Every finding on record at Steubenville Country Club Manor

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate and consistently recorded in the record. This affected one Resident (Resident #30) of one reviewed for advanced directives. The census was 42. Findings include: Review of the medical record for Resident #30 revealed they were was admitted to the facility on [DATE]. Diagnosis included Alzheimer's Disease, hyperlipidemia, atrial fibrillation, peripheral vascular disease, dementia, anxiety disorder, major depressive disorder, and malignant melanoma of the skin. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 dated 11/26/24 revealed the resident had severely impaired cognition. They required setup or clean up assistance for eating, supervision or touching assistance for oral hygiene, substantial to maximal assistance with toileting hygiene, dressing, personal hygiene, and bed mobility. Finally, the resident was dependent on staff for showers. Review of Resident #30's medical record revealed their hard copy chart indicated the advanced directive of Do Not Resuscitate Comfort Care - Arrest (DNR-CCA), which was signed by the physician. This would indicate full medical care is given until the moment of respiratory or cardiac arrest, at which point only comfort measurers would be provided. In the Electronic Medical Record (EMR), it indicated no advanced directive in the demographic section. Interview on 02/11/25 at 12:45 P.M. with Licensed Practical Nurse (LPN) #75 revealed the first-place staff would look for the resident's code status would be in EMR and if not indicated in the EMR, they would look in the resident's hard chart located at the desk. LPN #75 confirmed Resident #30's code status was not indicated in the EMR in the demographics section where they would normally look. Interview on 02/11/25 at 12:49 P.M. with the Assistant Director of Nursing (ADON) LPN #72 revealed they confirmed staff would look for the resident's code status in the EMR and if not indicated in the EMR they would look in the resident's hard chart. Review of facility policy titled Advanced Directives Policy and Procedure, last reviewed June 2024, revealed all Advance Directive document copies will be obtained and located in the EMR and in the resident's medical record that would be readily retrievable by facility staff.

Based on medical record review and staff interview, the facility failed to ensure Pre-Admission Screening and Resident Review (PASRR) was completed accurately upon admission to the facility. This affected one (Resident #8) of one residents reviewed for PASRR assessments. The facility census was 42. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] with diagnosis that included diabetes mellitus, adjust disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Review of the PASRR completed on 11/08/24 indicated Resident #8 had diagnosis of mood disorder and panic or other severe anxiety disorders. No evidence of bipolar disorder and post-traumatic stress disorder was indicated. On 02/1125 at 3:30 P.M. interview with Admissions Coordinator #59 verified Resident #8's PASRR did not include all current mental health diagnosis including bipolar disorder and post-traumatic stress disorder.

Based on medical record review and staff interview the facility failed to ensure resident blood pressures were monitored prior to administration of hypotensive medications and according to physician's medication order parameters. This affected one (Resident #99) of five residents reviewed for medication use. The facility census was 42. Findings include: Review of Resident #99's medical record revealed an admitted [DATE] with diagnoses that included history of falls with subdural hematoma and craniotomy, cerebrovascular accident, hypotension and hypertension. Further review of the medical record revealed a physician's order on 01/28/25 for the use of midodrine (anti-hypotensive medication) 10 milligrams (mg) three times daily with parameters to hold if systolic blood pressure is greater or equal to 150 millimeters of mercury (mmHg). Review of the Medication Administration Record (MAR) for Resident #99 revealed the medication administered as ordered with no evidence of blood pressure monitoring as indicated. On 02/12/25 at 1:40 P.M. interview with the Director of Nursing verified Resident #99's blood pressure was not monitored prior to administration of the Midodrine as ordered.

Based on interview and record review the facility failed to ensure residents medical record were complete and accurate related to documentation of care provided. This affected two residents (Resident #8 and #28) out of two residents reviewed for showers. The facility census was 42. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnosis included malignant neoplasm of upper lobe, left bronchus or lung, obstructive pulmonary disease, diabetes mellitus, arteriosclerotic heart disease, dependence on supplemental oxygen, pulmonary edema, hypertension, malignant neoplasm of right breast, and uterine cancer. Review of Resident #28's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had intact cognition. Resident #28 required setup and clean up assistance with eating, oral hygiene, supervision or touching assistance for toileting hygiene, personal hygiene, and bed mobility. They required partial to moderate assistance for dressing and showers. Review of Resident #28's care plan dated 10/24/24 revealed the resident required assistance with Activities of Daily Living (ADLs) related to malignant neoplasm of left bronchus or lung, intraductal carcinoma left breast, malignant neoplasm of right breast, history of shortness of breath (SOB) with exertion, SOB while lying flat, oxygen dependent, unsteady gait, and a fall prior to admission. Interventions and goals included the resident would improve current level of functions, showers every Monday, Wednesday, and Friday on night shift and as needed per the resident's preference. Review of Resident #28's Certified Nursing Assistant (CNA) tasks revealed under ADL-Bathing- Showers every Monday, Wednesday, and Fridays nights and as needed per the resident preference. Resident requests time to be around 8:00 P.M. Review of Resident #28's CNA shower task documentation revealed from 01/12/25 to 02/12/25 there was only one shower documented as completed on 02/08/25. Interview on 02/12/25 at 9:55 A.M. with the Director of Nursing (DON) confirmed there was no documentation of completed showers. Interview on 02/12/25 at 1:45 P.M. with Resident #28 revealed they received the majority of their showers. And do refuse at times if not feeling well. Interview on 02/12/25 at 2:10 P.M. with CNA #111 revealed within the last month the facility had started to document showers in the Electronic Medical Record (EMR) under the tasks tab but prior to this they were documenting on paper. CNA #111 stated, at times, they would forget to document and stated, if not documented they were not done. Interview on 02/12/25 at 2:15 P.M. with CNA #96 revealed they were to document showers in the EMR but will forget to document the showers. 28701 2. Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses that include diabetes mellitus, adjustment disorder with mixed anxiety and depression, bipolar disorder and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 01/23/25 indicated Resident #8 had an intact and independent cognition level and required staff assistance with showers/bathing. Care Plans for Resident #8 indicated the resident required staff assistance with showers/bathing. Review of the Certified Nurse Aide (CNA) bathing records revealed only one documented shower/bath provided in the prior 30 days on 01/15/25. Interview with Resident #8 on 02/10/25 at 7:30 P.M. revealed she will miss showers at times. The resident states they receive a shower once or twice a week, but would prefer three times a week. On 02/12/25 at 1:45 P.M. interview with the Director of Nursing verified CNA staff have not been accurately documented shower/baths provided for residents including Resident #8. Review of facility policy titled Shower Policy for Country Club Manor, last reviewed February 2025, revealed the purpose was to maintain the personal hygiene and dignity of residents while ensuring that the nursing home provides a safe, clean, and respectful environment. Under the section titled Shower Sheet and Documentation, revealed 1. Completion of the Shower Sheet: After each shower (or refusal), the designated staff member will fill out a shower sheet, which will include the following, resident's name, date of shower or refusal, time of shower or refusal, reason for refusal, staff involved, outcome of attempt. 2. Shower refusal documentation: if the resident refuses, additional notes should be made in the care plan and the shower sheet. Any refusals should be reviewed regularly by the care team to assess ongoing needs or concerns.

Based on medical record review, policy review and staff interview, the facility failed to ensure an assessment for proper indication of antibiotic use was completed prior to utilizing antibiotic medications. The affected three (Residents #7, #8 and #10) of five residents reviewed for medications. The facility census was 42. Findings include: 1. Review of Resident #7's medical record revealed an admitted [DATE] with diagnosis that included Alzheimer's disease, tracheostomy and fibromyalgia. Further review of the medical record including physician's orders revealed the use of the following antibiotics:: 09/07/24, doxycycline (antibiotic)100 milligrams (mg) twice daily for nine days for a wound infection; 08/27/24, Bactrim DS (antibiotic) 800-160 mg twice daily for 10 days for cellulitis; 03/19/24, cephalexin (antibiotic) 500 mg four times daily for infection, no indication was found for use of the medication; 02/19/24, ciprofloxacin (antibiotic) 500 mg twice daily for 10 days for infectious sputum. Further review of the medical record revealed no evidence of any assessment completed to determine appropriate indication for the use of the above antibiotic medications. 2. Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses that included diabetes mellitus, adjust disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Further review of the medical record including physician's orders revealed the use of the following antibiotics: 12/10/24, ceftriaxone (antibiotic) one gram (gm) intramuscularly daily for seven days for a urinary tract infection.; 11/22/24, ampicillin (antibiotic) 500 mg three times daily for ten days for a urinary tract infection and 11/10/24 doxycycline 100 mg twice daily for ten days for cellulitis. Further review of the medical record revealed no evidence of any assessment completed to determine appropriate indication for the use of the above antibiotic medications. 3. Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease and diabetes mellitus. Further review of the medical record including physician's orders revealed the use of the following antibiotics: 10/10/24, cephalexin (antibiotic) 250 mg every day for seven days for cellulitis; 09/06/24, cefuroxime (antibiotic) 500 mg twice daily for five days for pneumonia; 05/11/24, Augmentin (antibiotic) 875-125 mg twice daily for 10 days for pneumonia; 03/05/24, ceftriaxone (antibiotic) one gm intramuscularly for seven days for pneumonia. Further review of the medical record revealed no evidence of any assessment completed to determine appropriate indication for the use of the above antibiotic medications. On 02/12/25 at 1:10 P.M. interview with Licensed Practical Nurse (LPN) #72, revealed she was the infection preventionist for the facility and started the position in early December 2024. The pervious infection preventionist and administrative nursing staff left no antibiotic assessments. LPN #72 verified that no antibiotic assessments were completed for Residents #7, #8 and #10 for the above dates. LPN #72 indicated the facility utilized the McGeer Criteria to determine appropriate use of antibiotics. Review of the facility policy Antibiotic Stewardship Program dated 05/2024 indicated the nurse that is receiving the orders from the physician to ensure that the infection meet the McGeer Guidelines (criteria used to determine appropriate use of antibiotics) by use of the McGeer Criteria for Infection Surveillance Checklist. Checklist should be completed with every suspected infection.

Based on medical record review, policy review and staff interview, the facility failed to ensure a resident was offered influenza and pneumococcal vaccines after admission to the facility. This affected one (Resident #8) of five residents reviewed for vaccines. The facility census was 42. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] with diagnosis that included diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Further review of the medical record including immunization revealed no evidence of any vaccines administered including influenza or pneumococcal. No evidence of any declination was found within the medical record. On 02/13/25 at 10:45 A.M. interview with Licensed Practical Nurse (LPN) #72 indicated the facility policy was to offer vaccines to residents annually and did not indicate anything related to new admission residents after the facility's annual vaccine clinic. LPN #72 verified Resident #8 was not reviewed or offered influenza or pneumococcal vaccines following admission to the facility. Review of the facility policy Influenza Vaccine dated 03/2021 indicated the influenza vaccine will be offered to all of the residents annually. The policy did not indicate any instructions for new admissions to the facility. Review of the facility policy Pneumococcal Vaccine dated 03/2021 revealed no instructions for new admissions to the facility including review and offering vaccines.

Based on medical record review, policy review and staff interview, the facility failed to ensure a resident was offered COVID-19 vaccines after admission to the facility. This affected one (Resident #8) of five residents reviewed for vaccines. The facility census was 42. Findings include: Review of Resident #8's medical record revealed an admitted [DATE] with diagnosis that included diabetes mellitus, adjust disorder with mixed anxiety and depressed mood, bipolar disorder and post-traumatic stress disorder. Further review of the medical record including immunization revealed no evidence of any vaccines administered including COVID-19. No evidence of any declination was found within the medical record. Review of the undated facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents and Staff revealed no evidence of instructions regarding offering and/or reviewing of vaccines following admission to the facility. On 02/13/25 at 10:45 A.M. interview with Licensed Practical Nurse (LPN) #72 indicated the facility policy was to offer vaccines to residents annually and did not indicate anything related to new admission residents after the facility annual vaccine clinic. LPN #72 verified Resident #8 was not reviewed or offered COVID-19 vaccine following admission to the facility.

Based on observation, interviews, and review of the daily posting it was determined the facility failed to ensure accomodation of resident needs to ensure resident's call lights were answered timely. This affected four residents (#3, #9, #20, and #40) of 41 residents residing in the facility. Findings included: Review of the daily posting dated 10/02/24 revealed the census was 41. There was one Registered Nurse (RN), two Licensed Practical Nurses (LPN), and seven State tested Nurses' Aides (STNA) to provide direct care to the 41 residents residing in the facility. Observation on 10/02/24 at 7:31 A.M. of call lights revealed Resident #9's call light had been activated prior to the surveyor entering the unit. The call light was activated until 7:39 A.M. when a staff member answered the light. Staff were observed walking by the call light and a housekeeping staff was observed in the hallway during the eight-minute observation and no one answered Resident #9's call light. Observation on 10/02/24 at 8:00 A.M., revealed Resident #20's call light was activated. The call light was not answered until 8:21 A.M. by State tested Nurse Aide (STNA) #173. Interview on 10/02/24 at 8:23 A.M., with Resident #9 confirmed call lights were not answered timely. The resident reported she has waited 30 minutes to an hour for staff to answer her call light. The resident reported she has chronic pain and needs to keep her pain medication on a schedule to manage her pain. The resident reported she must activate her light prior to needing pain medication due to the anticipation it would take staff awhile to respond to her call light. Interview on 10/02/24 at 8:25 A.M., with STNA #173 confirmed she was the first staff member to respond to Resident #20's call light. The STNA reported she was not sure who was assigned to that unit due to the assignment sheet was missing this morning and staff were going back and forth from both units helping each other. Interview on 10/02/24 at 12:57 P.M., with Resident #3 confirmed staff do not respond timely to call lights. The resident reported sometimes it takes up to an hour for staff to respond to her call light. Observation on 10/02/24 at 1:04 P.M., revealed Resident #3's call light was activated prior to the surveyor entering the unit. The call light was not answered until 1:12 P.M. Observation on 10/02/24 at 1:16 P.M., revealed Resident #40's call light was activated. The call light was not answered until 1:26 P.M. Interview on 10/02/24 at 1:20 P.M. with LPN #153 confirmed staff do not answer call lights timely. The LPN reported staffing shortages was not the issue. The LPN reported staff either ignore the call lights or refuse to provide care to certain residents. Interview on 10/02/24 at 1:35 P.M., with the Director of Nursing (DON) revealed staff not answering call lights timely has been an issue for a few months. The DON reported staffing shortage was not the issue for example today the facility had three nurses and seven STNA's for 41 residents and the issue seems to be staff congregate in one area. This deficiency represents non-compliance investigated under Complaint Number OH00157827.

