14 assessed the wound to the left fifth toe to be a stage four pressure ulcer. Review of a weekly wound report dated 11/17/14 assessed the wound to the left fourth toe to be a stage four pressure ulcer. Review of the TAR dated November 2014 revealed the treatment to the sacral/ishial/ posterior left thigh wound was not documented as completed on 11/02/14, 11/09/14, 11/14/14 and 11/23/14. Interview with LPN #102 on 12/01/14 at 9:20 A.M. verified there was no documentation in the medical record for Resident #1 that the treatment was completed on 11/02/14, 11/09/14, 11/14/14 and 11/23/14. Review of the TAR dated November 2014 revealed the treatments were not documented as completed to the left fifth toe on 11/08/14, 11/09/14, 11/11/14, 11/14/14 and the treatment to left fourth toe on 11/08/14, 11/09/14, 11/11/14, 11/14/14, and 11/23/14. Interview with LPN #102 on 12/01/14 at 9:20 A.M. verified there was no documentation in the medical record for Resident #1 that the treatments were completed to the left fifth toe on 11/08/14, 11/09/14, 11/11/14, 11/14/14 and the treatment to left fourth toe on 11/08/14, 11/09/14, 11/11/14, 11/14/14, and 11/23/14. 2. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden Scale assessment for risk of developing pressure ulcers dated 04/14/14 revealed the resident was at moderate risk. Review of the weekly skin grids and weekly skin assessments with ADON #63 on 12/02/14 at 7:40 A.M., revealed the resident sustained [REDACTED]. a. Review of the documentation of the first pressure ulcer revealed it was found on 05/08/14 to the left heel with only a measurement on the 05/26/14 weekly wound grid of 0.4 by 0.3 by 0.1 blister according to the facilities description would be a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister) The intervention was to off load the heels and turn and reposition every two hours. Review of the next weekly wound grid indicated a measurement of 2.6 by 2 blister. The next weekly wound assessment dated [DATE] indicated undermining and tunneling with slough and a scant amount of serous drainage measuring 0.7 centimeters (cm) by 0.4 cm by less then 0.1 cm. according to the facility's description was a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) discovered on 06/16/14. The intervention was to turn and reposition every two hours and float the heels. Review of the next weekly wound assessment dated [DATE] indicated measurement of 2.0 cm by 1.0 cm by less than 0.1cm with 100 percent eschar present which indicated unstageable. The next weekly wound assessment dated [DATE] indicated measurement of 2.0 cm by 1.5 cm by less than 0.1cm with 100 percent slough and scant amount of serous drainage. The intervention was to turn and reposition every two hours and float the heels. The resident left the faciity on [DATE] and returned on 07/22/14. The resident returned with the above left heal pressure ulcer and additional various stages of pressure ulcers to the buttock area. b. Review of the weekly wound report dated 08/04/14 revealed the resident developed an in house pressure to the right heel measuring 0.5 cm by 1.0 cm suspected deep tissue injury. The interventions was pad and protect with foam pad and prevalon boots while in bed. Review of the 08/04/14 weekly wound report revealed the continued with the stage II left heel measuring 0.5 cm by 0.7 cm showing [MEDICATION NAME] tissue 90 percent and 10 percent granulated tissue present. The intervention was to off load heels and turn and reposition every two hours. Review of the weekly wound report dated 08/11/14 for the right heel revealed the intact blister measuring 1.7 cm by 2.2 cm. The interventions were to off load heels and turn and reposition every two hours. Skin prep and pad and protect with foam dressing. No staging on assessment. Review of the 08/11/14 weekly wound report dated 08/11/14 for the left heel revealed measuring 0.4cm by 0.3 cm by 0.1cm Stage II with [MEDICATION NAME] tissue 100 percent. The interventions was off load heels, turn and reposition every two hours. Skin prep and pad and protect daily with foam dressing prevalon boots at all times when in bed. There were no further assessments or wound grids until a weekly wound assessment was completed on 09/04/14 and a weekly wound grid was completed on 09/08/14. Review of