Every finding on record at Springs of Lima the

Based on record review, observation, staff interview, and policy review, the facility failed to ensure medications were not prepared prior to administration. This affected three (#03, #04, and #13) out of three residents reviewed for medication administration. The facility census was 54. Findings include: 1. Review of the medical record for Resident #03 revealed an admitted [DATE] with medical diagnoses of anemia, thrombocytopenia, morbid obesity, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the medical record for Resident #03 revealed an admission assessment dated [DATE] which indicated Resident #03 was cognitively intact. Review of the medical record for Resident #03 revealed a Functional Abilities assessment, dated 10/28/24, which revealed Resident #03 required set-up assistance with eating, toilet hygiene, bathing, bed mobility, and transfers. 2. Review of the medical record for Resident #04 revealed an admitted [DATE] with medical diagnoses of Alzheimer's disease, atrial fibrillation, hypertension, and depression. Review of the medical record for Resident #04 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/01/24, which indicated Resident #04 had severe cognitive impairment and required partial/moderate staff assistance with bathing, bed mobility, and transfers, and supervision with toilet hygiene. 3. Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of chronic respiratory failure, spinal bifida, depression, anxiety, and bipolar disorder. Review of the medical record for Resident #13 revealed a quarterly MDS assessment, dated 08/08/24, which indicated Resident #13 was cognitively intact and required substantial/maximum staff assistance for toilet hygiene, bathing, bed mobility and transfers. Observation with interview on 11/01/24 at 9:03 A.M. revealed Licensed Practical Nurse (LPN) #200 was standing at the medication cart on 400 Hall with three medication pill cups filled with medications sitting on top of her cart. The observation revealed each medication cup was labeled with Resident #03, #04, and #13 names. Interview with LPN #200 confirmed she had prepared the medications for Resident #03, #04, and #13 while standing at the nurse's station and stated she was going to bring the medications to the resident's rooms. Review of the facility policy titled, Medication Administration, revised November 2018 stated medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. The policy stated when mediations are administered by mobile cart and taken to the resident's location (room, dining room, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to ensure care and treatment of a resident's colostomy was provided. This affected one (#16) of one resident reviewed for colostomy care. The census was 55. Findings included: Review of the medical record for Resident #16 revealed an admitted [DATE]. The resident was admitted with a diagnosis including the encounter for attention to a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was assessed with intact cognition and an ostomy. Review of Resident #16's admission physician orders from 04/19/24 were absent for care of the colostomy. Further review revealed orders for care and treatment of the colostomy were not initiated until 05/24/24 which included to burp and empty the colostomy bag and wafer every three days and as needed when soiled and dislodged. On 05/26/24, Resident #16 received an order for staff to apply Adapt stoma powder topically with special instructions to use as needed on the skin around the stoma when the colostomy bag was changed. There was no evidence of care or treatment to Resident #16's colostomy until the initiation of the orders. Interview with Regional Nurse #600 on 08/15/24 at 1:30 P.M. verified Resident #16 did not have orders for care and services of the colostomy until 05/24/24 and there was lack of documentation of colostomy care in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00156307.

Based on medical record review and staff interview, the facility failed to ensure a care plan was initiated to address care and services for a resident with a respiratory infection. This affected one (#15) of three reviewed for respiratory infections. The census was 55. Findings included : Review of the medical record for Resident #15 revealed an admitted [DATE]. The resident was admitted with diagnoses including rhabdomyolysis and pulmonary fibrosis. The resident was discharged on [DATE]. Review of a chest x-ray image for Resident #15 dated 06/04/24 revealed there were bilateral opacities which may represent multifocal infectious process, to include viral agent with out pleural effusion. Review of physician orders for Resident #15 revealed an order dated 06/05/24 for the antibiotic Zithromax (azithromycin) 500 milligrams (mg) to give one tablet orally with special instructions give for three days and once a day. Review of Resident # 15's care plan revealed there was no care plan initiated to include care and services, with measurable objectives, for the treatment of the resident's respiratory infection. Interview with Regional Nurse #600 on 08/15/24 at 1:30 P.M. verified there was not a care plan initiated for Resident #15's respiratory infection which occurred on 06/04/24. This deficiency represents an incidental finding discovered during investigation of Complaint Number OH00156307.