Based on medical record review, review of shower schedule, and interviews the facility failed to ensure resident dependent on staff for bathing had bath preference honored. This affected three residents (#9, #22, and #43) of three records reviewed. Findings included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure, paraplegia, pressure ulcer to heels and sacrum, chronic kidney disease, heart disease, chronic pain, colostomy, gastrostomy, and urinary catheter. Review of the shower sheet (undated) revealed Resident #9's shower days were Tuesday and Thursday. Review of Resident #9's bath task dated [DATE] to [DATE] revealed no evidence the resident received a shower. Interview on [DATE] at 8:23 A.M., with Resident #9 revealed she just returned to the facility on [DATE] after being hospitalized for two months. The resident reported she has never had a shower since she was originally admitted to the facility, however she would like to have a shower. The resident reported she was dependent of staff for showering because she was a paraplegic. Interview on [DATE] at 1:35 P.M., with the Director of Nursing (DON) confirmed there was no documented evidence Resident #9 had received a shower per her preference. 2. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including hemiplegia, cerebral infarction, need assistance with personal care, dysphagia, visual lost both eyes, dermatitis, and dementia. Review of Resident #22's risk for self-care deficit: bathing, dressing, feeding plan of care initiated on [DATE] revealed to encourage the resident to participate in planning day to day care. Maintain consistent schedule with daily routine. Provide assistance with activities of daily living (ADL). Review of shower schedule (undated) revealed the resident scheduled for a shower on Tuesday, Thursday, and Friday. Review of Resident #22 bathing task dated [DATE] to [DATE] revealed the resident was bathed on [DATE] and [DATE] and was totally dependent on staff. The task did not include the type of bath (shower/bed bath) the resident received. Interview on [DATE] at 11:54 A.M., with Licensed Practical Nurse (LPN) 173 revealed Resident #22's wife has voiced concerns that staff would not provide care or check on her husband due to his inappropriate sexual behaviors. The wife has placed a camera in the room and has evidence, but she continues to have concerns. Interview on [DATE] at 1:35 P.M. with the director of nursing (DON) confirmed there was no documented evidence resident received a bath/shower on Tuesday, Thursday, or Friday except for the two documented in the electronic medical record under task on [DATE] and [DATE]. The DON confirmed the task doesn't indicate what type of bath (shower or bed bath) was performed. 3. Record review revealed Resident #43 was admitted to the facility on [DATE] and expired on [DATE]. The resident diagnoses included vertigo, cerebral infarctions, Raynaud's, history of falls, and history of transient ischemic attack. Review of Resident #43's bathing task revealed the resident received some type of bath on [DATE], [DATE], and [DATE] and was totally dependent on staff. Interview on [DATE] at 1:35 P.M., with the DON confirmed there was no documented evidence Resident #43 received a shower on [DATE] or [DATE] per his preference. The DON confirmed the task doesn't specify what type of bath the resident received on [DATE], [DATE], [DATE]. Interview on [DATE] at 9:42 A.M., with State tested Nurse's Aide (STNA) #171, #162, #184, #166 confirmed resident bathing preferences were not being honored. The STNA's reported they pass on to the next shift which showers were not performed on days, however they don't believe second shift were completing the showers as well because they don't even do their own scheduled showers, and dayshift tries to do second shift showers if they have time. Interview on [DATE] at 1:54 P.M., with Licensed Practical Nurse (LPN) #173 confirmed resident's bathing preferences were not being honored. The LPN reported staff report they don't have enough time to complete showers. This deficiency represents non-compliance investigated under Complaint Number OH00157827.

Based on review of personnel files and interview, the facility failed to ensure nursing assistants received required training prior to providing direct care to residents. This had the potential to affect all 46 residents. Findings include: 1. On [DATE] at 11::15 A.M., Employee #145 (who introduced herself as a nurse aide in training) stated she had not yet started nurse aide training classes. Employee #145 stated she had worked in a group home in the past. Employee #145 stated she had four 12 hours days of orientation with another aide. Employee #145 indicated her duties included helping with meals, providing showers, and providing incontinence care. Employee #145 stated she was performing all the same duties as state tested nursing assistants. Employee #145 stated she had never received dementia training or how to deal with aggressive behaviors. During orientation she received information about specific residents and their behaviors and preferences. On [DATE] at 1:26 P.M., Human Resource (HR) employee #150 verified Employee #145 was not in classes but was functioning as a state tested nursing assistant. HR #150 stated she was told by the Administrator that employees could work for four months until they got into a class. HR #150 stated Employee #145 had experience in a group home before hired but acknowledged the training was different. Review of Employee #145's personnel file indicated she was hired [DATE] as a nurse aide trainee. Review of the application for employment revealed Employee #145 had attended one year of nursing school but had not graduated. The year of nursing school attendance was not listed. Work experience over the last [AGE] years included a teacher's aide ([DATE] to [DATE], a laborer/intake personnel from [DATE] to [DATE], and a home manager from [DATE] to the time of the application. An orientation/annual skills checklist indicated Employee #145 had been signed off on nursing care on [DATE]. During review of the personnel records on [DATE], Registered Nurse (RN) #105 stated it was the aide who was orienting new nursing assistants who signed off on the skills checklist. 2. Review of State tested Nursing Assistant (STNA) #155's personnel file revealed a date of hire of [DATE]. Review of the application revealed STNA #155 had graduated high school. Her work experience included jobs in collections and retail. A nurse aide registry check dated [DATE] revealed she was not on the nurse aide registry. Review of a nurse aide orientation/annual skills checklist form revealed skills were checked off on [DATE]. Review of a certificate of successful completion of a nurse aide training and competency evaluation program (NATCEP) revealed a completion date of [DATE]. Review of nurse aide registry information revealed an original approval date of [DATE]. On [DATE] at 11:37 A.M., the Administrator was asked to explain the discrepancy between the completion of the skills checklist on [DATE] when the form indicated a hire date of [DATE]. On [DATE] at 1:46 P.M., the Administrator stated the [DATE] hire date was incorrect. The actual hire date was [DATE]. 3. Review of STNA #120's personnel file revealed a date of hire of [DATE]. Review of the application for employment revealed STNA #120 had attended some nursing classes but had not graduated. The years of attendance were not documented. Review of a nurse aide registry check revealed STNA #120 was not on the registry with a hand-written note that her registration had expired on [DATE]. Review of an orientation checklist revealed all skills were checked off on the date of hire. Review of a certificate of successful completion of a NATCEP program revealed a completion date of [DATE]. Review of nurse aide registry information revealed an original approval date of [DATE]. 4. Review of STNA #110's personnel file revealed a hire date of [DATE]. Review of the application for employment revealed STNA #110 started training as a medical assistant but did not graduate. The year of attendance was not documented. Work experience included retail, a housekeeping aide, and an aide for private home health. Review of a nurse aide registry check dated [DATE] revealed STNA #110 was not on the nurse aide registry. Review of an orientation /skills check list revealed all skills were signed off the date of hire. Review of a certificate of successful completion of a NATCEP program revealed a completion date of [DATE]. Review of nurse aide registry information revealed an original approval date of [DATE]. On [DATE] at 9:48 A.M., HR #150 verified all four of the above employees were hired as nursing assistants without being on the nurse aide registry at the time of hire and not being enrolled in nurse aide registry classes or enrolled in nursing school at the time of hire. The facility believed they had four months to get the aides into the nurse aide classes. HR #150 verified some of the employees had worked longer than four months but stated the Administrator decided who entered the NATCEP program and when.

Based on record review and investigation, the facility failed to ensure administrative staff maintained records in a secure and accessible area and failed to ensure incidents of elopement were investigated and evaluated to ensure safety of wandering residents. This affected all 46 residents. Findings include: 1. During an entrance conference with the Administrator on 05/16/24 at 12:51 P.M., a request was made for infection control surveillance logs for the past three months. On 05/16/24 at 4:50 P.M., the Administrator stated he could not locate evidence of infection control logs since February 2024. The prior Director of Nursing (DON)/Registered Nurse (RN) #200 kept the information on her personal ipad and her employment had ended on 05/15/24 and no records were available. On 05/21/24 at 9:15 A.M., RN #100 stated she was able to locate some infection control paper work through February 2024 but could find nothing since then. RN #100 stated she had been unable to find any information that showed an evaluation of the infection data and never recalled RN #200 discussing evaluations of any patterns or action needed in relation to infections. On 05/23/24 at 2:38 P.M., the Administrator reported the facility had requested the infection surveillance records from RN #200 and was told she left everything at the facility except what had been on her Macbook and she had deleted all of it. 2. During review of elopements by Resident #18 on 03/03/24 and 03/04/24, a request was made for any type of investigation. On 05/21/24 at 8:39 A.M., RN #100 stated the facility had been unable to locate any type of investigation/witness statements for the incidents on 03/03/24 or 03/04/24. RN #100 stated the Administrator informed he thought the previous Director of Nursing (DON)/RN #200 had a file that staff had been unable to locate. On 05/23/24 at 1:49 P.M., RN #125 verified she worked on 03/03/24 when Resident #18 was located by staff outside the facility on night shift and she returned without incident. RN #125 stated nobody had asked her for any additional details other than what she had reported. RN #125 stated she believed Resident #18 exited the facility out of the door by the kitchen. RN #125 stated she was not sure if the door alarmed or if it was shut off. On 05/23/24 at 2:38 P.M., the circumstances regarding Resident #18's elopement and lack of investigation was discussed with the Administrator. The Administrator stated after the nurses reported the elopement incidences to RN #200 she stated she would handle it from there and he believed she had followed up on it. The Administrator stated if Resident #18 left the door which was indicated during the interview with RN #125 it would have had to been out the door to the back patio. The Administrator indicated he was not sure if the door was alarmed. It used to have a battery operated alarm but he would double check. On 05/23/24 at 3:15 P.M., observation of the door in the dining room near the kitchen revealed a white alarm box. There was no sound when RN #100 opened the door three times. The door led to a courtyard with a gate which could be opened without alarming. RN #125 accompanied RN #100 and the surveyor outside and revealed Resident #18 was located outside the fenced in area and she ambulated with her around the building before going back inside on 03/03/24. On 05/23/24 at 3:17 P.M., the Administrator was informed no sound was heard when the door was opened. The Administrator responded the alarm did not sound at the door but there was a unit that alarmed at the nursing station. No alarming was heard at the nursing station and the Administrator confirmed he was unable to locate the box that he referred to. On 05/28/24 at 4:26 P.M., the Administrator stated the elopement on 03/03/24 occurred between 6:30 P.M. and 7:00 P.M. On 05/28/24 at 4:59 P.M. the Administrator stated he was unable to verify or find any written records for the last time the alarm on the dining room door leading to the patio was checked or monitored.

Based on observation, interview, and policy review, the facility failed to provide evidence of infection control surveillance and failed to implement proper hand hygiene and use of personal protective equipment (PPE) during care of a feeding tube. This affected Residents #3 and #22 and had the potential to affect all residents. The facility census was 46. Findings include: 1. During an entrance conference with the Administrator on 05/16/24 at 12:51 P.M., a request was made for infection control surveillance logs for the past three months. On 05/16/24 at 4:50 P.M., the Administrator stated he could not locate evidence of infection control logs since February 2024. Registered Nurse (RN) #200 kept the information on her personal ipad and her employment had ended on 05/15/24 and no records were available. On 05/20/24 at 8:04 A.M., RN #100 stated since the facility had been unable to locate infection control logs/surveillance she had calls out to the pharmacy to get antibiotic reports and was looking at orders in medical records. On 05/21/24 at 9:15 A.M., RN #100 carried some papers with her and stated she had some infection control sheets through February 2024 but could find nothing since then. When infections were discussed in risk meetings she did not recall RN #200 (the previous infection control preventionist) discussing evaluation of any trends or any action needed taken so RN #100 could not speak to evaluation of gathered information. RN #100 stated when she completed Minimum Data Set assessments she reviewed anybody on antibiotics to ensure they met McGeer's criteria for coding purposes but that was not documented either. On 05/23/24 at 2:38 P.M., the Administrator reported the facility had requested the infection surveillance records from RN #200 and was told she left everything at the facility except what had been on her Macbook and she had deleted all of it. 2. During medication administration observations on 05/20/24 at 5:10 A.M., Licensed Practical Nurse #170 dropped four pills on the cart while attempting to pour them from a plastic sleeve into a medication cup. LPN #170 used her bare hands to pick up two of the pills to put them back into the cup and stated she should not have done that. LPN #170 donned gloves to pick up the other two pills and placed them in the medication cup. After adding additional medications to the cup, all the medications were administered to Resident #22. 48567 3. Review of the Medical record for Resident #3 revealed she was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of the left femur, interstitial pulmonary disease, chronic obstructive pulmonary disease (COPD), emphysema, protein-calorie malnutrition, anorexia, cachexia, dehydration, adult failure to thrive, and gastrostomy status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. Further review of the MDS revealed Resident #3 had a feeding tube and received 51% or more of her calories from tube feedings. Review of the care plan dated 05/17/24 revealed Resident #3 the potential for nutritional problems related to tube feedings, adult failure to thrive, COPD, unspecified protein-calorie malnutrition, anorexia/cachexia, hypothyroidism, potential for altered fluid status, edentulous, hypokalemia, depression, variable oral intake, and the need for nutrition support and therapeutic diet. Interventions included providing enteral feedings and supplements as ordered. Review of the physician orders revealed an order dated 05/16/24 for Resident #3's percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed tube into the stomach of the resident for nutrition) to be flushed with 135 milliliters (ml) of water four times a day. Further review of the orders revealed an order dated 04/22/24 for enhanced barrier precautions instructing staff to wear a gown and gloves when providing device care or using devices, including a feeding tube. Review of the care plan dated 05/17/24 revealed Resident #3 the potential for nutritional problems related to tube feedings, adult failure to thrive, COPD, unspecified protein-calorie malnutrition, anorexia/cachexia, hypothyroidism, potential for altered fluid status, edentulous, hypokalemia, depression, variable oral intake, and the need for nutrition support and therapeutic diet. Interventions included providing enteral feedings and supplements as ordered. Observation on 05/21/24 at 12:12 P.M. of licensed practical nurse (LPN) #115 administering Resident #3's water flush revealed LPN #115 did not don a gown and did not wash her hands prior to donning gloves and starting the procedure. Further observation revealed LPN #115 paused the procedure after blousing 100 ml of water to obtain more water from Resident #3's bathroom sink to flush through the PEG tube. During this observation, no glove change or hand hygiene was performed as LPN #115 manipulated the sink faucet, refilled the graduate (plastic container used for measuring liquids) with water, and proceeded to administer another bolus of water through Resident #3's PEG tube. Interview on 05/21/24 at 12:18 P.M. with LPN #115 confirmed she did not perform hand hygiene prior to the water bolus via Resident #3's PEG tube. An additional interview conducted on 05/21/24 with LPN #115 at 3:40 P.M. confirmed her typical practice does not include donning a gown when providing tube feedings or rendering feeding tube care and that she had no gown on when she flushed Resident #3's PEG tube with water. Review of the policy dated 03/18/15, titled Hand Hygiene/Washing, revealed hands were to be washed thoroughly before and after providing direct resident care to reduce the transmission of organisms from nursing staff to resident and vice-versa. Review of the policy titled Enhanced Barrier Precautions, dated 03/27/24, revealed use of standard precautions, as well as donning a gown, was required for high contact resident care activities which included use or care of a feeding tube. This deficiency represents non-compliance investigated under Master Complaint Number OH00152953.