the weekly wound assessment dated [DATE] for the right heel revealed it was unstageable and measured 1.8 cm by 2.0 cm. The intervention was off load heels and turn and reposition every two hours. Review of the weekly wound report dated 09/04/14 for the left heel, not staged measuring 0.5 cm by 0.5 cm by 0.1 with [MEDICATION NAME] tissue 100 percent under comments resolved week two and scabbed. Intervention off load heels and turn and reposition every two hours. No weekly wound reports assessments after 09/04/14 until 11/10/14. Review of the wound grids dated 09/22/14, 09/29/14, 10/06/14 and 10/13/14 revealed the resident had a pressure area on the right heel that was declining. c. Review of the wound grid dated 10/20/14 revealed a new in house pressure ulcer described as a scab measuring 0.7 cm by 1.0 cm was found to be unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined) and the right heel was declining. There were no weekly wound assessment for this new area until 11/10/14. Review of the wound grid dated 10/27/14 revealed a right outer ankle declining and right heel blister declining. Review of the wound grid dated 11/03/14 revealed a right outer ankle declining 0.5 cm by 0.5cm by 0.1cm with drainage. Review of the weekly wound assessment 11/10/14 which indicated an unstageable right outer ankle measuring 0.6 cm by 0.5 cm by 0.2 cm with 100 percent granulated tissue present. No interventions were marked. No assessment for the right heel was completed. Review of the weekly wound assessment dated [DATE] revealed a right ankle measuring 0.6 cm by 0.5 cm by 0.2 cm with wound bed visible and 100 percent granulated tissue present. No interventions were marked. Review of the current skin care plan revealed altered skin integrity due to history of skin breakdown, decreased mobility and incontinence. Interventions included: -Administer treatment to area as ordered and monitor for effectiveness. -Assess and document wound size, depth, color, and drainage present at least weekly. -Monitor nutritional status and provide supplemental protein, minerals, vitamins as ordered to promote wound healing. -Pressure reducing devices to bed and chair. Review of the physician's orders [REDACTED]. On 11/25/14 at 11:00 A.M., the resident was observed sleeping in bed with the white tennis shoes on and heels not floated off bed. On 11/26/14 at 2:08 P.M., the surveyor observed RN #103 transfer the resident from the wheelchair into bed, remove the residents white tennis shoes and place her heels on the bed. On 12/01/14 at 1:40 P.M., the resident was observed in bed on her back with socks on the heels on bed. On 12/01/14 at 1:45 P.M., interview with STNA #58 verified the residents heels were not floated and were on the bed. On 12/01/14 at 1:50 P.M., interview with the DON verified the above observations and interviews and verified the residents heels were not floated while in bed as planned. The DON verified the skin assessments and/or grids were not completed weekly to monitor the pressure ulcers. 12/2/14 at 7:25 A.M., the resident was observed in the wheelchair in common area with white tennis shoes on and a four by four bandage observed under sock to right outer ankle. On 12/02/14 at 8:45 A.M., interview with ADON #63, and review of all the above assessments and/or grids revealed the lack of the consistent weekly assessments and/or grids. ADON #63 verified the staging on the assessments did not accurately reflect the facility's descriptions as indicated on the assessments. ADON #63 verified lack of skin assessments on shower days as indicated on the TARs. ADON #63 verified the family bought the resident a new pair of shoes in October 2014 and that was thought to be the cause of the right outer ankle pressure ulcer. The resident currently wore newer looking white tennis shoes. ADON #63 could not verify those were not the shoes that may have caused the pressure ulcer. ADON #63 verified the skin car plan did not indicate anything about the shoes. The facility was not able to provide documentation the resident was not wearing the shoes thought to have caused the right ankle pressure ulcer. ADON #63 verified the skin care plan was not up to date to include all pressure areas and was not specific to the resident. This deficiency substantiates Complaint Number OH 071.