Based on observation, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure medications were taken by the resident when administered and administered as ordered. This one (#13) of three residents reviewed for medications. The census was 55. Findings included: Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included acute kidney failure, syncope and collapse, orthostatic hypotension, congestive heart failure, and anemia. Review of Resident #13's admission physician orders from 08/09/24 revealed the resident was ordered the stool softeners Colace 100 milligrams (mg) and Citrucel one tablet by mouth, the antidepressant fluoxetine 40 mg by mouth, the pain medication gabapentin 600 mg two tablets by mouth, a probiotic tablet by mouth, the vitamin Foltx 2.6/25/2 mg one tablet by mouth, the pain medications Mobic 7.5 mg one tablet by mouth and tramadol 50 mg one tablet by mouth, the blood pressure medication metoprolol 25 mg one tablet by mouth, and the medication to treat an overactive bladder oxybutynin 10 mg one tablet by mouth. Further review of the physician order for gabapentin 600 mg two tablets by mouth revealed the order was discontinued on 08/12/24. Observation on 08/14/24 at 9:48 A.M. revealed on Resident #13's bedside table was a medication cup filled with medications. Further observation revealed no staff members in Resident #13's room. Interview with Resident #13 on 08/14/24 at 9:48 A.M. verified the nurse gave the resident the medication to be taken with his meal and the nurse had left them on the bedside table. Resident #13 stated he had dropped the medications on the floor and the person who brought the breakfast tray in picked them up and placed them back into the cup. Interview with License Practical Nurse (LPN) #200 on 08/14/24 at 9:51 A.M. verified she left the medications on the bedside for Resident # 13 so the resident could take the medication with breakfast. LPN #200 stated she administered 11 tablets to Resident #13 including one Colace 100 mg tablet, one Citrucel tablet, one fluoxetine 40 mg tablet, two gabapentin 600 mg tablets, one probiotic tablet, one Foltx 2.6/25/2 mg tablet, one Mobic 7.5 mg tablet, one tramadol 50 mg tablet, one metoprolol 25 mg tablet, and one oxybutynin 10 mg tablet. Interview with Regional Nurse #600 on 08/14/24 at 3:00 P.M. verified LPN #200 administered Resident #13 the resident gabapentin 600 mg in error due the medication being discontinued on 08/12/24. Review of the facility policy titled, Medication Administration - General Guidelines, revised January 2018, revealed medications are administered in accordance with written orders of the prescriber. The resident is always observed after administration to ensure that the dose was complete ingested. This deficiency represents an incidental finding discovered during investigation of Complaint Number OH00156307.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to change a resident's diet to a therapeutic diet as recommended by a dietician. This affected one (#10) of five residents reviewed for diets. The facility census was 46. Findings include: Review of Resident #10's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included acute kidney failure, type II diabetes, hydronephrosis (excess fluid in the kidney), ulcerative colitis, and enterocolitis due to clostridium difficile not specified as recurrent. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #10 was moderately cognitively impaired. Resident #10 required limited assistance with bed mobility, transfer, and dressing. Resident #10 required extensive assistance with toilet use and personal hygiene. Resident #10 displayed no behaviors during the review period. Review of Resident #10's care plan discontinued 06/01/23 revealed supports and interventions for effective communication, discharge plan to return home following the completion of therapy services, impaired skin integrity and nutrition risk. The supports and interventions for nutritional risk included to assist with meals as needed, dietician to re-evaluate as indicated, offer alternate food and beverage items as needed, and provide diet, supplements, medications, and adaptive equipment as ordered. Review of Resident #10's admission paperwork from the hospital dated 05/18/23 revealed Resident #10 was to be on a diabetic carbohydrate controlled diet. Review of Resident #10's physician orders revealed an order dated 05/19/23 for a regular diet with thin liquids. Review of the medical record revealed, on 05/22/23, it was noted Resident #10 was evaluated by the physician with Resident #10's daughters at the resident's bedside during the evaluation, and reported Resident #10 was not eating his dinner, was not getting what he ordered, and could not eat the things the facility brought to him. Resident #10 indicated the food items the facility provided to him raised his blood sugar levels too much. The physician noted the concerns would be brought to the nursing department's attention, and documented it was thought Resident #10 was having trouble ordering food for himself. Review of a progress note dated 05/23/23 revealed a nutritional assessment was completed by the dietician. It was noted Resident #10's diet order was for a regular diet with thin liquids. Resident #10's intakes were documented to be between 50 percent (%) and 100% of all meals since admission. It was recommended Resident #10 be changed to a controlled carbohydrate diet to help support his overall blood sugar level. Review of Resident #10's nutrition assessment dated [DATE] revealed Resident #10 was on a regular diet. The dietician recommended Resident #10 be changed to a controlled carbohydrate diet to help support blood sugar levels; however, no diet change was found in the medical record. Further review of Resident #10's medical record revealed no diet order changes were found, and Resident #10 continued to receive a regular diet. Interview on 07/06/23 at 9:04 A.M., with the Director of Nursing (DON) verified Resident #10's diet order from the hospital documentation dated 05/18/23 was not the diet order that was implemented at the facility on admission. The DON verified there were no adjustments made to Resident #10's diet order following the dietician's recommendation for a change on 05/23/23. Review of the facility policy titled, Diet Order Communication- Nursing to Dining, revised 12/31/22, revealed it was expected the communication of diet orders between nursing and the dietary department take place. Nursing was to input physician prescribed diet orders into the electronic health record (EHR). The physician diet orders in the EHR were to be compared weekly in the dining tray card system to insure consistency. This deficiency represents non-compliance investigated under Master Complaint Number OH00143265 and Complaint Number OH00143071.

Based on medical record review, observations, staff interviews, and review of the facility's policy, the facility failed to ensure a resident's fall interventions were in place as care planned. This affected one (#37) of four residents reviewed for falls. The facility census was 45. Findings include: Review of the medical record revealed Resident #37 was initially admitted to the facility on [DATE] with a re-entry on 08/30/22. Diagnoses included [CONDITION(S)], fracture of left wrist and hand, subsequent fracture with routine healing, strain of unspecified muscle, muscle weakness, difficulty in walking, weakness, lack of coordination, [CONDITION(S)], [CONDITION(S)] with behavioral disturbance, or [CONDITION(S)]. Review of the Minimum Data Set (MDS) assessment, dated 08/04/22, revealed Resident #37 was severely cognitively impaired. Resident #37 required limited one person assistance with bed mobility, transfers, walking in resident room, dressing, toilet use, and personal hygiene. Resident #37 had a history of falls. Review of the care plan, last updated on 08/30/22, revealed Resident #37 was at risk for falling with interventions including to keep the call light in reach. Observation on 09/07/22 at 8:40 A.M. revealed Resident #37 sitting in her recliner chair in the resident's room. Resident #37's call light was near the head of the bed and not within reach of Resident #37. Interview on 09/07/22 at 8:56 A.M. with Dietary Corporate Manager #293 verified the call light was not within reach of Resident #37. Observation on 09/08/22 at 10:28 A.M. revealed Resident #37 sitting in a wheelchair in the resident's room with the breakfast meal in front of her on the bedside table. The adaptive call light was on the bed near the head of the bed, out of reach of Resident #37. Interview on 09/08/22 at 10:51 A.M. with Registered Nurse (RN) #261 verified Resident #37's call light was not accessible to Resident #37. RN #261 verified Resident #37 does utilize the call light at times but was not always compliant. Observation on 09/12/22 at 7:53 A.M. revealed Resident #37 sitting in the wheelchair in the resident's room with the call light observed near the head of the bed and not within reach of Resident #37. Interview on 09/12/22 at 9:29 A.M. with RN Regional Support #290 revealed Resident #37 often transfers by herself and falls have occurred when Resident #37 transferred independently. Observation on 09/12/22 at 9:31 A.M. revealed Resident #37 was sitting in her recliner in the resident's room with the resident room light on and the breakfast meal tray on the bedside table near the resident. The call light was observed in the same position as the earlier observation, near the head of the bed, inaccessible to Resident #37. Subsequent interview with RN Regional Support #290 verified the call light was out of reach for Resident #37 and the facility staff had recently been in the resident room to deliver the meal tray. Review of the facility's policy titled Guidelines for Answering Call Lights, dated 05/11/16, revealed facility staff are to ensure the call light is plugged in securely to the outlet and in reach of the resident.

Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure resident weights were obtained as physician ordered. This affected one (Resident #40) of three residents reviewed for weight changes. The census was 45. Findings include: Review of Resident #40's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 07/06/22 revealed Resident #40 had a potential for complications of congestive heart failure with an intervention to obtain weight as ordered. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 08/09/22 and a new order was written dated 08/09/22 to weigh Resident #40 daily and notify the physician of weight gain of two pounds (lbs.) a day or three to five pounds a week. Review of Resident #40's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40's weights were consistently obtained in September 2022. Review of the most recent dietician assessment dated [DATE] revealed Resident #40 displayed significant weight gain between 06/30/33 and 08/30/22 with her weight initially down from Resident #40's normal and trending back up over the last month. Resident #40's weight gains were likely attributed to improved intakes since admission as well as [CONDITION(S)] to the bilateral lower extremities which Resident #40 recently had diuretics adjusted to treat the [CONDITION(S)]. Resident #40's meal intakes were noted between 75 percent (%) and 100% during the review period. Interview on 09/07/22 at 10:57 A.M. with Resident #40 stated her appetite was good and she was eating enough for her at each meal. Resident #40 stated the physician started her on diuretic medications to lessen her [CONDITION(S)] and it was causing her to urinate more often. Resident #40 stated she felt no distress and had no issues with her weight. Interview on 09/08/22 at 11:16 A.M. with Registered Nurse (RN) #239 stated Resident #40 was able to feed herself and had no recent issues with her weights. RN #239 verified Resident #40's weights were being monitored daily due to [CONDITION(S)] associated with congestive heart failure and not for nutritional concerns. RN #239 verified there was no documentation of Resident #40's weights being obtained on 08/10/22, 08/11/22, 08/14/22, 08/15/22, 08/16/22, 08/18/22, 08/19/22, 08/22/22, 08/24/22, 08/25/22, and 08/26/22, and stated the facility obtaining daily weights for residents had been a recurring issue. Review of a facility policy titled, Clinical Services-Weight Monitoring, revised 12/21/20, revealed weight monitoring is essential to the well-being of the residents the facility serves and requires a multidisciplinary approach. The facility will review for any missing weights weekly as ordered and daily as ordered.