Based on review of infection surveillance records and interview, the facility failed to ensure a minimum of one individual was qualified to perform the job of an infection preventionist. This had the potential to affect all 46 residents. Findings include: During the entrance conference with the Administrator on 05/16/24 at 12:51 P.M., he reported the Director of Nursing (DON) who had also been assigned as the facility's Infection Preventionist (IP) had a last day of employment at the facility on 05/15/24. On 05/21/24 at 9:15 A.M., Registered Nurse (RN) #100 verified the facility had no other staff member who had completed specialized training in infection prevention and control to serve as the IP.

Based on medical record review and interview, the facility failed to provide restorative nursing services, according to program instruction, to maintain residents' range of motion for four (Residents #2, #9, #10 and #42) of four residents reviewed for range of motion. The facility identified 11 residents on restorative programs for range of motion. The facility census was 46. 1. Review of Resident #10's medical records revealed diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus with diabetic neuropathy, malignant neoplasm of the glottis (center of the larynx (voice box) ), chronic peripheral venous insufficiency, heart disease, and macular degeneration. Review of a care plan initiated 02/05/24 revealed Resident #10 was on a restorative nursing program (RNP). Interventions included documenting participation in RNP, report to nursing complaints of pain during restorative active range of motion (AROM) programs and the registered nurse (RN) was to review compliance of and effectiveness of RNP. Review of restorative task revealed a program for bilateral lower extremity (BLE) AROM six to seven days a week, repetitions of ten while using three pound weights, cue to perform ten repetitions of abduction, adduction, external rotation and internal rotation of bilateral hips, cue to perform ten repetitions of dorsal flexion, plantar flexion, eversion and inversion to bilateral ankles, and cue to provide ten repetitions of flexion and extension to bilateral hips/knees. Review of restorative delivery records revealed the week of 04/28/24 to 05/04/24 revealed the RNP was offered once with a record of four minutes minutes provided. No refusals were documented. Records reflected the week of 05/05/24 to 05/11/24 the RNP was provided once for four minutes. The week of 05/12/24 through 05/18/24 documentation indicated the RNP was offered three times with two refusals. During review of restorative delivery records with RN #100 on 05/23/24 at 12:20 P.M., she verified the records did not indicate the RNP program was offered/delivered in accordance with program. On 05/23/24 at 1:12 P.M., Resident #10 stated staff rarely offered his ROM exercise program. 2. Review of Resident #9's medical record revealed diagnoses including heart disease, depression, pain in the right shoulder, muscle wasting, and dementia. A care plan initiated 04/03/23 revealed Resident #9 had AROM restorative program to his right shoulder related to complaints of pain. Resident #9 was able to perform range of motion (ROM) but required cues from staff and encouragement as needed. Interventions included documenting participation in the restorative program and report to nursing any pain/discomfort during the restorative program. A care plan initiated 04/03/23 revealed the resident had AROM restorative program to the right shoulder related to complaints of pain. The resident was able to perform ROM but required cues from staff and encouragement as needed. Interventions included documenting participation in the restorative program, report to nursing any signs or symptoms (s/s) of pain/discomfort during the restorative program. Review of the restorative delivery records revealed there were two programs. The first program was for assisted active range of motion (AAROM) to the right shoulder six to seven days a week, twice a day. The resident was to be cued to perform seven to ten repetitions to the left should while in a lying position, in bed or sitting in the chair of forward flexion and extension, abduction and adduction, and external/internal rotation. A hot pack was to be applied to the left shoulder to alleviate/decrease pain. Review of delivery records from 04/24/24 to 05/23/24 revealed the only day the services were documented twice in a day was on 04/29/24. Documentation revealed the week of 04/28/24 through 05/04/24 revealed the services were provided four days. Between 05/05/24 and 05/11/24 the RNP was documented twice with one of the sessions being four minutes. Between 05/12/24 and 05/18/24 documentation revealed the RNP was provided four days. No refusals were documented. On 05/23/24 at 12:20 P.M., RN #100 verified the records did not revealed the RNP was implemented as written. On 05/23/24 at 12:58 P.M., Resident #9 stated STNAs did not do his exercise program with him. He believed the only ones who did exercises consistently was when he received therapy. 3. Review of Resident #2's medical record revealed diagnoses including COPD, seizures, altered mental status, osteoarthritis and muscle wasting. Review of a care plan initiated 08/23/23 revealed Resident #2 was on restorative nursing programs for AAROM to both lower extremities and a transfer program. Interventions included documenting participation in RNP. Review of the restorative delivery records revealed between 04/28/24 and 05/04/24 the restorative program for transfers was provided three times. The AAROM program was provided four times. Restorative delivery records between 05/05/24 and 05/11/24 indicated both RNP programs were offered twice. Review of Restorative delivery records between 05/12/24 and 05/18/24 indicated both RNP programs were offered twice. On 05/23/24 at 12:20 P.M., RN #100 verified the records did not revealed the RNP was implemented as written. 4. Review of Resident #42's medical record revealed diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and major depressive disorder. A care plan initiated 08/23/23 that indicated RNPs for Passive Range of Motion (PROM) to be provided six to seven days a week and transfers to be provided twice a day. Review of the restorative delivery records between 04/28/24 and 05/04/24 indicated the ROM RNP was provided one time. There was no documentation of the transfer program being provided. Review of the restorative delivery records from 05/05/24 and 05/11/24 indicated both programs were administered one day. Review of restorative delivery records between 05/12//24 and 05/18/24 indicated both programs were provided one day. On 05/23/24 at 2:28 P.M., Restorative Aide #175 reported she worked four days a week but she was pulled to work the floor three to four of those days. Restorative Aide #175 stated she tried to do programs as time permitted (in addition to her floor assignment). She stated Management was aware. The only decline she had noted was with Resident #28 after she had returned from the hospital. Restorative aide #175 stated she had spoken to other aides about completing the restorative programs on their assignments when she was unavailable to do them. However, some of the other aides acted like it was not their responsibility and did not provide the programs.

Based on medical record review, review of pharmacy recommendations, and interviews the facility failed to ensure pharmacy recommendations were acted upon timely. This affected four (Residents #10, #13, #34, and #40) of five residents reviewed for medication use. The facility census was 46. Findings include: 1. Review of Resident #13's medical record revealed diagnoses including hemiplegia (paralysis of one side of the body) affecting the right dominant side, rhabdomyolysis (condition in which damaged skeletal muscle breaks down rapidly, contracture of the right hand, heart failure, benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland)., gastroesophageal reflux disease, stiffness of the right shoulder, speech disturbance, acquired absence of the spleen, history of falling, hypertension, and muscle wasting. Review or a medication regimen review dated 03/13/24 revealed a diagnosis was needed to support the use of risperidal (an antipsychotic medication). The physician response was blank. A physician order for risperidal 0.25 milligrams every day was written on 03/04/24. On 05/21/24 at 8:28 A.M., Registered Nurse (RN) #100 stated she had been unable to locate all the pharmacy reviews for the residents over the past six months so she had to contact pharmacy to get the reviews/recommendations resent to her and she was attempting to make sure the reviews had been addressed. RN #100 verified she had been unable to locate a diagnosis to justify the use of the risperidal. On 05/21/24 at 12:19 P.M., RN #100 stated the risperidal was originally started on 03/04/24 for behaviors. Resident #13 was followed by psychiatric services who indicated the risperidal was for behaviors. RN #100 verified she was unable to locate any information indicating an approved diagnosis for the use of antipsychotic medication or why the benefit of using risperidal would outweigh the risks. 2. Review of Resident #40's medical record revealed diagnoses including hypothyroidism and bipolar disorder. On 05/05/23 an order was written for synthroid 150 micrograms every day for hypothyroidism. Review of a pharmacy recommendation dated 11/26/23 addressed the use of synthroid with no Thyroid Stimulating Hormone (TSH) level scheduled in the chart. The area for the physician response revealed no response. There was no TSH level observed in the medical record since 11/26/23. On 05/21/24 at 8:28 A.M., RN #100 stated the facility had no previous TSH order written since the pharmacy review on 11/26/23. The last TSH obtained was 12/20/22. Review of the TSH level obtained 05/21/24 (after identification the lab test had not been obtained since 12/20/22) revealed the TSH level was 1.58 uIU/ML (equivalent to mili-international units/liter) with a reference range of 0.35 - 3.74 uIU/ML. 3. Review of Resident #34's medical record revealed diagnoses including type two diabetes mellitus and severe dementia with psychotic disturbance. On 08/01/23 an order was written for an insulin sliding scale with novolog (subcutaneously) (SQ) for blood sugar levels starting at 150 milligrams (mg) per deciliter (dL) of blood On 01/22/24, an order was written for levemir (long acting insulin) five units SQ every day. Review of the pharmacy review/recommendations since November 2023 revealed on 03/13/24 the pharmacy identified there was no order for an A1c level (test that measured average blood sugar levels over a two to three month period) although Resident #34 was receiving insulin. There were no A1c levels located since the review/recommendation. There was no physician response as the facility had to contact the pharmacy to provide pharmacy reviews since the reviews had not been available. On 05/21/24 at 8:28, RN #100 revealed the last A1c level she located was obtained 06/20/23 and the pharmacy recommendation had no been addressed. 4. Review of Resident #10's medical record revealed diagnoses including type two diabetes mellitus with diabetic neuropathy and chronic peripheral insufficiency. Insulin orders included: On 12/27/23 novolog 100 u/ml SQ per sliding scale with insulin starting for a blood glucose level of 165 mg/dL (normal range from 60-100) and on 12/27/23 tresiba 100 u/ml: administer 60 units in the morning SQ. Review of a pharmacy recommendation dated 11/26/23 revealed Resident #10 was receiving insulin but did not have an A1c level scheduled in the chart. No response was documented by the physician. No A1c results were located in the medical record since the pharmacy review was completed on 11/26/23. On 05/21/24 at 8:28 A.M., RN #100 stated Resident #10's last A1c was drawn 04/13/23 and when she contacted the doctor about the pharmacy review the physician stated he had provided standing orders that indicated if a resident was receiving insulin they should be followed by obtaining A1c labs. On 05/21/24 at at 12:16 P.M., RN #100 indicated she had gotten copies of pharmacy recommendation for the past six months and was trying to ensure they were addressed. The RN verified she was unable to locate the reviews for the last six months. This deficiency represents non-compliance investigated under Master Complaint Number OH00152953.

Based on observations, interviews and review of Medscape online information regarding humalog insulin storage the facility failed to ensure the proper labeling and storage of medications. This affected five residents (Resident #1, #21, #33, #45 and #48) of 46 residents with medications secured in the two facility identified medication carts. Findings include. 1. While observing the 100/200 hall medication cart with Registered Nurse (RN) #135 on 05/16/24 at 1:38 P.M., Resident #21 had two bottles of opened humalog insulin. The insulin was not dated as to when it was opened. RN #135 stated the insulin vials were transferred with Resident #21 from another facility upon admission so she did not know how long they had been opened. Review of the Electronic Health Record (EHR) revealed Resident #21 was admitted to the facility on [DATE]. Review of Medscape information on humalog insulin revealed open vials could be stored/used for up to 28 days after opening the vial. 2. While observing the 100/200 hall medication cart with Registered Nurse #135 on 05/16/24 at 1:38 P.M., Resident #1 was observed to have earwax removal solution opened on 03/21/24 with a label indicated the order was for a limited time. RN #135 stated once the order had been fulfilled, the earwax removal solution should have been discarded. 3. While observing the 100/200 hall medication cart with Registered Nurse #135 on 05/16/24 at 1:38 P.M., an inhaler with only the last name of Resident #48 was observed in the medication cart with no label. RN #135 stated the label would have been on the box. The empty box must have been sent with Resident #48 upon discharge. Review of the EHR revealed Resident #48 discharged from the facility 05/14/24. 4. During observations of the 300/400 medication cart with Licensed Practical Nurse (LPN) #140 on 05/16/24 at 1:50 P.M., she verified Resident #35's athlete's foot cream and triamcinolone cream, Resident #33's lotrisone cream, Resident #45's nystatin topical powder, and two additional topical creams she had removed from the cart were stored with residents' oral medications. None of the pills were observed to be contaminated by the creams. During an interview on 05/21/24 at 3:34 P.M., RN #100 stated the policy for storing medications was not specific but creams should be in the treatment cart, not with medications. Insulin was to be stored in accordance with manufacturer recommendations. This deficiency represents non-compliance investigated under Master Complaint Number OH00152953.