Based on record review, resident and family interview and staff interview the facility failed to ensure that ordered indwelling catheter care was done for Resident #35 who developed a urinary tract infection. This affected one resident of three residents reviewed for indwelling catheter, and had the potential to affect the twelve residents in the facility with an indwelling catheter. The harm occured with development of urinary tract infections and the lack of proper and timely cateter care. Findings include: Resident #35 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a long term indwelling urinary catheter (Foley) in place. There was a physician order [REDACTED]. There was a physician order [REDACTED]. Review of the resident ' s treatment administration record (TAR) for March, 2013 documented the Foley drainage bag and tubing were changed on 03/11/13 but not as scheduled on 03/25/13. The TAR for April, 2013 indicated the drainage bag and tubing were changed on 04/07/13 and on 04/11/13 and not changed again in April. The TAR for May, 2013 indicated the drainage bag and tubing were changed on 05/04/13 and 05/24/13 as scheduled. The TAR for June, 2013 indicated the drainage bag and tubing were not changed during the month of June. The TAR for July, 2013 indicated the drainage bag and tubing were not changed during that month. The TAR for August, 2013 indicated the drainage bag and tubing were changed on 08/11/13 and 08/25/13. There was a urinalysis and urine culture obtained 08/12/13 that were positive for a urinary tract infection. The resident was placed on anti-biotic therapy for the infection. On 09/12/13 at 10:10 A.M. the above information was verified with the facility director of nursing and the corporate nurse. On 09/11/13 at 3:15 P.M. the surveyor interviewed the resident and the resident ' s spouse. The resident ' s spouse stated that the Foley care was not provided every two weeks as ordered. The drainage bag and tubing were not changed from May 24, 2013 until August 11, 2013. This deficiency substantiates Complaint Number OH 730.

Based on record review and interview the facility failed to ensure nutritional supplements were initiated in a timely manner, failed to ensure Resident #63 received supplements as ordered and failed to ensure nutritional interventions were in place to prevent Resident #63 from sustaining a severe weight loss of eight percent in one month. This affected one resident (Resident #63) of four residents reviewed. The facility census was 92. Findings include: Resident #63 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's weight history was reviewed. The admission weight of 05/30/13 was 192 pounds. On 07/23/13, the resident weighed 188.5 pounds. This constitued a 3.5 pound weight loss. Between 07/23/13 and 08/15/13 the resident was noted to sustain a 9.5 pound weight loss. (from 188.5 pounds to 179 pounds). The dietary note of 07/03/13 at 5:19 P.M. identified the weight was 193 pounds. New skin issues included a deep tissue injury to right outer ankle, foot, fifth toe and left heel. Estimated nutritional needs to promote wound healing included 2200-2600 kilocalories and 110-120 grams (gm) of protein. The dietician recommended the initiation of a nutritional supplement, two ounces of Two Cal med pass, to be given three times day between meals for an additional 15 grams protein and 360 calories. Record review revealed the supplement recommendation, made on 07/03/13 was not ordered until 07/09/13, six days after the recommendation had been made. On 07/08/13, the medical record reflected Resident #63 developed new skin issues. On 7/11/13, the dietary note documented this weeks weight as 189 pounds with 72% average oral intakes. Skin status improving. Diet order is pureed low cholesterol with Two Cal, two ounces three times a day. The recommendation was to continue current medical nutrition therapy (MNT) and continue to follow weekly weights. Review of the July 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no evidence the supplement was given as ordered from 07/13/13 to and including 07/31/13. The record did not reflect any reason the supplement was not provided. Interview with licensed practical nurse (LPN) #6 on 08/15/13 at 12:45 P.M. verified the times and dates the supplement of Two Cal, two ounces was not adminstered as ordered from 07/13/13 to 07/31/13. LPN #6 verified the lack of documentation as to why the supplement was not provided as ordered. Review of the August 2013 MAR indicated [REDACTED].M. The documentation for 08/13/13, 08/14/13 and 08/15/13 revealed the supplement was not given three times a day as ordered and further verified by LPN #6. Review of the dietary note dated 07/23/13 revealed there was a recommendation to continue a supplement to promote wound healing. The note indicated the resident's intake was less than 75 percent. On 07/23/2013 at 11:59 A.M., the dietary note indicated the resident weighed 188.5 pounds. Intakes were noted to be 66 percent. The resident's estimated dietary needs were calculated to be 2150 calories and 68-85 grams of protein. On 07/23/13 the nurse practitioner wound consultant assessed the resident and determined