Based on medical record review, observations, staff interview, and review of the facility's policy, the facility failed to ensure Resident #37, who required assistance limited staff assistance for activities of daily living (ADL) care, received adequate assistance with nail care to promote proper hygiene. This affected one (#37) of three residents reviewed for activities of daily living. The facility identified all 45 residents residing in the facility required staff assistance with dressing and bathing. Findings include: Review of Resident #37's medical record revealed Resident #37 was initially admitted to the facility on [DATE] with re-entry on 08/30/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 08/04/22, revealed Resident #37 was severely cognitively impaired. Resident #37 required limited one person assistance with dressing and personal hygiene. Observations on 09/06/22 at 11:34 A.M. and on 09/08/22 at 10:28 A.M. revealed Resident #37's toenails were long. Interview on 09/08/22 at 10:51 A.M. with Registered Nurse (RN) #261 verified Resident #37's toenails were too long and did needed to be trimmed. Observation on 09/12/22 at 9:31 A.M. with RN Regional Support #290 revealed Resident #37's socks removed and toenails remained approximately the same length as previously observed. Interview on 09/12/22 at approximately 11:30 A.M. with RN Regional Support #290 revealed Resident #37 refused the last podiatry visit on 04/08/22 and was scheduled for the next visit on 09/21/22. RN Regional Support #290 verified Resident #37's nails also could be trimmed by nursing staff.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to notify the physician of resident's weight gain as ordered. This affected one (Resident #40) of three residents reviewed for weight changes. The facility census was 45. Findings include: Review of Resident #40's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 07/06/22 revealed Resident #40 had potential for complications of congestive heart failure with an intervention to obtain weight as ordered. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 08/09/22 and a new order was written dated 08/09/22 to weigh Resident #40 daily and notify the physician of weight gain of two pounds (lbs.) a day or three to five pounds a week. Review of Resident #40's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #40's weights revealed Resident #40's weight was 184.0 lbs. on 08/23/22 and the next weight obtained was on 08/27/22 and was 196.0 lbs. for a weight gain of 12.0 lbs. in four days. Resident #40's weight was obtained on 08/28/22 and was 201.0 lbs. for a weight gain of five lbs. in one day. Resident #40's weight was obtained on 08/29/22 and was 204.4 lbs. for a weight gain of 3.4 lbs. in one day. There was no evidence in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes dated 08/10/22, 08/11/22, 08/14/22, 08/15/22, 08/16/22, 08/18/22, 08/19/22, 08/22/22, 08/24/22, 08/25/22, and 08/26/22 revealed no documentation of the physician being notified of Resident #40's weights not being obtained. Further review of nursing progress notes dated 08/27/22, 08/28/22, and 08/29/22 revealed no documentation of the physician being notified of Resident #40's daily and weekly weight gains as physician ordered. Review of the most recent dietician assessment dated [DATE] revealed Resident #40 displayed significant weight gain between 06/30/33 and 08/30/22 with her weight initially down from Resident #40's normal and trending back up over the last month. Resident #40's weight gains were likely attributed to improved intakes since admission as well as [CONDITION(S)] to the bilateral lower extremities which Resident #40 recently had diuretics adjusted to treat the [CONDITION(S)]. Resident #40's meal intakes were noted between 75 percent (%) and 100 % during the review period. Interview on 09/08/22 at 11:16 A.M. with Registered Nurse (RN) #239 stated Resident #40 was able to feed herself and had no recent issues with her weights. RN #239 verified Resident #40's weights were being monitored daily due to [CONDITION(S)] associated with congestive heart failure and not for nutritional concerns. RN #239 verified there was no documentation of Resident #40's weights being obtained on 08/10/22, 08/11/22, 08/14/22, 08/15/22, 08/16/22, 08/18/22, 08/19/22, 08/22/22, 08/24/22, 08/25/22, and 08/26/22, and stated the facility obtaining daily weights for residents had been a recurring issue. RN #239 also stated notification of physician notification would be in the nursing progress notes and verified there was no documentation the physician was notified on the dates in August 2022 when Resident #40's weights were not obtained. RN #239 also verified the physician was not notified of Resident #40's weight gains on 08/27/22, 08/28/22, and 08/29/22. Review of a facility policy titled Notification of Change in Condition, dated 12/01/21, revealed the facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when there is a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly, or an accident involving the resident which results in an injury and had the potential for requiring physician intervention.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications were re-ordered correctly and administered as physician ordered. This affected one (Resident #41) of six residents reviewed for unnecessary medications. The facility census was 45. Findings include: Review of Resident #41's medical record revealed a re-admitted [DATE]. Diagnoses included diabetes mellitus type II with diabetic [CONDITION(S)], [CONDITION(S)], acute pulmonary [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and end stage renal disease. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed with intact cognition. Review of a physician order dated 04/18/21 revealed Resident #41 was ordered [MEDICATION(S)] 10 units subcutaneously at bedtime. Further review of the physician order revealed it was discontinued on 08/01/22. Review of Resident #41's current physician orders as of 09/08/22 revealed Resident #41's [MEDICATION(S)] order was scheduled to begin again in 2023. Review of a nursing progress note dated 08/01/22 revealed Resident #41 was out of [MEDICATION(S)], the physician was notified, and the facility was awaiting delivery of the medication. Review of additional physician orders revealed Resident #41 was ordered [MEDICATION(S)] insulin subcutaneously via sliding care three times daily and at bedtime on 12/10/20 and [MEDICATION(S)] subcutaneously five (5) units subcutaneously with meals on 04/18/21. Review of Resident #41's blood glucose levels obtained in August and September 2022 revealed Resident #41 had no blood glucose levels lower than 80 milligrams per deciliter (mg/dL) or greater than 354 mg/dL. Review of Resident #41's nursing progress notes dated between 08/10/22 and 09/08/22 revealed Resident #41 experienced no significant change in condition and the physician did not need to be notified due to blood glucose levels during this time frame. Review of a nursing progress note dated 09/08/22 revealed Resident #41 was to receive [MEDICATION(S)] 10 units at night and the re-order was put in the computer system to begin in 2023 instead of 2022. The physician was notified and gave an order to restart Resident #41's [MEDICATION(S)] on 09/08/22. Interview on 09/12/22 at 10:22 A.M. with Registered Nurse (RN) Regional Clinical Support #290 stated a nurse attempted to re-order Resident #41's insulin on 08/01/22 and inadvertently discontinued the order and put in a start date for the new order in 2023. RN Regional Clinical Support #290 verified this was an error and Resident #41 should have been receiving the [MEDICATION(S)] with no discontinuation. RN Regional Clinical Support #290 verified Resident #41 should have received the [MEDICATION(S)] between 08/01/22 and 09/07/22 and did not due to the ordering error. RN Regional Clinical Support #290 verified Resident #41 did not have any significant changes and Resident #41's blood glucose levels during that time frame did not require additional interventions. Review of a facility policy titled, Medication Administration General Guidelines, revised January 2018, revealed medications as administered in accordance with written orders of the prescriber. This deficiency substantiates Complaint Number OH 428.

Based on medical record review, observation, staff interview, policy review, and review of manufacturer's instructions, the facility failed to administer insulin as physician ordered and per the manufacturer's instructions which resulted in a significant medication error. This affected one (#25) of three residents observed during medication administration. The facility identified 14 residents in the facility who receive insulin. The facility census was 45. Findings include: Review of Resident #25's medical record revealed and admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25 sliding scale order revealed for blood glucose levels between 111 milligrams per deciliter (mg/dL) and 150 mg/dL, give one unit of insulin; between 151 mg/dL and 200 mg/dL, give three units of insulin; between 201 mg/dL and 250 mg/dL, give six units of insulin; between 251 mg/dL and 300 mg/dL, give nine units of insulin; between 301 mg/dL and 550 mg/dL, give 12 units of insulin; and between 351 mg/dL and 400 mg/dL, give 15 units of insulin. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/07/22 at 11:34 A.M. revealed Registered Nurse (RN) #229 preparing to administer Resident #25 her scheduled insulin. RN #229 obtained Resident #25's blood glucose level and was observed to be 261 mg/dL. RN #229 explained Resident #25 would receive a scheduled five units of [MEDICATION(S)] insulin, and based on Resident #25's blood glucose level, an additional nine units of [MEDICATION(S)] insulin for a total of 14 units of [MEDICATION(S)] insulin. RN #229 then removed Resident #25's [MEDICATION(S)] insulin pen from the medication cart, turned the dosage dial to 14 units, affixed the needle to the end of the insulin pen, walked to Resident #25's bedroom and administered the insulin subcutaneously into her abdomen without priming the insulin pen needle. Interview on 09/017/22 at 11:42 A.M. with RN #229 verified she did not prime the insulin pen prior to selecting the dose of insulin to administer to Resident #25. RN #229 stated she was not aware insulin pens needed to be primed with each administration, but rather thought priming only was needed on the initial dose of a new insulin pen. Review of a facility policy titled, Medication Administration General Guidelines, revised January 2018, revealed medications as administered in accordance with written orders of the prescriber. Review of a facility policy titled Vials and Ampules of Injectable Medications, revised January 2018, revealed vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations of the provider pharmacy's directions for storage, use, and disposal. Review of [MEDICATION(S)] insulin manufacturer's instructions, dated 2004, revealed the pen must be primed before each injection to make sure the pen is ready to dose. The user should affix a needle to the insulin pen and turn the dial knob until 2 can be seen in the dose window. The insulin pen should then be held with the needle pointed upwards, and when the administration button is pressed, insulin should be seen at the tip of the needle. The desired dose of insulin should then be selected, and if no insulin is seen at the tip of the needle, the process should be repeated. This deficiency substantiates Complaint Number OH 428.