Based on record review and interview, the facility failed to ensure the accuracy and completeness of medical records. This affected three known residents (Resident #13, 18, and #47) but had the potential to affect all residents in the facility. The census was 46. Findings include: 1. a Review of Resident #18's open medical record revealed diagnoses including dementia with agitation, type two diabetes mellitus, peripheral vascular disease, major depressive disorder, muscle wasting, anxiety disorder, long term use of insulin, vitamin B12 deficiency, and acute angle-closure glaucoma in bilateral eyes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired with a score of 9 out of a possible score of 15. The MDS indicated Resident #18 was able to make herself understood and was able to understand others. The assessment did not indicate any wandering during the specified time frame. Review of a nursing note dated 03/04/24 at 6:13 P.M. revealed the nurse noted Resident #18 wandering outside on the patio after dinner. A wander guard was in place and functioning properly earlier in the shift and when Resident #18 was assisted back inside. The note indicated the physician was notified of Resident #18's exit seeking/elopement and the family request of anti- anxiety on an as needed basis. The daughter was notified. On 05/20/24 at 2:15 P.M., Registered Nurse (RN) #105 was asked for any information she had on Resident #18 being located outside without supervision. Resident #105 provided documentation which revealed Resident #18 was also found at the rear of the facility on 03/03/24 unaccompanied by staff. On 05/20/24 between 2:30 P.M. and 2:35 P.M., the lack of documentation of the 03/03/24 incident was discussed with RN #100 who was unable to provide an explanation. Review of a Medical Records policy (dated 03/18/15) addressed photocopying of medical records on request. The content of the charts were not addressed. Review of a Medical Records policy (dated 03/18/15) addressed reviewing a resident's chart by a resident, guardian, a durable power of attorney or a family member. The contents of the chart was not addressed. Review of a Resident Incidents policy (dated March 2022) revealed an incident report was to be completed at the time any incident involving a resident occurred. All falls and incidents were to be charted on by nursing staff. The incident reports were not part of the resident's medical record and were only used for internal communications and statistical information for quarterly meetings. Review of the facility's Elopement policy (dated March 2024) revealed staff were to update plans of care with interventions to protect from further elopement. An incident report was to be completed. 1 b During an interview with RN #100 on 05/23/24 at 10:04 A.M., she revealed it was the facility's policy to bathe/offer to bathe every resident every other day. Review of bathing records for Resident #18 from 04/20/24 to 05/20/24 revealed eight baths were recorded RN #100 reported she believed the bathing occurred but staff were not documenting. Review of Resident #18's bladder documentation revealed most entries revealed Resident #18 was incontinent. No entries were made for 04/23/24, 04/25/24, 04/27/24, 04/28/24, 05/01/24, 05/02/24, 05/04/24, 05/06/24 through 05/08/24, 05/11/24 - 05/14/24, 05/16/24, or 05/19/24. Only on 04/22/24 did staff document on two shifts. Interview of RN #100 on 05/23/24 at 10:04 A.M. revealed she believed it was a documentation issue. 2. On 05/23/24 at 1:23 P.M., Licensed Practical Nurse (LPN) #115 stated she had heard of nurses on day shift giving night shift medications then night shift nurses signed off the were administered but she had never witnessed it and she administered/signed off administration of all her own medications. LPN #115 could or would not specify the dates/times/residents involved. On 05/23/24 at 1:49 P.M., Registered Nurse (RN) #125 stated she had worked night shift and two day shift nurses would sometimes administer 8:00 P.M. medications with medications ordered for 6:00 P.M. administration. RN #125 stated the day shift nurses thought they were helping and verified she had signed off administration of medications she had not personally administered. Review of the facility's Medication Administration policy (dated 07/24/23) revealed after a medication was administered the nurse should sign the Medication Administration Record (MAR). 3. Review of Resident #13's medical record revealed diagnosis included right side paralysis, muscle wasting, and stiffness of the right shoulder. Review of Resident #13's bathing records from 04/20/24 and 05/20/24 did not reveal baths were offered/provided every other day. Review of Resident #13's toilet use records from 04/20/24 and 05/20/24 revealed multiple days and/or shifts when there was no documentation of toileting assistance or incontinence care being provided. During an interview of RN #100 on 05/23/24 at 10:05 A.M., she reported she believed it was a documentation issue that baths were not provided every other day per policy or toileting/incontinence care was provided every shift. RN #100 stated she did not know if there was a written policy for baths but it was scheduled that residents in even rooms got showers on even days and residents in odd rooms got baths on odd days. 4. On 05/21/24 at 3:34 P.M., RN #100 provided a list of medications that had not been signed off as administered over the period of 05/14/24 through 05/20/24 per request. Among those not signed as administered were Resident #18's humalog via sliding scale on 05/14/24 at 4:00 P.M., Resident #15's exelon patches scheduled at 5:59 A.M. on 05/19/24 and 05/20/24, Resident #46's exelon patches scheduled at 5:59 A.M. on 05/19/24 and 05/20/24, Resident #19's exelon patches scheduled at 5:59 A.M. on 05/19/24 and 05/20/24, Resident #45's IV zosyn (antibiotic) scheduled for administration at 4:00 P.M. on 05/14/24, Resident #42's exelon patch scheduled for administration at 5:59 A.M. on 05/19/24 and 05/20/24. and Resident #10's novolog insulin scheduled by sliding scale on 05/14/24 at 4:00 P.M. The report also indicated a blood sugar was not recorded for Resident #38 on 05/14/24 at 5:00 P.M. On 05/21/24 at 3:34 P.M., RN #100 indicated she could not verify if the medications were administered and the blood sugar obtained or if nurses failed to document the administration. 48567 5. Review of the medical record for Resident #47 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, alcohol dependence with alcohol-induced persisting dementia, acute kidney failure, pneumonitis due to inhalation of food and vomit, dependence on supplemental oxygen, Barrett's esophagus without dysplasia, and unspecified toxic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 05/01/24 revealed Resident #47 had severely intact cognition. Further review of the MDS revealed Resident #47 was dependent for toileting, bathing, dressing, and personal care and required substantial assistance for toilet and tub transfers. The MDS assessment also revealed Resident #47 was always incontinent of bowel and bladder. Review of the care plan dated 01/15/24 revealed Resident #47 had an activities of daily living (ADL) self-care deficit related to impaired cognition, risk for falls, incontinence, impaired communication, and status post hospitalization due to multiple respiratory infections. Interventions included adjusting the level of support during the provision of Resident 47's ADL according to his changing abilities, cleaning and trimming nails on scheduled bath days, and providing Resident #47 a sponge bath in the event he is unable to tolerate a full bath or shower. Review of the care plan further revealed Resident #47 had bladder incontinence. Interventions included cleaning his perineal area with each episode of incontinence and monitoring and documenting any signs of urinary tract infection or changes in urinary frequency. Review of the physician orders revealed an order dated 03/29/24 for Resident #47 to have incontinence checks every one hour every day and every night. Review of bathing records for Resident #47 revealed no documentation of bathing during the last 30 days of his facility stay from 04/02/24 through 04/10/24, from 04/17/24 through 04/24/24, or from 04/27/24 through discharge date of [DATE]. Review of the medical record revealed Resident #47 had gone to the emergency roiagnom on [DATE] and returned 04/07/24. Review of the record for toilet use for the last 30 days of Resident #47's facility stay revealed no documentation of toilet use from 04/04/24 through 04/11/24, 04/13/24, 04/14/24, from 04/17/24 through 04/24/24, or from 04/28/24 through 05/01/24. Further review revealed documentation of Resident #47's refusal of toileting on 04/26/27. Interview on 05/21/24 at 4:55 P.M. with Registered Nurse (RN) #100 verified the periods when no bathing was documented and stated she believed Resident #47 was receiving his baths and it was a documentation issue. Further interview with RN #100 verified the records only indicated the support provided for the bathing activity and did not specify what type of bath was provided. During this interview, RN #100 also verified toileting records were incomplete. This deficiency represents non-compliance investigated under Master Complaint Number OH00152953 and Complaint Number OH00152844.

Based on observation, medical record review and interview, the facility failed to implement the use of a stop sign across a resident's room to deter wandering residents from entering her room. This affected one (Resident #29) of three residents reviewed for falls. The facility census was 46. Findings include: Review of Resident #29's medical record revealed diagnoses including dementia, need for assistance with personal care, and cognitive communication deficit. Review of a care plan initiated 01/14/14 indicated Resident #29 had a self care performance deficit with potential for fluctuations and/or decline related to dementia, forgetfulness and impaired decision making. The care plan was updated to initiate a stop sign to the doorway to deter wandering residents from entering starting 01/26/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was able to make herself understood and was able to understand others. Resident #29 was assessed as being severely cognitively impaired. On 05/16/24 at 1:35 P.M., Resident #29 was observed lying in bed. A sign posted on the wall indicated a stop sign (a mesh sign that is velcroed to each side of a resident's door and indicates stop on the sign to deter residents from entering room uninvited). was to be used at all times. There was a stop sign present at the entrance of the room but it was not across the door. On 05/16/24 at 2:24 P.M. Resident #29 was lying in bed. The stop sign was not across the door. Both ends of the stop sign were attached to the left doorframe. Interview of State tested Nursing Assistant (STNA) #110, who was passing by, revealed the stop sign was initiated to keep Resident #47 (no longer residing at the facility) out of the room so the stop sign was not utilized. On 05/16/24 at 2:37 P.M., Licensed Practical Nurse (LPN) #140 stated Resident #29's stop sign was initiated to deter wandering residents from entering her room. Although Resident #47 was no longer in the facility, the facility had another wandering resident, (Resident #31) but she seldom wandered into other resident rooms. LPN #140 verified the stop sign should have been in place and the LPN #140 hung the stop sign. On 05/20/24 at 10:58 A.M., Resident #29 was observed lying in bed. The stop sign was not across the door. Three unidentified staff members passed by the doorway without addressing it/placing the stop sign in the appropriate position. On 05/20/24 at 1:22 P.M., Resident #29 was observed lying in bed. The stop sign was not over the doorway. LPN #140 passed the room without addressing the stop sign.

Based on medical record review, policy review, and interview, the facility failed to ensure Resident #18's family/responsible party and physician were notified when Resident #18 was located outside the facility unaccompanied by staff. This affected one (Resident #18) of three residents reviewed for elopement. The facility census was 46. Findings include: Review of Resident #18's open medical record revealed diagnoses including dementia with agitation, type two diabetes mellitus, peripheral vascular disease, major depressive disorder, muscle wasting, anxiety disorder, long term use of insulin, vitamin B12 deficiency, and acute angle-closure glaucoma in bilateral eyes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #18 was moderately cognitively impaired with a score of nine out of a possible score of 15. The MDS indicated Resident #18 was able to make herself understood and was able to understand others. The assessment did not indicate any wandering during the specified time frame. Review of a wandering risk scale dated 12/15/23 revealed Resident #18 was assessed as a high risk to wander: The assessment revealed Resident #18 was ambulatory and able to communicate. Resident #18 had a history of wandering, had a medical diagnosis of dementia/cognitive impairment, had a diagnosis impacting gait/mobility or strength, and had wandered in the past month. The assessment indicated Resident #18 had often wandered around the facility stating she was going home. No interventions were noted on 12/15/23 when Resident #18 was assessed at high risk for wandering with knowledge that she was stating she wanted to go home. Review of a Brief Interview for Mental Status exam (BIMS) dated 01/23/24 revealed a score of three (out of a possible score of 15) indicating Resident #18 was severely cognitively impaired. Review of an incident report dated 03/03/24 at 11:23 P.M. indicated Resident #18 was found outside the back of the building by housekeeping staff stating she was going home. No injuries were noted. The mental status portion of the incident report indicated Resident #18 was oriented to person only but was confused to place and time. The incident report indicated Resident #18 was ambulatory without assistance. No notification of the physician or family/responsible party were noted according to the report. No nursing note was located regarding Resident #18 being found outside unaccompanied by staff on 03/03/24. On 05/21/24 at 5:02 P.M., Registered Nurse (RN) #100 was informed a note was not located for the 03/03/24 incident and there was no evidence of notification of the physician or responsible party. No further information was provided. On 05/23/24 at 1:49 P.M., RN #125 verified she worked on 03/03/24 when Resident #18 was located by staff outside the facility on night shift and she returned without incident. RN #125 indicated she did not recall if she called the physician or family to notify them but she did text the Administrator. Review of the facility's Elopement policy, dated 03/18/15, revealed management was to notify the family and physician of an elopement incident.

Based on medical record review, the facility post-fall monitoring report and interview, the facility failed to ensure neurological checks (series of assessments which reflect a resident's brain and neurological function) where completed, after unwitnessed falls, for one (Resident #13) of three residents reviewed for falls. The census was 46. Findings include: Review of Resident #13's medical record revealed diagnoses that included right sided paralysis, muscle wasting, contracture of the right hand, heart failure, stiffness of the right shoulder, speech disturbance, history of falling and hypertension. A physician's order dated 01/07/24 revealed the bed was to be in the lowest position at all times. Review of the fall information with Registered Nurse (RN) #100 revealed the following information. a. A nursing note dated 01/19/24 at 6:48 P.M. indicated a State tested Nursing Assistant (STNA) notified the nurse Resident #13 was on the floor, in the bathroom, laying on his left side. No injuries were noted. Resident #13 was educated on the importance of using the call light for assistance. Neurological checks were started. On 05/21/24 at 9:48 A.M., RN #100 provided the facility's post fall 72-hour monitoring report which indicated an unwitnessed fall, or a fall in which a resident struck his/her head, required neurological checks. An initial check was to be completed followed by checks every 15 minutes four times, then every 30 minutes twice, then every hour twice and once per shift for 72 hours. RN #100 verified staff documented neurological checks on 01/19/24 between 6:00 P.M. and 7:00 P.M. only. b. Review of a nursing note dated 02/19/24 at 6:50 P.M. indicated Resident #13 was attempting to go to the bathroom without assistance when he stood and fell over. No injuries were noted. Neurological checks were initiated. On 05/21/24 at 8:51 A.M., RN #100 verified the neurological checks were initiated at 4:00 P.M. and were completed until 8:00 A.M. on 07/20/24, not fulfilling the expectation for 72 hour monitoring. c. Review of a nursing note dated 05/02/24 at 2:46 P.M. indicated the nurse was notified by an STNA that Resident #13 was found on his bathroom floor at 12:45 P.M. Resident #13 was ambulating without assistance. No injuries were noted. The note indicated neurological checks were initiated. On 05/02/24 at 9:05 A.M., RN #100 verified there was no record of neurological checks being initiated.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of information from diabetes.org and interview the facility failed to adequately monitor Resident #40 related to the administration of diabetic medication. Actual harm occurred on 07/22/23 when Resident #40 was found by staff with a change in mental status/condition after oral hypoglycemic medications had been adjusted and no routine blood glucose monitoring was ordered/completed. Resident #40 was emergently transferred to the hospital and subsequently admitted with a diagnosis of hypoglycemia (low blood glucose/sugar level). This affected one resident (#40) of three residents reviewed for blood glucose monitoring. The facility census was 46. Findings include: Review of Resident #40's medical record revealed an admitted [DATE] with diagnoses that included diabetes mellitus (long term) and chronic obstructive pulmonary disease. Further review of the medical record including the Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 07/28/23 revealed Resident #40 had intact cognition. Review of admission medication orders revealed Resident #40 was prescribed metformin (diabetic medication) 500 milligram (mg) tablet twice daily and Tresiba (diabetic medication) 12 units subcutaneous weekly. Following admission on 07/19/23 Resident #40's physician evaluated the resident and changed her diabetic medications. The Tresiba was discontinued, glipizide (diabetic medication) five mg twice daily was added, and metformin was increased to 1000 mg twice daily. There was no physician order for blood glucose monitoring (BGM) upon admission or after evaluation by the physician. Review of a nursing note revealed on 07/22/23 at 8:00 P.M. revealed Resident #40 was sitting up on the edge of the bed and suddenly fell back onto the bed and wasn't answering questions or following commands. Upon assessment, the resident was laying flat. A neurological assessment showed the resident was unable to grip the nurse's hands and her left eye was deviating outward. At 8:05 P.M. 911 was activated to have the resident transported to the emergency room for a change in mental status and possible stroke symptoms. There was no documented evidence that the resident's blood glucose level was checked or considered a potential issue as part of the resident's assessment at the time of this acute change in condition. The resident was admitted to the hospital with a diagnosis of hypoglycemia (low blood glucose level). There was no documented evidence the resident's blood glucose was assessed prior to her hospital transfer, in the ambulance or as part of the resident's history and physical at the hospital. Review of the hospital history and physical dated 07/23/23 revealed the resident was brought to the hospital from the facility for altered mental status. The resident was found to be hypoglycemic upon emergency medical services arrival and subsequently brought to the emergency department. After several rounds of glucose replacement with oral glucose and intravenous ampules of dextrose the resident's mental status had improved and had returned to baseline; however, the resident had reoccurring hypoglycemia requiring ampules of dextrose and finally IV dextrose drip initiation. Further review of the medical record revealed the resident returned to the facility on [DATE] with orders to decrease the metformin to 500 mg twice a day and orders to check the resident's blood glucose levels before meals and at bedtime. Interview with Resident #40's representative on 09/21/23 at 8:49 A.M. revealed upon admission there was no blood glucose monitoring (BGM) completed and the resident had a hypoglycemic episode resulting in transfer and admission to the hospital. Interview with Resident #40 on 09/21/23 at 9:00 A.M. revealed upon admission the facility the physician changed her diabetic medications and they were not monitoring her blood glucose level. The resident stated she was confused and weak and she fell over in bed three days after admission when her blood sugar dropped, and staff had to send her to the hospital. Interview with Registered Nurse (RN) #109 on 09/21/23 at 11:25 A.M. verified Resident #40 was admitted to the facility without BGM while on diabetic medications and had diabetic medication changes shortly after admission. RN #109 further verified Resident #40 was transferred and admitted to the hospital on 07/22/23 for hypoglycemia. Interview with Resident #40's physician on 09/21/23 at 1:40 P.M. revealed diabetic medication changes were made upon admission due to the Tresiba medication not being on the pharmacy formulary. The physician further indicated he assumed Resident #40 was already ordered BGM and BGM should have been completed due to the resident being diabetic and having diabetic medication changes. Review of the diabetes.org website revealed hypoglycemia is the technical term for low blood glucose. It's when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. Here are a few causes: too much insulin or oral diabetic medication, and too little food. The deficiency was corrected on 08/16/23 when the facility implemented the following corrective actions: Review of the facility survey history revealed a deficiency was issued during a survey completed on 07/07/23 related to the lack of monitoring and timely care of a resident with diabetes mellitus resulting in a significant change in condition and hospitalization . Resident #40 was admitted to the facility on [DATE]. On 07/01/23 the facility implemented a plan to monitor for ongoing compliance weekly for two months and then monthly on a continuing basis thereafter. The monitoring would specifically audit Glucagon vials were available in the emergency crash cart in the training center through direct visual inspection of the crash cart. Pharmacy would also complete their own audit of Glucagon vials being present in emergency crash cart during their normal monthly visits. These audits were completed by the facility Risk Management Team which consists of the MDS RN, Administrator, DON/IP and CO-DON. Additionally, the DON/IP, CO-DON & MDS RN would audit any other resident who was admitted in the future for actual bloods sugar amounts and correct dose (of insulin) administered through direct observation of nurse when taken and administered. The monitoring would also be accomplished through chart review and direct observation of the electronic medication administration record (EMAR) and electronic treatment administration record (ETAR). The monitoring would also include auditing signs and symptoms section of the ETAR that nurses are now signing every shift. This monitoring would be completed three times a week with a different nurse each time for one month beginning 07/01/23 and then weekly for 2 months thereafter. The facility reviewed concerns in their Quality Assessment Performance Improvement (QAPI) for effectiveness and compliance during a meeting initially on 07/06/23. The facility then reviewed recommendations as a result of QAPI by 08/16/2023. The facility implemented new standing orders in point click care (PCC) for any resident that is a diabetic is to have blood sugars to be checked before and after meals and at night. This systemic change would ensure that staff would be reminded on the ETAR to obtain the resident's blood sugar even if a resident was not on insulin but a diabetic. This was completed for Resident #40 upon re-admission on 07/24/23. The facility implemented a plan for all diabetic residents to have laminated signs placed in their rooms by facility nursing staff to assist all staff in identifying signs and symptoms of high and low blood sugars. The facility Resident Navigator would monitor that these signs were placed upon admission through direct observation and visual inspection of resident's room. This monitoring began on 07/31/23 and was to be completed as residents were admitted and weekly for all current residents who were diabetic. The facility implemented a plan for any newly hired staff to receive education/training as part of the orientation process. This education would be provided by the DON/RN and Personnel Director as well as designated facility staff completing the training for the new employee. The facility indicated the QAPI committee would meet again in August 2023 to determine effectiveness and compliance with all corrective actions. Between 08/16/23 and 09/21/23 no additional resident concerns were identified related to diabetic monitoring and/or incidents of hypoglycemia for residents. This deficiency represents non-compliance investigated under Complaint Number OH00146265.