the skin condition was deteriorating. Review of laboratory testing dated 08/05/13 documented a low [MEDICATION NAME] level of 2.5 mg/dl (normal range per lab report 3.4-5.0). Review of the 08/09/13 dietary note indicated to discontinue the Two Cal supplement and change to Ensure. On 08/09/13 the dietary note indicated the dietician met with the resident's niece to discuss oral supplements for the resident. Average oral intakes of 68 percent were noted. The dietary progress note recommended to discontinue the supplement of Two Cal and change to Ensure or Ensure Clear and to administer the supplement daily at 2:00 P.M. and at bedtime. This new supplement would provide an extra 18 grams protein and 500 calories. The dietary recommendation for the nutritional supplement, made on 08/09/13 was not ordered by the physician until 08/14/13; five days after the recommendation. On 8/14/2013 at 5:40 P.M., the dietary note indicated the dietician reassessed the resident. The note indicated the resident had a significant weight loss in one month. The current August body weight was noted to be 175 pounds and a July weight was 189 pounds. The note indicated the weights showed a loss of 8% in one month. Average oral intakes were noted to be 69% and the oral intake was noted to be 'fair'. The resident's nutritional needs were re-estimated for weight repletion/wounds and noted to be 2386-2784 calories, 95-119 grams protein/day and 2400 milliliters's fluid/day. The dietary note indicted the Two Cal supplement was changed to Ensure and was to be given at 2:00 P.M. and in the evening for an extra 18 grams protein and 500 calories. The note indicated the resident was taking supplements fair to good. The recommendation was made at that time to increase the Ensure supplement to three times a day for a total of 750 extra calories and 27 grams protein. Additionally, it was recommended one ounce liquid protein supplement to be given one time a day for an extra 15 grams protein and 101 calories. The medical record reflected the Ensure supplement was documented as being taken only one time at 7:00 P.M. on 08/14/13 instead of the ordered twice daily. Additionally, the amount consumed was not documented. This deficiency substantiates Complaint Number OH 401.

Based on medical record review, staff interview, review of facility policy and procedures, review of hospital laboratory results, review of facility's laboratory results and review of Laboratory Diagnostic Tests with Nursing Implications, 5th Edition, the facility failed to monitor therapeutic blood levels for one (Resident #97) of three sampled residents who received oral and injectable anticoagulant (blood thinning) therapy. This resulted in Immediate Jeopardy for Resident #97 who received both anticoagulant medications for eight (8) days with only one laboratory test completed to monitor for therapeutic blood levels. Eighteen of 94 residents were receiving anticoagulant therapy at the time of the survey. On [DATE] at 2:30 P.M., the administrator, director of nursing (DON), director of operations Registered Nurse (RN) #1 and the corporate director of quality assurance & risk management were notified that Immediate Jeopardy began on [DATE] when the facility failed to implement a physician order to monitor Resident #97's [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) blood levels every day until the INR was greater than 2.0, then every Monday and Thursday. Resident #97 continued to receive the anticoagulant medication [MEDICATION NAME] 5 milligrams (mg) daily for seven (7) days and daily subcutaneous injection of the anticoagulant medication [MEDICATION NAME] without PT/INR blood monitoring. On [DATE] at 10:30 P.M., the resident became "very lethargic" with short labored breathing and then became unresponsive. She was transferred to the emergency department. At the emergency department, the resident was found to have a brain bleed and a critically high INR level above 9.0 (therapeutic range was 2.0 to 3.0). The resident was transferred to a hospital where she expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: -On [DATE], the DON, assistant director of nursing (ADON) and the director of operations RN #1 audited the medical records of all residents to ensure every resident on anticoagulant therapy had current physician and laboratory orders, including PT/INR; that the laboratory blood work results were being obtained as ordered and the physician was being notified of the results. -On [DATE], the DON, ADON and director of operations RN #1 verified that all 18 residents who were on anticoagulant therapy had a current "Anticoagulant Precautions" form and a current "Anticoagulant Flow Sheet" placed in their Medication Administration Record. There were no other residents identified who were not receiving their anticoagulant therapy and PT/INR blood levels as ordered. -On [DATE], the facility implemented a new "Anticoagulant Alert" form that was to be completed whenever a resident was admitted with or had a new order for an anticoagulant; the form was to notify the nursing management team to audit the resident's record to verify the anticoagulant order and orders for