Based on review of Quality Assessment and Assurance (QAA) Committee/Quality Assurance Improvement Program (QAPI) meeting sign in sheets and staff interview, the facility failed to ensure the Medical Director or designee attended QAA Committee/QAPI meetings at least quarterly. This had the potential to affect all 45 residents residing in the facility. Findings include: Review of QAA Committee/QAPI meeting sign in sheets between September 2021 and August 2022 revealed the facility held meetings monthly and the Medical Director or a designee did not attend the meetings at least quarterly as required. Further review of the QAA Committee/QAPI meeting sign in sheets revealed the Medical Director attended the meeting on 09/24/21, and did not attend another meeting until 04/27/22. There was no documentation of Medical Director designees present at any of the QAA Committee/QAPI meetings between September 2021 and August 2022. Interview on 09/12/22 at 12:27 P.M. with the Administrator verified the facility held QAA Committee/QAPI meetings monthly between September 2021 and August 2022 and verified the Medical Director or a designee was not present for any meetings in the fourth quarter of 2021 and the first quarter of 2022 as required. Each monthly QAA Committee/QAPI meeting sign in sheet between September 2021 and August 2022 was reviewed with the Administrator during the interview, and she verified there were no designees that attended the QAA Committee/QAPI meetings during that time frame.

Based on record review, staff interviews and policy review, the facility failed to ensure a resident was safely transferred per physician orders and assessments. This affected one resident (#14) of three residents reviewed for falls. The facility census was 52. Findings Include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included right femur fracture, [CONDITION(S)] flutter, muscle weakness, [CONDITION(S)] [CONDITION(S)], unsteady on feet, sick [MEDICATION(S)] syndrome, cognitive communication deficit, repeated falls, unspecified dementia, hypertension, anxiety disorder, cardiac pacemaker, visual and auditory hallucinations, anticoagulant use, [CONDITION(S)], nonrheumatic mitral valve insufficiency, coronary angioplasty, dysphagia, history of COVID-19, [CONDITION(S)], moderate protein calorie malnutrition, difficulty walking, and [CONDITION(S)] fibrillation. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 required extensive two person assistance with bed mobility and transfers. Toileting was documented as total dependence requiring the assistance of two persons. Review of the physician's orders revealed an order for mechanical lift for transfers dated 02/15/21. Continued review revealed the order had a discontinuation date of 07/26/21 (date of survey). Review of the plan of care for Resident #14 revealed the resident was at risk for falling related to weakness, balance difficulties, and cognitive status which could impair safety awareness. Interventions included two staff for all transfers (07/18/21), encourage and assist resident to assume standing position slowly, ensure the floor is free of liquids and foreign objects, keep call light within reach, keep personal items and frequently used items within reach, provide non-skid footwear, staff to assist resident with transfers as needed and therapy to evaluate and treat as needed. Review of a progress note dated 07/17/21 at 9:12 P.M., revealed while transferring Resident #14 to bed using a gait belt, the resident's legs gave out and the resident was lowered to the floor. No documented injuries with active range of motion of all four extremities. Resident denied pain. Review of the interdisciplinary review note dated 07/20/21 at 2:23 P.M., revealed Resident #14 did not sustain any injuries as a result of being lowered to the floor by one staff member with gait belt being used at the time of the incident. Resident was referred to therapy and staff were to be educated on utilizing two assist for transfers. Interview on 07/26/21 at 9:25 A.M., with Licensed Practical Nurse (LPN) #32 revealed she was the one who was transferring Resident #14 on 07/17/21. LPN #32 reported mistakenly transferring the resident by herself with a gait belt. LPN #32 was assisting the resident from the wheelchair to the bed with a gait belt. She lowered the resident to the floor once her legs gave out. After lowering the resident to the floor and double checking her report paperwork, the LPN noted that the resident was a two assist. LPN #32 reported no resident injuries at the time of the incident. The nurse summoned additional assistance at that time and then transferred Resident #14 into bed. LPN #32 confirmed no knowledge that Resident #14 had an order for mechanical transfer and stated apparently the order had not been updated. Interviews on 07/26/21 at 9:35 A.M., with Registered Nurse (RN) #20 confirmed Resident #14 to have a MDS assessment dated [DATE] indicating the resident to be identified as an extensive two person assist for transfers. RN #20 was not aware of the mechanical lift order dated 02/15/21 and the Administrator confirmed the facility was not utilizing this mechanism of transfer for Resident #14. Interview on 07/26/21 at 9:45 A.M., with the Administrator confirmed the Director of Nursing (DON) had provided verbal education to LPN #32 as the LPN had acknowledged and was aware of the error in transferring Resident #14. Review of a policy titled, Fall Management Program Guidelines with a revision date of 05/22/18, revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The facility recognizes even the most vigilant efforts may not prevent all falls and injuries. In these cases, intensive efforts will be directed toward minimizing or preventing injury. This deficiency substantiates Complaint Number OH 136.