Based on observation, medical record review, review of Fire Department emergency response documentation, emergency room documentation, review of the facility policy titled Medical Emergencies, and interviews with residents, staff, and family, the facility failed to provide timely care and services for the monitoring and treatment of sign and symptoms of hypoglycemia (low blood sugar) for Resident #38, who had a diagnosis of diabetes mellitus. This resulted in Immediate Jeopardy with serious life-threatening harm on 06/08/23 at approximately 11:30 P.M. when State tested Nursing Assistant (STNA) #131 and STNA #132 noted Resident #38 was cold and clammy when assisting him to bed but failed to immediately report this change in condition to the nurse until approximately two hours and 45 minutes later (around 2:15 A.M.). The resident was then discovered by Licensed Practical Nurse (LPN) #94 on 06/09/23 at 2:17 A.M. unresponsive with vomit on his bed and a blood sugar of 32 milligrams per deciliter (mg/dl) (per the Centers for Disease Control, a blood sugar below 70 mg/dl is considered hypoglycemic). Emergency Medical Services (EMS) was notified and Resident #38 was transferred to the emergency room where he was intubated, placed on a ventilator, treated for aspiration pneumonia and a myocardial infarction (MI), likely due to the hypoglycemia. The resident remained hospitalized for 12 days. This affected one resident (#38) of three residents reviewed for change in condition. The facility census was 38. On 06/28/23 at 5:19 P.M., the Administrator and Director of Nursing (DON) #93 were notified Immediate Jeopardy began on 06/08/23 at approximately 11:30 P.M. when care and treatment was delayed for Resident #38 after direct care staff (STNA #131 and #132) failed to notify Licensed Practical Nurse (LPN) #94 when the resident presented with an acute change in condition; being cold and clammy indicative of hypoglycemia. The change in condition was not reported to the resident's nurse until 06/09/23 at approximately 2:15 A.M. at which time the resident was found to be unresponsive with a blood sugar of 32 mg/dl (hypoglycemic). The resident required emergency medical services and hospitalization for treatment as a result of the incident. The Immediate Jeopardy was removed on 06/29/23 when the facility implemented the following corrective actions: On 06/15/23 at approximately 10:30 A.M. the Director of Nursing / Infection Preventionist (DON/IP), educated staff working in facility on the importance of notifying nurse immediately of any change in condition for residents. On 06/16/23 at 12:00 P.M. the facility conducted a Quality Assurance Performance Improvement (QAPI) committee meeting with the Medical Director, DON/IP, Administrator, Minimum Data Set Registered Nurse (MDS/RN), and Social Service Designee (SSD). The meeting included: Identifying the problem of nurse aide failing to inform nurse of resident showing signs and symptoms of hypoglycemia resulting in resident sent to emergency room . Care conference to be scheduled upon Resident #38's return to facility. Education provided to staff immediately on importance of notifying nurse on any change of condition identified by nurse aides. Pharmacy consulted per request of family for alternatives in monitoring blood sugars. On 06/27/23 at 8:00 P.M. the DON/IP, completed a Medication Error Report upon discovery of miscalculated dose of insulin administered on 06/08/23 at 9:30 P.M. for Resident #38. The nurse who committed the error was notified in person at facility of the error by DON/IP at 8:05 P.M. Education for this nurse and all other nurses related to medication administration/medication errors was completed on 06/28/23 and 06/29/23. On 06/28/23 at 12:00 P.M. facility Administrator and DON had care conference with Resident #38's daughter, stepfather, ombudsman and ombudsman assistant to notify of the medication error and discuss plan of care moving forward. On 06/28/23 at 6:00 P.M. the Medical Director provided standing orders and recommendations for updating the facility current Insulin Shock / Hypoglycemia policy and procedure. The facility indicated staff training would be completed on the updated policy on 06/28/23 and 06/29/23. On 06/28/23 from 8:00 P.M. to 06/29/23 at 3:00 P.M. staff education was provided for all staff, including 11 licensed nurses, 21 STNAs, six laundry staff, five housekeeping staff, nine dietary staff, 10 administrative staff, five activity staff, two maintenance staff, four drivers/transportation and four therapy staff. Education included: New information in point click care under the care profile for each resident who was receiving insulin to monitor for signs and symptoms. Resident #38 had his care profile updated to labile diabetic and monitor for signs and symptoms. Additionally, monitoring for signs and symptoms was added to electronic treatment administration record (ETAR) for nurses to sign off every (q) shift. On 06/28/23, the DON and Administrator updated the facility Insulin Shock / Hypoglycemia policy and procedure based on the Medical Director's recommendations and standing orders. Additionally, a new policy for insulin administration per scale with formula was created. Furthermore, nursing staff were educated on the location of Glucagon vials for injection in emergency crash cart and that two would always be available. On 06/28/23, the facility implemented and educated all staff on the Early Warning Report form to be utilized when reporting signs and symptoms as an added back up to verbal notification and provide record of the initial verbal notification. These reports would be audited daily by DON/IP, CO-DON, and or RN Desk Nurse through review of form, progress notes and confirmation with nurse it was reported to. Additionally, floor nurses would review the importance of reporting signs and symptoms with nurse aides and other staff present during morning stand up meetings. The Risk Management Team would also audit nurse aides through interviews of six different nurse aides weekly for one month. Furthermore, the audit would also include review Early Warning Report forms weekly for one month to ensure staff were reporting signs and symptoms to nurses timely and accurately beginning in the week of July 1, 2023. The DON/IP completed one and one training of all licensed nursing staff personnel on the importance of adequate monitoring related to new protocol and procedures according to updated Insulin Shock / Hypoglycemia. On 06/29/23 at 10:00 A.M. the DON/IP spoke with pharmacy to confirm and implement that the facility would now keep two vials of Glucagon in the crash cart for quicker response in a medical emergency. On 06/29/23 at 1:25 P.M. the DON/IP completed an audit for Resident #10, who also received insulin utilizing formula. The audit reviewed May and June 2023 to ensure the resident was administered the correct dose of insulin if needed and/or to ensure the dose of insulin administered was calculated correctly. On 06/29/23 the facility implemented a plan to monitor (beginning 07/01/23) for ongoing compliance of all outlined corrections weekly for two months and then monthly on a continuing basis thereafter. The monitoring would specifically audit that the Glucagon vials were in the emergency crash cart in the training center through direct visual inspection of the crash cart. Pharmacy would also complete their own audit of Glucagon vials being present in emergency crash cart during their normal monthly visits. Audits would be completed by the Risk Management Team which consists of MDS RN, Administrator, DON/IP and CO-DON. Additionally, the DON/IP, CO-DON & MDS RN would audit Resident #10 and #38 and any other resident who was admitted in the future for actual bloods sugar amounts and correct dose of insulin being administered through direct observation of nurse when taken and administered. The monitoring would also be accomplished through chart review and direct observation of the electronic medication administration record (EMAR) and electronic treatment administration record (ETAR). The monitoring would also include auditing signs and symptoms section of the electronic treatment administration record (ETAR) that nurses were now signing every shift. This monitoring would occur three times a week with a different nurse each time for one month beginning 07/01/23 and then weekly for two months thereafter. All corrective actions outlined above would be reviewed in QAPI for effectiveness and compliance at next scheduled meeting in July 2023. Interviews 06/30/23 between 1:22 P.M. and 1:53 P.M. with STNA's #97, #101, and #108 revealed they had been educated on the signs and symptoms of hyper and hypoglycemia. They were knowledgeable, able to verbalize symptoms and were aware they were to report signs and symptoms to the nurse. Interviews 06/30/23 between 1:43 P.M. and 2:51 P.M. with Licensed Practical Nurses #88, #94 and Registered Nurse #92 verified the nurses were knowledgeable and able to verbalize signs and symptoms of hypo and hyperglycemia. The nurses were aware of the treatment for hyper and hypoglycemia. Further, they were knowledgeable regarding the new process to store two injectable glucagon in the crash cart and two in the emergency box. The new policy to count weekly the amount of available Glucagon injectables in the crash cart weekly. In addition, the nurses were educated to check the dosage of insulin coverage for accuracy. Although the Immediate Jeopardy was removed on 06/29/23, 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 in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility from home on 05/26/23. Resident #38 had diagnoses including chronic obstructive pulmonary disease, thoracic thoracolumbar and lumbosacral intervertebral disc disorder, hypercholesterolemia, osteoarthritis, and hyperlipidemia. The resident was discharged to the hospital on 06/09/23 and was readmitted to the facility on [DATE] with additional diagnoses that included encephalopathy, acute respiratory failure, Type 1 diabetes mellitus (body does not make insulin), pneumonia, seizures, abnormal plasma proteins, altered mental state, convulsions, and hyperglycemia. Record review of the Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #38 was independent for daily decision with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment revealed the resident was able to understand others and be understood, he had no behaviors. Resident #38 required limited assistive of two staff for bed ability, extensive assistant of two staff to transfer, assist of two staff to walk in room, limited assistance of one staff to walk in corridor, extensive assistive of two staff for dressing, extensive assistive of one staff for eating, limited assist of one staff for toilet and personal hygiene. The resident had a loss of liquids and solids from mouth when eating or drinking and coughing or choking during meals and when taking medications. The resident utilized the wheelchair. Resident #38 was occasionally incontinent of urine and always incontinent of stool. The assessment noted the resident received insulin injections seven day a week. Resident #38's admission physician orders included blood sugar monitoring four times a day without (insulin) coverage for the diagnosis of diabetes mellitus. Medication orders included NovoLog Mix 70/30 subcutaneous suspension (70-30) (a long-acting insulin) 100 Units/milliliter, inject 20 unit subcutaneously in the morning for diabetes and inject 12 unit subcutaneously in the evening for diabetes. This medication was ordered to be given routinely each day. Record review revealed on 06/02/23 Resident #38 required one on one (1:1) staff supervision for all meals for safety due to aspiration risk. Record review revealed from admission (05/26/23 through 06/05/23) Resident #38's blood sugar levels ranged from 78 mg/dl to 482/dl, generally in the 200 mg/dl to 350 mg/dl range. On 06/05/23 Medical Director (MD) #134 became the physician of record for Resident #38. A new order was received on this date for Novolog (insulin) coverage (a rapid acting insulin) via a sliding scale four times a day for blood sugars using a formula for blood glucose levels greater than 150. For blood glucose levels above 150, staff would divide the result by 30 and minus 3 to determine the number of Novolog units to administer subcutaneously. The sliding scale coverage was to be used following blood glucose monitoring daily at 6:00 A.M., 11:00 A.M., 4:00 P.M. and 10:00 P.M. Review of the medical record revealed Medical Director (MD) #134 visited and met the resident for the first time on 06/08/23 at approximately 3:40 P.M. Medical Director #134 wrote orders to fax blood sugar results every shift until 06/12/23, to increase the morning dose of routine NovoLog Mix 70/30 subcutaneous suspension (70-30) 100 units/ML (Insulin Aspart Protamine & Aspart (Human)) to 30 units subcutaneously in the morning for diabetes (an increase of 10 units), inject 10 units subcutaneously in the afternoon for diabetes (added the new afternoon dose) and inject 12 units subcutaneously in the evening for diabetes (no change in dosage). Review of the 06/08/23 physician progress note included chronic obstructive pulmonary disease had been stable despite the presence of rhonchi on exam at this time. Diabetes mellitus has been sub-optimally controlled, and medications would be adjusted. The resident had significant expressive dysphasia however, conversation could be completed satisfactorily. Review of the meal intake record revealed Resident #38 did not eat breakfast on 06/08/23 and ate 76-100 percent for both lunch and supper. Review of the medication administration record (MAR) revealed on 06/08/23 the resident's 4:00 P.M. blood sugar was 204 and the resident was administered four units of insulin. The 10:00 P.M. blood sugar was 290 and the resident was administered 10 units Novolog insulin, which was an error as the resident should have been administered seven units. Review of Resident #38's nurse's notes revealed on 06/09/23 a 5:44 A.M. late entry note entered by Licensed Practical Nurse (LPN) #94 revealed at 2:17 A.M. STNA #131 reported to this nurse the resident was cold and clammy. Upon entering resident's room, the resident was breathing heavily with vomit on right side of bed. When this nurse called out resident's name, the resident did not respond. The LPN walked closer to resident's bedside called out again with no response. Began sternal rubs with no response. This nurse ran to cart and grabbed blood pressure cuff, pulse oximeter and glucometer. Blood pressure was 122/77 millimeters of mercury (mm/Hg), temperature was 98.0 degrees Fahrenheit, respirations 22 per minute, pulse 94 beats per minute, oxygen saturation 97 percent on room air. Blood glucose monitoring was 32 mg/dl . Glucagon gel administered and blood glucose increased to 37 mg/dl. 911 called at 2:20 A.M. to transport resident to emergency room for evaluation and treatment. This nurse stayed with resident at bedside until emergency medical technicians (EMT) arrived at 2:33 A.M. EMT immediately started an intravenous line and dextrose was administered. The resident's blood glucose increased to 302 mg/dl. The LPN assisted EMT staff to get resident onto the gurney. Resident left the building with the Fire Department at 2:47 A.M. Review of the Fire Department (EMT) record for this incident revealed they received the call at 2:21 A.M., arrived at 2:29 A.M. and found the resident unresponsive. EMTs placed an intravenous line and administered 25 grams of glucose intravenously. At 2:40 A.M. the resident's blood sugar was 302. A non-rebreather mask was placed at 12 liters of oxygen per minute. Response improved but the resident was still unresponsive. Skin was clammy and diaphoretic. The resident was pale. Pupils three millimeters (mm) and sluggish. Departed facility at 2:41 A.M., arrived at the emergency room 2:46 A.M. and transferred to emergency room cart 2:48 A.M. Review of the Emergency Department documentation revealed on 06/09/23 at 2:50 A.M. Resident #38 was brought in with a 95% oxygen saturation, and respirations of 17 breaths per minute. The resident was intubated and placed on a ventilator by 3:00 A.M. An electrocardiogram revealed the resident likely has non-ST elevated myocardial infarction (NSTEMI) secondary to hypoglycemia. A CT scan of lungs revealed apparent bilateral infiltrates (secondary to possible aspiration pneumonia). The resident was monitored in the emergency room by a critical care nurse until 6:00 P.M. 06/09/23 when a bed opened, and he was then transferred to a larger medical center. The resident remained stable although critical requiring intubation and central line placement. Diagnoses included altered mental status and possible aspiration pneumonia. Resident #38 was discharged back to the facility on [DATE] with diagnoses including change in mental status, elevated troponin levels, hyperglycemia, pneumonia, acute respiratory failure, and seizure. Additional diagnoses included provoked seizure, uncontrolled type 1 diabetes mellitus with hypoglycemia. Interview on 06/27/23 at 2:42 P.M. with DON #93 revealed it was discovered STNA #131 and #132 reported Resident #38 was cool and clammy around 11:30 P.M. when they put him to bed the night of 06/08/23. STNA #131 reportedly asked STNA #132 if the resident was diabetic and she said no. Hours later in conversation, STNA #131 told the nurse the resident was cold and clammy when they put him to bed which prompted the nurse to go check him. Upon checking on the resident, he was found unresponsive. STNA #132 was suspended 06/09/23 and terminated 06/12/23 for failure to report in part because she did not seem to understand the seriousness of not reporting a change in condition when the resident was cold and clammy. Interview on 06/27/23 at 5:52 P.M. with RN #96 revealed she was on duty 06/08/23 from 6:00 P.M. until 10:00 P.M. Resident #38 was in the lounge watching television and she asked him if he had a snack and he said yes. RN #96 revealed Resident #38 was usually the last resident to bed. The RN stated she obtained the resident's blood sugar at 9:30 P.M. and it was 290 mg/dl and she administered the sliding scale insulin coverage of 10 units of Novolog insulin. At the time of the interview, RN #96 was unaware she had not administered the correct dose of insulin and had given the resident three units of insulin too much. The RN concluded with the formula blood sugar divided by 30 minus three she must not have subtracted the three units. Interview on 06/27/23 at 6:15 P.M. with LPN #94 revealed she had a conversation with Resident #38 on the evening of 06/08/23. The resident was eating a snack about 11:00 P.M. in the front television area. She knew he had a drink but was unsure what the snack was. LPN #94 reported STNA's #131 and #132 said that they took the resident back to his room around 11:30 P.M. STNA #131 told LPN #94 in conversation after 2:00 A.M. that Resident #38 was cold and clammy when they put him to bed. STNA #131 said she asked STNA #132 if the resident was diabetic, and the STNA said no. LPN #94 stated she had checked on the resident through the night from the doorway and he appeared to be sleeping, so she did not turn on the light in the room. She could not tell if the resident was cold and clammy during her observations. After STNA #131 reported to her the resident had been cold and clammy when assisted to bed, she immediately went back to check him (around 2:15 A.M.), and she heard gurgling respirations from the door. When she turned on the light in the room, she noted the resident had vomited on his bed. She yelled his name twice and received no response. She had no response from a sternal rub. LPN #94 put on the call light, and no one came. She ran out and got equipment. STNA #131 saw her and came back to the room. STNA #131 had her phone and the LPN stated she told the STNA to call 911 and then proceeded to try to check the resident's blood (glucose) sugar. LPN #94 had a hard time getting blood for the blood sugar. The resident's blood sugar was low at 32 mg/dl. The LPN stated she ran out of the resident's room and found glucagon gel. She stated it was all she could find. She could not find injectable glucagon. She squirted the gel in the resident's cheek and massaged it. She knew she was not to give it orally when a resident was unconscious, but she didn't know what else to do to help him. The gel got Resident #38's blood sugar up to 37 mg/dl. The squad came and started an intravenous (IV) and pushed glucose IV. His blood sugar was 300 plus after they administered the IV glucose. When EMT staff got the resident on the gurney, he started having seizure like activity and was still not responding. The resident was transferred to the hospital. The LPN contacted the resident's daughter later and was told the resident was intubated, and they were waiting to transfer him to another hospital when a bed opened. LPN #94 said if the STNA staff had told her the resident was cold and clammy at the time they put him to bed, she would have assessed him and intervened at that time. LPN #94 revealed the whole situation could have been avoided if she was told he was having symptoms when the staff assisted him to bed at 11:30 P.M. Interview on 06/28/23 at 2:38 P.M. with DON #93 verified STNA #131 and #132 did not report timely a change in Resident #38's condition. Further interview verified the facility failed to investigate to determine if there were any other reasons why the resident's blood glucose level would have dropped so low. The facility had not investigated whether the resident was administered the correct amounts of insulin prior to the incident. The facility did not complete an investigation to determine if the appropriate interventions were available and provided during the emergency, including the availability of injectable glucagon. On 06/28/23 at 2:23 P.M. Resident #38 was observed sitting in his wheelchair. The resident was alert and his speech was slow but comprehensible. The resident indicated the night he went into the hospital, he did not remember if he felt ill. He said he remembered feeling tired. Telephone interview on 06/28/23 at 4:55 P.M. with MD #134 revealed he just took over the care of Resident #38 and was adjusting his insulin to better control the resident's blood sugars. The MD did not think giving three extra units of Novolog insulin would drop a blood sugar to 32 mg/dl. He questioned whether there was an infection or some other process in play. He indicated the nursing home doesn't have intravenous glucose on hand, they leave it up to the emergency team. However, they should have the glucagon for injection for emergencies. He indicated he would work with the facility to ensure the nurses have the medication needed on hand and staff have the proper education to alert the nurses of change. There was a Glucagon 1 mg in the emergency kit. It was dated 05/24/23. So, it should have been there when the nurse looked that night. Interview on 06/28/23 at 5:55 P.M. with LPN #89 revealed the medication room was to have two injectable Glucagon, but stated there was a problem keeping them stocked. She indicated on 05/24/23 she had a resident whose blood glucose dropped to 49 mg/dl on one hand and 43 mg/dl on the other hand. The Medical Director ordered 1 mg of Glucagon and when that nurse went in the medication room, and they had no injectable medication. She said the resident was alert, so she was able to give the gel and this resident's blood sugar went up to 82. She said she called the pharmacy and told them they needed two sent. Observation of the medication room on 06/28/23 at 5:55 P.M. revealed the emergency box had one injectable Glucagon labeled 05/24/23. Interview on 06/29/23 at 11:18 A.M. with STNA #132 revealed she was one of the two aides to put Resident #38 to bed the night of 06/08/23. STNA #132 stated she did not touch Resident #38's skin and feel if it was cold or clammy. The other aide said he was cold and clammy. She doesn't remember being asked if he was diabetic. STNA #132 did not know if the resident was diabetic or not. STNA #132 also said she did not know being cold and clammy was a sign of a blood sugar dropping. She indicated she was outside when the other staff went to his room about 2:30 A.M. When she arrived, the nurse was taking his blood pressure. He had something red coming out of his mouth. He had rattly respirations. The nurse was yelling they did not have the proper things to take care of him. They gave him a gel in his mouth. The STNA stated she told the nurse she did not know if someone was cold and clammy that was a sign of a diabetic reaction. The STNA stated, if the resident was a high-risk diabetic, she should have been told of the situation. She again stated she didn't know the resident was a diabetic. Review of the email from the Administrator on 06/29/23 at 1:06 P.M. revealed DON #93 confirmed the error in the amount of insulin coverage the resident had received received as noted above. Interview on 06/29/23 at 4:16 P.M. with STNA #131 revealed Resident #38 was the last person they put to bed that night (06/08/23) because she was told he liked to stay up. The STNA revealed the resident's skin was very cold to the touch when they (she and STNA #132) put him to bed. He was shaking a lot but was talking. The STNA stated she asked the other aide if the resident was diabetic, and she said no. The resident did not appear to be sweating. She stated if he wasn't she wouldn't have even asked the other aide if he was diabetic and would have reported the situation to the nurse. After everything settled down (the residents were all in bed, etc), she stated staff were talking about situations and things learned over the years. She said she brought up about a resident who was cold and sweating a lot and he was having a diabetic reaction and that made her think of Resident #38 and how cold he was when he was assisted to bed. The STNA said she asked the other aide if he was diabetic, and she said no. The STNA revealed the nurse then looked at her and said, yes, he was a diabetic and ran back there (to his room) and found him not responding. When the STNA got there, he had thrown up on his left shoulder. The STNA stated she was only an aide; she had seen diabetic reactions from her experience but in nurse aide training they really do not go into the signs and symptoms of diabetes. Review of the facility policy, titled Medical Emergencies, dated 03/18/15 revealed for insulin shock nursing staff would be familiar with the symptoms and treatment of insulin shock. Symptoms of insulin shock were sweating, restlessness, vertigo, pallor or flushing face, weakness, diplopia, dilated pupils and increase pulse. Call for help and stay with the resident. If the victim was conscious and able to swallow you may give orange juice. Use glucose or comparable product per directions. Notify physician and provide treatment as directed. This deficiency is an incidental finding to Complaint Number OH00143538.