PT/INR were on the resident's MAR indicated [REDACTED] "Anticoagulant Flow Sheet" was also implemented to verify that laboratory results were obtained. -On [DATE], the facility implemented the use of notification stickers on medical records of residents who were ordered to receive anticoagulant therapy as a reminder for the nurse to verify the current order and laboratory results. -On [DATE], the facility's pharmacy audited laboratory results for every resident in the facility to verify there was a current physician's order that matched the laboratory orders they had in their system. The pharmacy also audited laboratory orders to ensure they were completed as ordered with special emphasis on residents on [MEDICATION NAME] therapy. Although the Immediate Jeopardy was removed when the facility reassessed the 18 current residents receiving anticoagulant therapy to ensure all required lab tests were obtained as ordered, and residents were free of signs and symptoms of bleeding, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: -On [DATE] and [DATE], Licensed Practical Nurses (LPNs) #106, #115 and #116 who worked on Resident #97's unit from [DATE] through [DATE], received disciplinary warnings for failure to verify that Resident #97 had a PT/INR drawn as ordered, and continued to administer [MEDICATION NAME] and/or [MEDICATION NAME] injections to Resident #97 without PT/INR results and physician notification. -On [DATE], [DATE] and [DATE], the DON and ADON conducted mandatory in-service training for all licensed nursing staff regarding anticoagulant medications, risk factors, PT/INR laboratory testing, and the use of the "Anticoagulant Precautions" form, the "Anticoagulant Flow Sheet" and the "Anticoagulant Alert" form monitoring tools. As of [DATE] all 32 licensed nursing staff had completed the mandatory in-service regarding anticoagulant therapy. -On [DATE] from 2:30 P.M. through 8:30 P.M., LPNs #102, #103, #104, #105, #106, #107, #108, #109, #110 and #111 were interviewed and demonstrated knowledge of the facility's new "Anticoagulant Precautions" form, "Anticoagulant Alert" form, and "Anticoagulant Flow Sheet" form and their responsibilities for checking for laboratory values of PT/INR's prior to the administration of [MEDICATION NAME] to the residents and monitoring residents receiving anticoagulant therapy. -On [DATE] and [DATE], review of medical records for Residents #53, #58, #40, #35, #79, #59, #71, #98, #82, #60, #77 and #12 revealed "Anticoagulant Precautions" forms, "Anticoagulant Flow Sheet" forms and "Anticoagulant Alert" forms had been implemented and all required lab tests were obtained as ordered. Findings include: Review of Resident #97's medical record revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician's orders dated [DATE] revealed Resident #97 was to receive [MEDICATION NAME] 5 milligrams (mg) every day. According to Laboratory Diagnostic Tests with Nursing Implications, 5th Edition, pages ,[DATE], [MEDICATION NAME] is an oral anticoagulant to decrease the clotting process, and the INR blood test was devised to more precisely monitor the effect of [MEDICATION NAME] therapy on a person's blood clotting ability. The [DATE] physican's orders included an order for [REDACTED]. Resident #97's interim plan of care for anticoagulation therapy dated [DATE] included the goal that the resident would be free from uncontrolled bleeding. Interventions to accomplish this goal included to administer anticoagulant medications as ordered by the physician; monitor for signs and symptoms of abnormal bleeding, including dark black stools and coffee ground emesis, notify the physician if abnormal bleeding occurred; obtain PT/INR blood tests as ordered; notify the physician of the results; and the resident was to use a soft toothbrush to prevent the gums from bleeding. Review of Resident #97's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also received the [MEDICATION NAME] injections every twelve hours from [DATE] through [DATE], for 15 doses. PT/INR test results dated [DATE] were found in Resident #97's medical record. The INR results were 1.1 on [DATE]. No further PT/INR's were completed for the resident and the [MEDICATION NAME] 5 mg and [MEDICATION NAME] 120 mg medications continued to be given daily to the resident. Nursing notes dated [DATE] at 5:45 A.M., written by the night shift nurse LPN #106, revealed Resident #97 had a shower and was found with "multiple bruises on arms and abdomen from [MEDICATION NAME] injections. Will continue to monitor." Nursing notes dated [DATE] at 4:00 A.M., written by LPN #106, revealed Resident #97 responded to verbal stimuli, was "lethargic" but arousable. The resident stated she was "just not feeling well." Nursing notes dated [DATE] (no time indicated), written by LPN #106, revealed the resident was "very lethargic" and was "too sleepy to go" to a doctor appointment on [DATE]. A call was placed to the physician. The physician ordered all medications put on hold for [DATE] and to call the physician in the morning to report the resident's condition. Nursing notes dated [DATE] at 9:30 A.M., written by the day shift nurse LPN #109, indicated the resident