Based on medical record review, observations, resident and staff interviews and review of facility policy, the facility failed to ensure medications were properly stored, when medications were left unattended in a resident's room. This affected one (#3) randomly observed resident with medication left unattended at the bedside. This had the potential to affect two (#3 and #4) who were roommates and were cognitively impaired. The facility census was 47. Findings included: Medical record review for Resident #3 revealed an admitted d of 08/21/20. [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set (MDS) Assessment 3.0 dated 08/27/20 revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating the resident was cognitively impaired. Resident #3 required extensive assistance for bed mobility, transfers, dressing, toileting, and maintaining hygiene. Review of Resident #3's care plan dated 08/28/20 revealed Resident #3 demonstrated cognitive impairment which was anticipated to progress. Medical record review for Resident #4 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set MDS Assessment 3.0 dated 09/04/20 revealed a BIMS score of 99, indicating Resident #4 was cognitively impaired. Resident #4 required extensive assistance for bed mobility, transfers, dressing, toileting, and maintaining hygiene. Review of Resident #4's care plan last reviewed 09/18/20 revealed Resident #4 wandered and had impaired cognition. Observation on 11/25/20 at 9:14 A.M. revealed Resident #3 and Resident #4 were roommates. Resident #4 was lying in bed sleeping, while Resident #3 was seated in a recliner chair with a tray table positioned next to him within reach. On the table was a cup of multiple pills of different shapes, sizes, and colors. Further observation revealed staff were not in the residents' room or nearby. Interview on 11/25/20 at 9:14 A.M. with Resident #3 verified his morning medications were sitting on the tray table next to him and that he had not taken them yet. Interview on 11/25/20 at 9:17 A.M. Registered Nurse (RN) #500 verified Resident #3's medications were left unattended in Resident #3's room and verified there were multiple pills in a small cup on Resident #3's tray table. RN #500 explained that medications should never be left unattended in a resident's room and staff were to observe residents taking their medications. RN #500 reported Medication Aide #250 had passed medication that morning. RN #500 removed the cup of pills immediately. Interview on 11/25/20 at 9:20 A.M. Medication Aide #250 verified the medication should not have been left unattended and Resident #3 should have been observed taking his medications. Medication Aide #250 reported Resident #3's medication was taken to him around 7:00 A.M. and that she did not stay to ensure Resident #3 had actually taken the medication. Medication Aide #250 reported she did not believe Resident #3 was able to administer his own medications. Further review of Resident #3's Medication Administration Record [REDACTED].M. to 10:00 A.M.: [MEDICATION NAME] 325 milligrams (mg) two tablets; [MEDICATION NAME] five mg one tablet; Keflex 500 mg one cap; [MEDICATION NAME] (vitamins a, c, e-zinc-[MEDICATION NAME]) capsule; 14, 320-226-200 unit-mg-unit one capsule; rosuvastatin five mg one tablet; and Vitamin B-12 1,000 mcg one tablet. Record review for Resident #3 revealed there was no assessment, physician order, care plan and/or other documentation regarding self-administration of medications. Review of facility policy titled, Medication Storage in the Facility, revised October 2019 revealed medications were to be stored safely, securely, and properly. The medication supply would be accessible only to licensed facility personnel, pharmacy personnel, or facility personnel lawfully authorized to administer medications. Review of facility policy titled, Medication Administration General Guidelines, revised November 2018, revealed the resident was always observed after administrator to ensure the dose was completely ingested.

Based on closed medical record review, hospice notes review, staff interview and review of facility policy the facility failed to implement interventions for a resident who had no bowel movement for 12 days. This affected one resident (#1) of three residents reviewed for constipation. The facility identified 25 residents with a [DIAGNOSES REDACTED]. Findings include: Review of the closed medical record revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. It is rare, and rapidly progresses), [MEDICAL CONDITIONS], obesity, vitamin deficiency, [MEDICAL CONDITION], asthma, chronic pain, constipation, urinary incontinence, disorientation, [MEDICAL CONDITION], history of falls and restlessness and agitation. Review of a comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long-term memory issues and moderately impaired cognitive skills for decision making. The resident had verbal and physical behaviors that interfered with his care during one to three days of the assessment period. The resident also had episodes of other behaviors not directed towards others and rejection of care. The resident required extensive assistance for bed mobility, transfers, dressing, eating, toileting and personal hygiene and was totally dependent on staff for walking and bathing. The resident was unsteady on his feet and was only able to stabilize with staff assistance. Resident #1 was frequently incontinent of urine and had an ostomy, with constipation present. A scheduled pain medication regimen in addition to as needed pain medications were in place for chronic pain. Indicators of pain included non-verbal sounds, vocal complaints of pain, facial expressions, were present daily. There was a terminal prognosis. A fall had been experienced in the last month prior to admission as well as in the last two to six months prior to admission. No falls had been sustained since admission. A risk of pressure ulcers was present but there were no skin issues. Antipsychotic, antidepressant, opioid and antianxiety medications were administered. Oxygen was used by the resident. Review of a Resident Bowel and bladder by shift Chart dated 09/01/20 through 09/17/20 revealed Resident #1 had a bowel movement (BM) on 09/02/20 and 09/14/20. Review of a progress note dated 09/14/20 at 12:20 P.M. revealed the hospice nurse was in and the family had concerns with the resident's bowels not moving. Review of Hospice visit notes, dated 09/14/20 revealed the family voiced concern regarding the resident not having a BM in over two weeks. A rectal check was performed and there was no stool to be removed. A suppository was placed at that time to help induce a BM. No prior documentation was available to reveal the BM status had been monitored. Review of the Medication Administration Record (MAR) dated 09/2020 revealed the resident had [MEDICATION NAME] sodium (stool softener) ordered to be given daily as well as Senna (for contstipation). The MAR revealed the medications were not given on six days. On 09/02/20 the medications were not available and they were refused on 09/06/20, 09/07/20 and 09/20/20. The medications were also held on 09/13/20, 09/14/20 and 09/16/20 due to the resident's condition. The MAR further revealed a [MEDICATION NAME] suppository 10 milligrams was ordered to be given rectally daily as needed for constipation. One dose was documented on 09/14/20. [MEDICATION NAME] (to treat constipation) 17 grams by mouth was ordered daily as needed for constipation and was not administered. No order set for BM protocol was documented on the MAR. Interview with Licensed Practical Nurse (LPN) #35 on 11/09/20 at 9:10 A.M. revealed nurses received a list each day of residents who had not had a BM in the past 72 hours, from Registered Nurse (RN) #30. She stated at that time, she then checks with the residents and starts them on their bowel protocol, which could be different for each resident, but normally consisted of oral laxatives, rectal suppositories and fleets enemas. She further stated she did not recall Resident #1 being on the list. Interview with RN #30 on 11/09/20 at 10:00 A.M. revealed she used the Detail Reports of the information the State tested Nursing Assistants (STNA's) documented in the care tracker, to develop a BM list to give to the nurses each day that included residents with no BM for the past 72 hours. She stated the list was not kept. She further stated she did not recall if Resident #1 had been on the list or not. Interview with Licensed Social worker #70 on 11/09/20 at 3:20 P.M. revealed the family of Resident #1 came to her with a concern the resident had not had a BM for two weeks. She stated she went to the Director of Health Services and the floor nurse and they pulled up care tracker, where the BM's were documented. She stated it was found the resident had not had a BM since 09/02/20. She stated this was on 09/14/20. Interview with the Administrator, via email on 11/10/20 at 3:52 P.M. verified Resident #1 went from 09/02/20 to 09/14/20 with no BM or interventions from staff. She further verified there was no documentation of notification of the resident not having a BM after 72 hours, and longer, to the physician or family prior to 09/14/20. She further verified the bowel protocols were not followed and there was no abdominal assessment documented. Review of facility policy Bowel Protocol Guidelines dated 05/11/16, revealed an order Follow Bowel Protocol was to be obtained for each resident on admission and printed on the monthly physician order [REDACTED]. The 72 hour follow up on the bowel and bladder circumstance form was to be completed until the resident had a BM of the bowel pattern returned to normal for the resident. An assessment of the abdomen was to be completed each shift that included abdominal distention, pain and bowel sounds. Nursing staff was to assess for effectiveness within 24 hours of the first step before proceeding to the next level. This deficiency substantiates Complaint Number OH 825.