Based on record review and interviews, the facility failed to ensure Resident #1 was supervised and seated in a wheelchair that was in good repair. Actual harm occurred on 10/18/2020 at 2:00 P.M. when Resident #1 was seated in a broken wheelchair and left unsupervised in a television room, which resulted in a fall with injury to her head. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 51 residents . Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed she had severe cognitive impairment, needed extensive assistance of two staff for bed mobility and was totally dependent on two staff for transfers, toileting, and dressing. The fall assessment completed on 08/03/2020 revealed a score of 95, which indicated she was a high risk for falling (score of 45 or greater). Review of the Progress Note dated 10/18/2020 written by Licensed Practical Nurse (LPN) #100 revealed Resident #1 was found on the floor face down in the television room with her wheelchair tipped forward on the leg rests. A lump was present on the left side of her head. No bleeding was noted by LPN#100 and vital signs were taken. When she was asked about pain Resident #1 stated she hurt everywhere. LPN #100 attempted to notify the physician without success, so the medical director was notified who ordered the resident sent to the emergency room for an evaluation. Review of the facility Physical Therapy (PT) Evaluation and Plan of Treatment, dated 10/16/2020 and written by Physical Therapist (PT) #800, revealed Resident #1 had kyphotic posture (hump back with shoulders rounded forward ) with her head forward and rigid muscle tone. She could maintain sitting balance with assistance and upper extremity support. The clinical impression was she needed physical therapy due to decreased seated balance and coordination and decreased range of motion. Review of the facility Fall Investigation Form, dated 10/18/2020 completed by LPN #100 revealed the time of the fall was 2:00 P.M. The cause of the fall was listed as a broken wheelchair. The form indicated the resident sustained [REDACTED]. Review of the hospital emergency room Report, dated 10/18/2020, revealed Resident #1 was seen due to a fall at the facility. The physical findings indicated Resident #1 was alert, oriented to person, and had a small hematoma to the left frontal forehead. A head and cervical spine scan were completed and reported as age appropriate, no mass effect, bleeding, hemorrhage, or fractures. Review of the facility Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 10/20/2020 and written by Registered Occupational Therapist (ROT) #900, revealed Resident #1 was a [AGE] year old resident with a recent fall from her wheelchair and emergency room assessment. She was referred to therapy for fall prevention, custom wheelchair evaluation, and wheelchair positioning. On 10/27/2020 at 12:11 P.M., interview with the Director of Nursing (DON) revealed Resident #1 had an unwitnessed fall from her wheelchair on 10/18/2020 due to a malfunction in her wheelchair. The DON said Resident #1 sustained a hematoma to her temple area sending her to the emergency room for an evaluation. She returned the same day and other than the hematoma, she was at her baseline. Interview on 10/27/2020 at 12:44 P.M. with LPN #100 revealed she was the staff member who found Resident #1 after she fell from her wheelchair on 10/18/2020. LPN #100 said she was working the 6:00 A.M. to 6:30 P.M. shift, and was standing at her medication cart when she heard a bang. She went to look where the noise came from and found Resident #1 had fallen out of her wheelchair onto the floor in the television room, and her wheelchair was tipped over. When she found Resident #1 she was awake, laying on her stomach, and had a small lump to the side of her forehead; the resident was not bleeding. She said the resident had dementia so she asked her a simple question if she was hurting anywhere. The resident replied her stomach was hurting. LPN #100 said the fall was unwitnessed, there were no other staff in the television room with the resident, and she did not have a call light available to her. After notifying the physician she was sent to the emergency room . When asked why she thought the resident fell out of her chair, LPN #100 revealed her wheelchair was malfunctioning as it was always tilted forward and did not position completely straight. She added therapy had put seat guards in her chair prior to the fall to try to keep her from leaning forward in it, but she really needed a new wheelchair. LPN #100 said Resident #1 no longer used that chair. This deficiency resulted from incidental findings discovered during the investigation of Complaint Number OH 457.