was very lethargic and complained of "general malaise." Nursing notes dated [DATE] at 10:30 P.M., written by the evening shift nurse LPN #110, revealed the resident had short labored breathing. The resident's temperature was 100.5 degrees Fahrenheit (F) (normal temperature=98.6 degrees F). Physician #1 was notified and Resident #97 was sent to the hospital emergency department. Review of a hospital laboratory Result Detail form dated [DATE] revealed a PT/INR blood test was drawn on Resident #97 at 11:30 P.M. in the hospital's emergency department. The PT/INR results were critical (greater than 9.0). During interview with the DON on [DATE] at 2:00 P.M., she stated the facility received a telephone call from Resident #97's family (unspecified) on the morning of [DATE]. She stated the family said the resident had a "brain bleed" and had expired in the hospital. On [DATE] at 2:55 P.M., during interview with State tested Nurse Aide (STNA) #112, she stated that she worked the day shift on [DATE]. She stated that Resident #97 "was not my resident" but she saw a student nurse feeding breakfast to the resident. She stated the resident was unable to feed herself as she usually did. She stated "she (the resident) would not eat any lunch or drink anything." She stated "we put her back to bed after lunch; it took three of us to put her back because the resident was unable to help us at all." "She (the resident) was not herself. I didn't know what was going on with her." On [DATE] at 3:00 P.M., during an interview, STNA #113, who worked a double shift on [DATE] from 7:00 A.M. through 11:30 P.M., stated she was assigned to Resident #97 during both shifts. She stated the resident was "real lethargic all day" , unable to feed herself and was "really too drowsy to do anything." She stated the resident would not eat any lunch or supper or drink any liquids. She stated "she was not herself, something was wrong with her." On [DATE] at 3:10 P.M., interview of STNA #114 revealed that he came into work on [DATE] during the evening shift. He stated that Resident #97 was in bed all shift. He stated "they told me in report that she was not right." He stated "we did frequent checks on the resident" and during the last rounds the resident had "labored breathing." He stated "I went and got the nurse and then she went to the hospital." On [DATE] at 6:10 P.M., during a telephone interview with LPN #109 who worked the day shift on [DATE], she stated Resident #97 "was so lethargic." She stated "I asked the night shift nurse what was wrong with her." She stated "I paged the doctor about 8:30 A.M., and he put all her medications on hold and ordered for some blood work to be done." She stated the resident had an appointment that morning but was so lethargic she was unable to go and "I had to cancel it." She stated "I couldn't send her out to an appointment like that, she was too lethargic." On [DATE] at 7:00 P.M., the surveyor received a telephone call from LPN #110 who worked the evening shift of [DATE]. LPN #110 stated that all Resident #97's medications were held on [DATE] because she was "too lethargic." When questioned as to why she did not call the physician again, she stated "it was my understanding that the doctor knew she was lethargic and told us to monitor her." She stated "after supper the resident had respiratory issues and then I called the doctor." She stated that " this was my second day of orientation in the facility." Review of the facility's "Employee Counseling/Disciplinary Action Documentation" dated [DATE] revealed LPNs #115 and #116 received written warnings because they did not verify Resident #97's INR was completed prior to the administration of [MEDICATION NAME] to the resident. On [DATE], LPN #106 received a written warning because she did not verify that Resident #97 had a PT/INR drawn as ordered prior to the administration of [MEDICATION NAME] and/or [MEDICATION NAME] injection to Resident #97. Review of the facility policy and procedure "Administration of [MEDICATION NAME] and Maintaining The [MEDICATION NAME] Log" revised [DATE] revealed the following procedure: 1. A valid order for [MEDICATION NAME] must be received prior to administration. 2. If the ordered dose is outside the usual recommended dose, the nurse will confirm the dose ordered with the physician prior to administration. 3. Every resident receiving [MEDICATION NAME] must have an order for [REDACTED]. 4. A PT/INR will be drawn as ordered by the physician/CNP and notified of the results in a timely manner. 5. PT/INR results should be reviewed with the physician/CNP and a specific order obtained regarding maintaining/adjusting the dose or holding scheduled doses prior to administration of the next scheduled dose of [MEDICATION NAME]. 6. It is the responsibility of a nurse to know the results of the most recent PT/INR and the current dose of [MEDICATION NAME] ordered prior to administering a dose of [MEDICATION NAME] to the resident. 7. Nursing staff will note if signs of potential adverse drug events occur. 8. If signs of possible adverse drug events occur the physician/CNP will be notified. This deficiency substantiates Complaint Number OH 003.