Based on record review and staff interview the facility failed to follow physician orders [REDACTED]. This affected one resident, (Resident #42) of one reviewed for catheter care. The current census was 54. Findings include: Record review of Resident #42 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set, (MDS), quarterly assessment dated [DATE] revealed the resident had intact cognition and had an indwelling Foley catheter. Further review of the medical record revealed on 06/11/19 and 08/08/19 the resident was seen by a urologist for the indwelling catheter. Per the urology notes the resident was to have the indwelling catheter changed every six weeks. Review of progress notes dated 06/11/19 revealed the nurse documented Resident #42 went to an appointment with urology. Per the note the nurse documented the new orders received were to continue Foley catheter with every 6 week change. Review of Resident #42's physician orders [REDACTED]. No further orders regarding changing the catheter every six weeks was noted in the orders Interview on 09/04/19 at 8:09 [NAME]M. with Resident #42 revealed she was aware she had an indwelling catheter. Per Resident #42 she had no discomfort from the catheter but the resident stated she was unsure when the last time the catheter had been changed. Interview on 09/05/19 at 3:04 P.M. with the Director of Nursing (DON) and the Regional Nurse #200 revealed the resident's urology notes had not been received by the facility. Per Regional Nurse #200 when a resident has an indwelling catheter and there are no specific physician order [REDACTED].#200 verified there was a note on 06/11/19 from the nurse regarding the order to change the catheter every six weeks and the order had not been transcribed into Resident #42's treatment administration record.

Based on medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure the physician and [MEDICAL TREATMENT] center were notified of a change in a resident's condition. This affected one (Resident #15) of one resident reviewed for [MEDICAL TREATMENT]. The facility identified only one resident receiving [MEDICAL TREATMENT]. The facility census was 54. Findings include: Review of Resident #15's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment dated [DATE] revealed mild impairment in cognition. The resident received anticoagulant medication three days during the assessment period. Review of the resident's physician's orders [REDACTED]. On 05/23/19, an order was written to monitor for signs and symptoms of bleeding and increased or abnormal bruising, and to notify physician if symptoms occur. The resident had an order dated 06/14/19 for [MEDICATION NAME] (blood thinner) and an order dated 06/20/19 for apixaban (anticoagulant). Review of the resident's [MEDICAL TREATMENT] care plan dated 06/14/19 revealed interventions included coordinating care with the [MEDICAL TREATMENT] center. If bleeding from shunt site, apply pressure, call physician. If excessive bleeding, call nine-one-one (911). Review of the resident's care plan dated 06/20/19 for resident's risk for excessive bleeding and bruising related to medications included interventions to notify the physician of abnormal bruising and or bleeding. Review of the resident's nursing notes dated 08/22/19 revealed the resident was sent to the hospital due to uncontrolled bleeding from her right arm arteriovenous (AV) fistula following [MEDICAL TREATMENT]. The resident returned to the facility on [DATE]. There were no further notes indicating bleeding issues until 09/04/19 at 4:58 [NAME]M. The note revealed the resident called the nurse in to look at her right arm. She had pulled off her cotton ball and tape from [MEDICAL TREATMENT] and it was bleeding. Bruit and thrill were present. The area was cleaned and a band-aid was applied. Approximately an hour later, the resident called the nurse back in and the bleeding had not stopped. The nurse documented she applied and island dressing and wrapped kerlix around to apply pressure. She rechecked the resident at 4:30 [NAME]M. and the bleeding had stopped. On 09/04/19 at 5:26 P.M. it was documented the resident continued to have excess bleeding from fistula at this time. This nurse cleaned the area and covered it with a dressing and secured with coban to apply pressure. Continued review of the nursing notes revealed no indication the physician was notified of the bleeding until 09/04/19 at 5:46 P.M. and the [MEDICAL TREATMENT] center was not notified until 09/05/19. Interview with Resident #15 on 09/04/19 at 7:55 [NAME]M. revealed she had experienced bleeding from the AV fistula on her right arm earlier in the morning. She stated she thought it was under control at that time and there was no bleeding noted through the bandage. She stated she had to be sent to the hospital due to bleeding from her AV fistula on 08/22/19. She stated she was on blood thinner medication. Interview with Regional Nurse #200 on 09/05/19 at 2:17 P.M. verified the physician was not notified of the resident's AV fistula bleeding until 09/04/19 at 5:46 P.M. She also verified the [MEDICAL TREATMENT] center was not notified of the bleeding until 09/05/19. Review of a facility policy titled Notification of a Change in Condition revised on 05/23/18 revealed the facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when there is a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly. Documentation of notification or notification attempts should be recorded in the resident electronic record. Review of a facility policy titled Guidelines for [MEDICAL TREATMENT] reviewed on 05/22/18 revealed the purpose was to provide communication to [MEDICAL TREATMENT] providers and monitoring of residents receiving [MEDICAL TREATMENT]. Procedures included: upon return from [MEDICAL TREATMENT], the facility shall provide ongoing monitoring of the shunt site for signs of complication. Monitor the arteriovenous (AV) fistula/graft/central venous catheter daily and document in resident medical record. If abnormal bleeding is noted apply pressure to area and call 911 for transfer to the hospital. Notify the attending physician, [MEDICAL TREATMENT] center and responsible party of adverse findings. Document notifications in medical records.