Based on record review and interview the facility failed to provide one resident (Resident #11) adequate assistance during a wheelchair transport to prevent a fall with major injury. Actual Harm occurred on 08/06/19 when Resident #11, who required extensive assistance from staff for wheelchair transportation, sustained a fall from her wheelchair when her nightgown got caught in the wheel of the wheelchair causing the resident to fall from the wheelchair landing on her face and sustaining an orbital (facial) fracture. This affected one resident (Resident #11) of two reviewed for accidents. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had intact cognition, required extensive assist of one staff member for transportation off the unit, extensive assist of two staff for dressing and had one fall with a major injury. Review of an incident note, dated 08/06/19 at 5:14 P.M. revealed the nurse was summoned to the top of the 400 hall by the nursing assistant as Resident #11 had fallen out of her wheelchair on to the floor after her night gown had gotten caught in her wheelchair wheel. The resident landed face down on the carpet. The resident never lost consciousness. The resident had several skin tears and a dry dressing was applied. The resident was alert and able to answer the nurse's questions. The resident was noted to have a large hematoma to the left side of her forehead and left side of her face. The physician was contacted and ordered the resident be sent to the emergency room (ER) for an evaluation. Review of the fall investigation dated 08/06/19 at 3:25 P.M. revealed the nursing assistant was propelling Resident #11 in her wheelchair when the resident's gown got caught in the front wheel of the wheelchair causing the resident to fall face first. The injuries the resident sustained [REDACTED]. The resident was log rolled onto her back and left there until the ambulance arrived to send her to the emergency room (ER). New interventions put into place were to encourage the resident to wear proper clothing while up in the wheelchair and if she wanted to wear a gown during the day in the wheelchair it would need to be tied up. Review of the hospital report, dated 08/06/19 revealed Resident #11 had a fractured orbital. Review of the neurological check list dated 08/06/19 at 3:35 P.M. revealed Resident #11 had unequal pupils, the left was six millimeters and the right was four millimeters. Review of the hospital head computed tomography scan (CT scan) report dated 08/06/19 revealed Resident #11 had a left orbital floor fracture with herniation of orbital fat of uncertain chronicity. Review of hospital facial bone CT scan report dated 08/06/19 revealed Resident #11 had a large left orbital floor fracture with osseous defect measuring approximately six millimeter. There was herniation of the intraorbital fat through the defect. Interview on 11/25/19 at 2:59 P.M. with Resident #11 revealed she had sustained a facial fracture when a staff person was pushing her down the hallway and her hospital gown got wrapped around the front wheel and threw her out of the wheelchair. On 11/27/19 at 10:54 [NAME]M. interview with the Director of Nursing (DON) verified the nursing assistant was pushing Resident #11 down the hallway on 08/06/19 when her gown became caught in the front wheel of the wheelchair. The resident was tipped over in the wheelchair and fractured her orbital bone.

Based on record review, interview, and policy review the facility failed to implement an effective pain management program for one resident (Resident #12). Actual Harm occurred when the facility failed to assess Resident #12 for pain and implement an effective pain management program which resulted in the resident experiencing increased pain. The facility failed to recognize the significant change in condition of Resident #12 who experienced pain with care, crying out through the night, and altered mental status. The resident was hospitalized with an acute comminuted [MEDICAL CONDITION] acetabulum extending into the right iliac crest. This affected one resident (Resident #12) of two residents reviewed for pain management. Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan indicated she was continent of bowel and bladder, fed self in the dining room, and was cognitively intact. Review of nurse's notes dated 09/18/18 at 7:35 A.M. revealed the resident was found on the floor near her bed. The resident complained of right hip pain radiating down to her knee. The resident had a reddened area on right hip and right knee. The resident was transported to the emergency room and returned at 1:15 P.M., with order for [MEDICATION NAME] 50 milligrams (mg) one every six hours as needed (prn) for pain for three days. The hospital x-rays indicated no fractures noted. On 09/19/18 there were no nursing progress notes. The MAR indicated [REDACTED].M. There was no evidence of an assessment of the pain including site of pain, pain rating, or the effectiveness of the pain medication. On 09/20/18 at 5:40 A.M., the resident was noted to have cried out thru the night and had increased pain during care. The resident had been incontinent of urine and had to be checked and changed every two hours. There was no evidence the physician was notified of this change in condition. At 10:21 A.M., Resident #12 continued to complain of pain, especially to the right hip, was incontinent of bowel and bladder and was unable to feed herself. She had a flat affect when spoken to. The physician was notified, and the resident was sent to the emergency room for an evaluation. There was no evidence the resident had received any pain medication on 09/20/18. Review of Resident #12's hospital notes, dated 09/20/18, revealed the resident had complaints of pain in the right hip. The resident was admitted to the hospital with [REDACTED]. Review of Resident #12's pain assessment, completed on 07/05/18, indicated the resident had no pain and had been on [MEDICATION NAME] (nerve pain and anticonvulsant medication) scheduled three times daily for pain management. The [MEDICATION NAME] was discontinued on 09/20/18. There was no evidence the resident's pain assessment was revised after change of condition and change of medication regimen. Review of Resident #12's pain care plan revealed the resident had episodes of pain related to lumbar compression fracture, lower back pain, and functional decline. The interventions included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain. Monitor and document for probable causes of each pain episode. Remove or limit causes where possible. Monitor, record, and report to nurse the loss of appetite or refusal to eat, complaints of pain, or requests for pain treatment. Notify physician if interventions were unsuccessful or if current complaint is a significant change from resident's experience of pain. Report changes in usual routine, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Interview on 09/25/18 at 6:22 P.M. with Licensed Practical Nurse (LPN) #126 revealed she was the nurse that was responsible for Resident #12's care the night of 09/19/18 till the morning of 09/20/18. She confirmed the resident was not herself and was incontinent of urine requiring check and changes every two hours, which was unusual for the resident. She reported she had medicated the resident at 8:00 P.M. on 09/19/18 with [MEDICATION NAME] 50 mg. She reported the resident cried out through the night and was uncomfortable and in pain as they rolled her to provided incontinence care. She thought the pain was just residual pain from a fall that occurred the morning of 09/18/18. The LPN indicated it was no excuse; however, she did not notify the physician of the residents increased pain or change in condition. She was going to let dayshift take are of notifying the doctor to see if he wanted an additional x-ray done. LPN #126 reported the physician doesn't like to write prescriptions for pain medication; however, she did not give the resident any additional pain medication even though the [MEDICATION NAME] was scheduled every six hours as needed, and the resident also had an as needed order for Tylenol for pain that she could have administered. She could not recall if she had offered the resident any additional pain medication, but if she had the resident must have not responded. The LPN reported she should have called the doctor that night and gave the resident another pain pill; however, she had learned a lesson from this incident and felt bad they had turned the resident so much that night when she had a [MEDICAL CONDITION]. Review of the Pain Management policy, dated 03/18/15, revealed the resident would be assessed for pain upon admission/re-admission, change of resident's condition for resident who experience acute and/or chronic pain. The facility would use a standardized pain intensity scale for use during comprehensive pain assessment with change of condition.