Based on medical record review and staff interview, the facility failed to ensure a care plan was implemented for safety concerns related to utilization of a motorized wheelchair. This affected one resident (#39) of 15 reviewed for care plans. The facility census was 54. Findings include: Review of Resident #39's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #39's Minimum Data Set ((MDS) dated [DATE] revealed the resident had no cognitive impairment. Review of the resident release of responsibility for leave of absence form revealed Resident #39 had signed in and out of the facility on 06/19/19. Review of Resident #39's care plans revealed the care plan was silent regarding resident safety related to utilization of a motorized wheelchair after an incident that occurred on 06/19/19. Review of Resident #39's progress note dated 06/20/19 revealed the resident was observed on a nearby busy road on a motorized wheelchair on 06/19/19. The progress note further revealed Resident #39 had been educated on safety concerns when leaving the campus in the motorized wheelchair. Interview on 09/04/19 at 9:01 [NAME]M. with Resident #39 confirmed being on the road in a motorized wheelchair and that in the past he had taken the local Regional Transit Authority bus for transportation services. Resident #39 revealed knowledge that motoring on the road was not safe practice in the motorized wheelchair. Interview on 09/04/19 at 9:22 [NAME]M. with Director of Social Services (DSS) #240 revealed Resident #39 was observed by staff to be motoring on the road by the facility in a motorized wheelchair. The DSS confirmed the resident was his own responsible person and revealed the resident used a slow moving vehicle flag for safety when motoring outside of the facility. Interview on 09/04/19 at 3:15 P.M. with Regional Registered Nurse (RRN) #200 confirmed Resident #39's care plan had not been updated for inclusion of motorized wheelchair safety after the incident that occurred on 06/19/19.

Based on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to observe a resident during medication administration, resulting in unsupervised medications. This affected one randomly observed Resident (#25) during the first stage of the survey process. This also had the potential to affect one Resident (#45) whom the facility identified as confused and independently ambulatory on the 300 hall. The facility census was 54. Findings include: Review of Resident #25's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed mild impairment in cognition. Review of the resident's physician's orders [REDACTED]. Observation of Resident #25 on 09/03/19 at 9:20 [NAME]M. revealed the resident was sitting in her recliner in her room. She had three medications sitting in a pill cup on her bedside table. At the time of the observation, the resident stated she did not have water so she was waiting to take them. Interview with Registered Nurse (RN) #220 on 09/03/19 at 9:23 [NAME]M. verified Resident #25's medications were left on her bedside table. She stated the resident would not always take her medications. She stated the medications were pantoprazole 40 mg, vitamin D3 2,000 units, and calcium [MEDICATION NAME] 200 mg. Review of a facility policy titled Medication Administration-General Guidelines revised 01/2017 revealed the resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the Medication Administration Record, [REDACTED]

Based on observation, medical record review, staff interview and review of a facility policy, the facility failed to ensure a resident received a mechanically altered diet per the physician's orders [REDACTED].#2) of three residents reviewed for nutrition. This had the potential to affect 11 residents the facility identified as receiving mechanically altered diets. The facility census was 54. Findings include: Review of Resident #2's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment dated [DATE] revealed a staff assessment for cognition indicated the resident's cognition was moderately impaired. He required supervision with one staff for eating. He was receiving a mechanically altered diet. Review of the resident's speech therapy consult dated 06/18/19 revealed the resident presented with mild-moderate oropharyngeal dysphagia. Recommendation was for a mechanical soft diet with ground meat and added sauces/gravies with avoidance of mixed consistencies. Nectar thick liquids with strict use of compensatory strategies. Review of the resident's care plan dated 07/03/19 and revised on 09/03/19 revealed the resident had impaired swallowing related to dysphagia from past [MEDICAL CONDITION]. Interventions included providing diet as ordered, monitor and report difficulties swallowing, and observe resident closely for signs of choking and/or aspiration. Review of the resident's physician's orders [REDACTED]. Observation of the resident eating breakfast in the dining room on 09/05/19 at 8:50 [NAME]M. revealed he had mechanical ground bacon with no sauce or gravy and thin liquid coffee, which he was drinking. The resident was coughing. Observation of the resident's meal ticket revealed he was to have sauce or gravy on his ground meat and nectar thickened liquids. Interview and observation with Registered Nurse (RN) Clinical Support #210 on 09/05/19 at 8:51 [NAME]M. verified the resident had thin liquid coffee and he did not have gravy or sauce on his mechanically ground bacon. She verified the resident was coughing. She stated the nursing staff would begin monitoring the resident for signs of aspiration immediately. Interview with Regional Nurse #200 on 09/05/19 at 9:30 [NAME]M. revealed the facility did not have a policy regarding following a diet order. Review of a facility policy titled Thickened Liquids dated on 05/23/18 revealed the purpose of the policy was to assure residents receive appropriate consistency of liquids, as ordered by the physician to prevent complications such as choking or aspiration. Procedures included the correct fluid consistency will be placed on each resident's tray card. Only fluids of correct consistency shall be provided for meals and snacks.