Based on review of the medical record, fall investigation, hospital records, facility Resident Incident policy and staff interviews the facility failed to provide supervision as care planned for two residents, (Resident #52 and Resident #53), to ensure safety from falling. This resulted in Immediate Jeopardy when Resident #53 was not provided adequate supervision while in bed resulting in the resident rolling out of bed face first onto the floor. Resident #53 sustained life-threatening head injuries that resulted in the resident's death. The facility also failed to ensure new fall interventions and fall root analysis were implemented and completed following falls for two residents (Residents #41 and #31). This affected four of four residents sampled for falls (Resident #31, Resident #41, Resident #52, and Resident #53) The facility census was 51. On [DATE] at 12:43 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 6:45 A.M., when Resident #53 was not provided adequate supervision and left unattended in a bed in the high position resulting in Resident #53 rolling out of bed face first. Resident #53 sustained a traumatic subarachnoid hemorrhage of the left posterior, inferior, frontal and temporal regions and a [MEDICAL CONDITION] maxillary buttress. Resident #53 expired on [DATE] due to a massive brain bleed resulting from the subarachnoid hemorrhage as result of the fall. This was documented as the cause of death on the death certificate. The Immediate Jeopardy was removed on [DATE] at 11:00 A.M. when the facility implemented the following corrective action: · On [DATE] (no time identified) State tested Nurse Aides (STNAs) #6 and #7 (who provided care to Resident #53 on [DATE]) were provided one on one in-service to ensure all needed equipment was in the room prior to care, Staff were instructed to stand next to the bed while the bed was in a working position (high), and if they had to move away from the bed to place the bed back into low position. · On [DATE] at 1:15 P.M. the Corrective Action Team (CAT) met and developed a plan and timeline for interventions to be implemented regarding the Immediate Jeopardy. The CAT consisted of: the Administrator, DON, Registered Nurse (RN) #10, Licensed Practical Nurse (LPN) #2, STNA #12, the Personnel Director, and Admissions Director. · On [DATE] at 8:00 A.M. the DON and ADON began auditing all residents' fall risk assessments including Residents #31, #41, #52, and #53. Residents #31 and #41 audits and updates were completed by [DATE] at 1:00 P.M. The DON and ADON also reviewed the plans of care for appropriate fall interventions and they were updated accordingly by the DON and ADON. These audits were completed on [DATE] by 2:00 A.M. This included updating care plans, treatment administration records, and the Restorative Aide binder when applicable to reflect the most current fall interventions. · On [DATE] at 10:00 A.M. the ADON and LPN #2 reviewed and updated the Restorative Aide Binder to reflect the most current assistance need of residents and whether the resident required a one or two person assist. This review was completed and the updated Restorative Aide binder made available to STNAs on [DATE] at 2:00 A.M. · On [DATE] at 1:00 P.M. the DON and RN #10 began conducting education on Plan of Correction for Falls for all staff. This education was completed in person or by phone. All staff were to be educated on where the Restorative Binder was located (Nurse Training Center); making sure to check Restorative Binder for resident assistive needs daily at beginning of the shift, the location of the care plans (behind the Nurses' Station) and where to find the current fall interventions in the care plan. All staff were educated on the location and use of the Resident Current Intervention (RCI) form. All nurses were educated on their responsibility for completing the RCI form and placing it on the clip board at the Nurses Station. All nurses were educated on the Fall Investigation reports and the procedure for completion, making copies, and where to place said copies. As of [DATE] at 9:00 A.M., 32 of 80 staff members were educated. The DON, RN #10, and Administrator conducted an all staff meeting on [DATE] at 2:00 P.M. to educate an additional 26 staff. Any other staff on leave of absences or vacation will be educated on the first day of return to work. · On [DATE] (no time identified) the facility implemented a new intervention that the Fall Investigation reports will be copied and placed in the DON, RN #10, Administrator, and Therapy bins so the Fall Investigation can be reviewed and immediate intervention put in place if necessary. Each fall investigation will then be reviewed weekly by the interdisciplinary team (IDT) during meetings to assess effectiveness of current interventions. · On [DATE] at 1:00 P.M. the Fall Committee met to review all corrective measures. The Fall Committee will meet monthly, until compliance with all measures has been achieved, to review and assess the Fall Investigation reports and the effectiveness of the corrective actions. The Fall Committee members include: Administrator, DON, RN #10, STNA #8, Therapy Representative, STNA #13, Housekeeping/Laundry Representative, and Dietary Staff Representative. · On [DATE] (no time identified) the facility developed a Fall Audit Sheet and Intervention Walk through Sheet. Compliance and effectiveness of actions will be on a weekly basis for one month, reevaluated to determine if more weeks are necessary and then monthly thereafter for six months. These audits will be completed by the DON, RN #10, RN #11, and LPN #2. The audits and implementation of the audit tools is scheduled to be implemented on [DATE]. · On [DATE] (no time identified) the facility developed and implemented a new form titled Resident Current Intervention (RCI) for any resident who has a fall and an intervention implemented. Each resident will then have an RCI sheet filled out by the nurse and placed on a clip board at the Nurses' Station. All staff will then sign RCI sheets to acknowledge that they are aware of the current intervention. · On [DATE] at 10:30 A.M. review of Residents #31, #41, #1, and #37 medical records revealed the residents' assessed need for assistance, fall risk, fall plans of care, fall interventions, and information contained in the Restorative Aide binder were accurate and complete. · On [DATE] at 11:00 A.M. interviews with STNAs #6, #9, #13, #5; LPNs #3, #14; RN #11, and Activity Staff #13 revealed the staff had received education and were knowledgeable regarding the location of the care plans and the Restorative Binder and making sure to check the Restorative Binder for resident assistive needs daily at the beginning of the shift and where to find the current fall interventions in the care plan and location and use of the RCI form. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1.Review of the closed medical record revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 (MDS) assessment, dated [DATE], revealed Resident #53 had severe cognitive impairment. The resident was totally dependent two or more staff for assistance with bed mobility, transfers, dressing, personal hygiene and toilet use. Review of the most recent fall risk assessment dated [DATE] revealed Resident #53 was at moderate risk for falls. Review of the plan of care for falls dated [DATE] and revised on [DATE], revealed Resident #53 was at risk for falls related to impaired balance and gait, history of falls, urinary incontinence, [MEDICAL CONDITION] medication use, dementia, and impaired judgment. Interventions included to ensure the call light was in reach and encourage the resident to use it, prompt response to all request for assistance, bed against the wall to define perimeters, bed in lowest position when occupied, encourage the resident to participate in activities, appropriate footwear when ambulating or wheeled walker, mat to left side of bed, and safe environment. Review of Resident #53's June, (YEAR) orders and treatment administration records revealed to keep bed in lowest position while occupied, mat to left side of bed, bed against wall to define perimeter, and Hoyer lift for all transfers. Review of Resident #53's STNA flow sheet dated June, (YEAR) revealed low bed with mats, two person assist and Hoyer lift. Further review revealed bed against the wall was crossed out. Review of nursing notes on [DATE] at 6:45 A.M. documented LPN #11 was called to Resident #53's room and the resident was on the floor. An assessment was completed, and Resident #53 was sent to the emergency room . The power of attorney, physician, and transport were called. Review of hospital records dated [DATE] to [DATE] revealed on [DATE] Resident #53 had fallen about three feet out of bed. She was a dependent adult requiring ,[DATE] care. The scan of the head and neck showed maxillary buttress fracture (central mid-face) and traumatic subarachnoid hemorrhage of the left posterior, inferior, frontal and temporal regions. Initial strategy was to transfer Resident #53 to a neurosurgical unit, but the family objected because she was a do not resuscitate (DNR). Resident #53 was referred to the hospice unit at the hospital and admitted for maxillary buttress fracture and traumatic subarachnoid hemorrhage. Resident #53 expired on [DATE] and the body was released to the funeral home. Review of Resident #53's death certificate dated [DATE] revealed the resident expired on [DATE] from a massive brain bleed due to a subarachnoid hemorrhage related to a fall. Review of the fall investigation dated [DATE] revealed factors that may have contributed to the fall were equipment and furniture placement, height position of the bed and mattress, equipment, fall mats, cognition. The resident was sent to the emergency room for evaluation and the action plan was to monitor the resident upon readmission. The fall investigation included two attached written statements from the STNAs caring for Resident #53, STNA #6's statement indicated on [DATE] she had washed and dressed Resident #53 and then left the room to get the Hoyer lift. STNA #7 stayed in the room. As she walked through the doorway with the Hoyer lift, she heard the resident hit the ground. She looked up and saw the resident face down on the floor and bleeding. She ran for help. STNA #7's statement dated [DATE] revealed she had the bed up high to hip level to prepare the resident with transfer. The resident was on her back, lying on the Hoyer lift pad. STNA #7 turned away to get the dirty linen out of the way as the other aide was bringing in the Hoyer lift. The resident's legs began to lean to the right side and she started to fall out of the bed. STNA #7 tried to catch her but it all happened too fast, and the resident hit the floor face first. According to the fall investigation, both STNAs were provided one-on-one in-service on [DATE] to ensure all needed equipment was in the room prior to care, staff was to stand next to the bed while the bed was in working position, and if they had to move away from the bed to place the bed back into low position. Interview on [DATE] at 7:25 A.M., with STNA #4 and STNA #5 reported the residents fall interventions were located the restorative book. Interview on [DATE] at 7:30 with STNA #8 revealed the STNA did not have access to the electronic medical records and she was not sure where to find the resident fall interventions except in the restorative books. Interview on [DATE] at 7:35 A.M., with the DON revealed the STNAs were notified of changes in resident care in stand-up meetings and they had access to the printed resident plan of cares located at the nurse's station. She verified the restorative books did not include all the residents' current fall intervention. Interview on [DATE] at 8:49 A.M., with the DON revealed it was reported to her that Resident #53's right side of the bed was against the wall. One of the STNAs left the room to get the Hoyer lift and the second STNA stayed in the resident's room. They had the resident's bed in the high position. The second STNA was moving linen off the floor to clear a pathway for the hoyer lift when the resident had rolled out of bed face first hitting the floor. The DON provided the two staff members (STNA #6 and STNA #7) education on appropriate supervision with transfers, never leave the bed in high position, and to ensure the appropriate equipment was ready and available. The DON confirmed Resident #53 required assistance of two staff with bed mobility and transfers. Interview via telephone on [DATE] at 12:51 P.M., with STNA #6 verified she worked the morning of [DATE]. STNA #6 stated STNA #7 and herself had washed and dressed Resident #53 and placed a Hoyer lift pad under the resident. The resident was lying flat in the bed when she left the room to get the Hoyer lift. She reported STNA #7 had stayed in the room with the resident, however the STNA had turned away for a minute to get something or move something. STNA #6 stated as she was pushing the Hoyer lift through the doorway she heard the resident hit the floor. She did not see the resident or the other STNA prior to the resident hitting the floor. STNA #6 reported Resident #53 was not able to turn herself in bed. STNA #6 verified she was provided one on one education regarding never turn away from a high bed, ensure equipment was available, and to ensure two staff members were with residents that required two person assistance with care. Review of the Resident Incident policy, dated [DATE], revealed all residents would have a fall risk assessment upon admission and post-fall assessment. All residents would be assessed for fall risk upon admission and quarterly. A care plan would be developed with interventions. If a resident fell , complete an incident report, head to toe assessment and a post fall 72-monitoring report would be completed. All unwitnessed falls required neurologic checks. Staff were to proceed with appropriate interventions and/or physician orders. 2. Review of the closed medical record revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated [DATE] revealed Resident #52's cognition was intact. The resident required extensive assist of two or more staff for bed mobility and was totally dependent on two or more staff for transfers. Review of the most recent fall assessment dated [DATE] revealed Resident #52 was at low risk for falls. Further review revealed staff indicated the resident had not fallen before. However, review of the medical record revealed Resident#52 was noted to have fallen [DATE], [DATE], and [DATE]. Review of Resident #52's orders and treatment administration records for June, (YEAR) revealed to keep the bed in the lowest position while occupied, mat to the left and right side of the bed, and a Hoyer lift for all transfers. Review of the plan of care for falls dated [DATE], revealed Resident #52 was at risk for falls related to gait/balance problems. Intervention included to anticipate the resident's needs, call light in reach, prompt response to call light, assist with all requests, encourage to sleep in bed instead of recliner, bed in lowest locked position, mats to both sides of the bed, re-educated resident of proper height to place lift chair to deter the chance the resident would slide out, and reminder sign placed in resident's room. Review of a fall investigation dated [DATE] revealed Resident #52 slid out of bed when one staff member was providing care. The resident was lowered to the floor. Skin tears were noted to the top of the right foot and right lower leg. Resident #52 complained of right hip and leg pain and was sent to the emergency room for evaluation. Further review of the fall investigation revealed a written statement by STNA #9 dated [DATE] that indicated she was washing the resident and when she went to roll the resident over on her side to pull the clean sheet through the resident reported her feet were slipping. The STNA ran around the bed to lift them up, but the resident's legs slid too, and they both slid to the floor on her knees. STNA #9 gently sat the resident on the floor and got the nurse. According to the fall investigation, STNA #9 was educated on the fact the resident required the assistance of two staff members with all care. Interview on [DATE] at 3:05 P.M. and [DATE] at 8:55 A.M., with the DON verified the fall assessment dated [DATE] was inaccurate as the resident had fallen previously. She confirmed Resident #52 required two staff member's assistance with bed mobility and on [DATE] only one staff member was providing care. The result was Resident #52 fell out of the opposite side of the bed. The DON reported she had provided education to the staff member (STNA #9) regarding providing care to a resident that required assistance of two. The DON verified the resident received skin tears because of the fall and was sent to the emergency room for evaluation. 3. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #41 was dependent on staff for all care. Review of the most recent fall assessment dated [DATE] revealed Resident #41 was at high risk for falls. Review of the fall plan of care dated [DATE] revealed Resident #41 was at risk for falls due to a history of previous falls prior to admission, fluctuating blood sugars, impaired balance, use of [MEDICATION NAME], impaired decision making, and amputation of the 5th toe on the left foot. Review of the interventions including resolved interventions revealed no evidence the resident had any new fall intervention implemented since June, (YEAR) even though the resident had sustained four falls within that time frame. Review of the fall incident reports revealed Resident #41 had fallen on [DATE] with no injuries noted. The resident was found in her room on floor on [DATE] and had sustained a laceration to the left eyebrow. The resident was found on the mat beside the bed, [DATE] with no injuries noted. Resident #41 was found on the floor by the bed on [DATE] with no injuries noted. Further review revealed no evidence the facility identified the root cause of the falls or implemented new fall interventions. On [DATE] at 3:22 P.M., interview with the DON confirmed the resident had fallen on [DATE], [DATE], [DATE], and [DATE] without evidence of root analysis of the cause of the fall or new fall interventions being implemented. The DON reported the new fall investigation forms did not include the root analysis like the previous forms she had utilized. The DON verified the printed care plans located at the nurse's station were not updated to reflect the resident's current fall interventions. 4. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent fall assessment dated [DATE] revealed Resident #31 was at high risk for falls. Review of the MDS dated [DATE] revealed Resident #31 required extensive assistance of one staff member for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. The resident required limited assistance with walking in the room and corridor. Review of the fall care plan dated [DATE] revealed Resident #31 was at risk for falls related to impaired balance and gait and a history of dizziness. There was no evidence the resident had any new fall intervention implemented since [DATE], however, she had sustained three falls since then. Review of a fall investigation revealed Resident #31 had fallen on [DATE] with no injuries noted. The resident fell out of a chair on her knees on [DATE] and no injuries were noted. The resident was found on the floor in her room during rounds on [DATE] with no injuries noted. Further review revealed no evidence of the root cause of the falls or appropriate interventions initiated. On [DATE] at 9:13 A.M., interview with the DON confirmed Resident #31 had fallen on [DATE], [DATE], and [DATE]. She reported the three-fall investigations had been left in her in-box and not reviewed or fall intervention implemented because she had been on vacation. This deficiency substantiates Complaint Number OH 425.

Based on medical record review, observation, resident, staff, and physician interview, facility policy review and review of documentation from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to accurately assess, implement interventions and treat avoidable facility acquired pressure ulcers in a timely manner. This resulted in Immediate Jeopardy for four residents: Resident #52 sustained a decline in a pressure ulcer from a Stage II to unstageable; the resident became septic and required hospitalization . Residents #62 and #65 sustained a decline in pressure ulcers and Resident #22 developed two unstageable pressure ulcers. This affected four (Residents #22, #52, #62 and #65) of five residents reviewed for pressure ulcers. The facility identified six residents with facility acquired pressure ulcers. The facility census was 49. On [DATE] at 2:20 P.M., Administrator #31 was notified the Immediate Jeopardy began on [DATE], when Resident #52 had a decline in a pressure ulcer on the left buttocks and the attending physician (Physician #100) was not notified. Consequently, Resident #52 required hospitalization and intravenous antibiotic therapy for the wound. Resident #62 was admitted with a pressure area to the left heel, however was not assessed for the risk of pressure ulcers on admission and no pressure reduction interventions were implemented resulting in a decline to the left heel pressure ulcer. Resident #22 was not assessed on admission for risk of pressure ulcers and no interventions were implemented; consequently Resident #22 developed two unstageable pressures on the coccyx. Resident #65 was admitted with pressure ulcers to the right and left heels and right buttock. Resident #65 was not assessed for the risk of pressure ulcers on admission and sustained a decline in an existing pressure area to the buttock. The Immediate Jeopardy was removed on [DATE] when the facility initiated the following corrective actions: · On [DATE], the facility implemented a Weekly Wound Tracking form and Weekly Physician Notification Form. · On [DATE], nursing education for Staging of Wounds, Assessment of Wounds, use of the Weekly Wound Tracking form and Weekly Physician Notification Form, use of Braden Scales and Nursing Interventions for Residents at risk for Pressure Ulcers was completed by the director of nursing (DON) and Risk Manager #1 for all licensed nursing staff which included six Registered Nurses (RN) and five Licensed Practical nurses (LPN). LPN #19 was inserviced by phone on [DATE]. · On [DATE], inservice training for Skin and Wound Management was completed by the DON and Risk Manager #1 for the licensed nursing staff of six RNs and six LPNs. LPN #19 was inserviced by phone call on [DATE]. · On [DATE], pressure ulcer risk assessments were completed by nursing staff for all 49 residents in the facility and pressure reduction devices as appropriate were implemented. · On [DATE], 13 licensed nurses and 25 of 29 State-tested Nurse Aides (STNA) were in-serviced by the DON and Risk Manager #1 on the importance of turning and repositioning residents to prevent pressure ulcers, notification of staff of skin breakdown, skin barrier cream importance, shower sheets that are completed with any concerns. The remaining four STNAs would be inserviced on their return to work and prior to providing care. · On [DATE], at 11:00 A.M. observation of the wound treatment for [REDACTED]. · On [DATE], observation of Resident #52 at 10:48 A.M. revealed the resident was in an Airodyne (specialty) bed and on her right side. Physician ordered Ankle Foot Orthosis (AFO) boots were in place and pressure reduction devices for wounds to the feet and the [DEVICE] was set to 125 mmhg per order for a buttock pressure ulcer. · On [DATE], a 'Dressing Technique' audit was implemented to be completed weekly by Wound Nurse #12 for all residents with dressing changes until all concerns were addressed and then completed monthly. The facility identified six residents with pressure areas. · On [DATE], an audit tool was implemented 'Walk through Aides Audit Tool' for turning and repositioning, proper care of residents and use of pressure relieving interventions as presented to 25 of 29 STNAs on [DATE]. The remaining four STNAs would be trained in the use of the tool upon their return to work and prior to providing care. · On [DATE], interviews with RN #1 at 8:31 A.M., and LPN #60 at 8:33 A.M., verified knowledge of how to assess and treat a resident with a pressure ulcer and verified recent inservice training on pressure ulcers. Interview with STNA #49 at 9:15 A.M. verified a recent inservice on care of the resident with a pressure ulcer. · On [DATE] at 2:05 P.M. observation with the DON of LPN #60 completing the treatment for [REDACTED]. [REDACTED]. · A follow-up wound in-service was scheduled for [DATE] for all licensed nurses. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for than minimal harm that is not Immediate Jeopardy) as on-going random audits and monitoring by the facility to ensure the continued skin assessment and provision of care could not be evaluated yet for effectiveness and not all direct care staff had completed inservice training. Findings include: 1. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Pressure Sore Risk assessment dated [DATE] revealed Resident #52 was at low risk for developing pressure ulcers. The pressure ulcer risk assessment dated [DATE] determined Resident #52 was at moderate risk for the development of pressure ulcers. The risk factors included slight sensory impairment, very moist tissues, chair-fast, slightly limited mobility, inadequate nutrition, and a problem with friction/shearing. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #52 was at risk for pressure ulcers, had a pressure reducing device for the bed, an application of nonsurgical dressing, and application of ointments. Further review revealed Resident #52 required one to two assist with activities of daily living. Review of the skin grid dated [DATE] (unknown author) revealed Resident #52 was found with a 5.0 centimeter (cm) in length by 2.0 cm in width 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. Presents as a shiny or dry shallow ulcer without slough or bruising) dark pink area on the left buttocks, a 0.2cm in length by 0.5 cm in width Stage II pink open area on left buttocks and a 0.5 cm length by 1.0 cm width Stage II pink open area on the left buttocks. In addition Resident #52 had a 1.5 cm in length by 1.0 cm in width by zero depth Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue) intact dark pink area on the left heel, 0.5 cm in length by 0.5 cm width by 0 cm depth Stage I intact dark pink area on left big toe, and 0.5 length by 0.5 width by 0 cm depth intact dark pink area on left medial foot. Review of the nurse's note dated [DATE] revealed Resident #52 had a 5.0 cm by 2.0 cm hard, dark area on the left buttocks with two small areas inside. New physician orders [REDACTED]. Additional physician orders [REDACTED]. Review of Resident #52's care plan for skin impairment for left buttocks, left heel, left foot, and left medial foot revealed Resident #52 was at risk for skin impairment due to mobility, incontinence, [MEDICAL CONDITION] lower extremities, and poor appetite. Interventions included to administer treatments as ordered, monitor for effectiveness and to monitor nutritional status. Monitor skin during care and report abnormal findings. Weekly skin checks were to be conducted. Review of Resident #52's skin grid by an unknown author dated [DATE] documented the two Stage II pressure areas on Resident #52 left buttocks were now one area measuring 7.0 cm in length by 3.0 cm in width by 0.5. The pressure area was categorized as a Stage II open dark purple/pink/brownish area. The left heel increased to a Stage II measuring 2.0 cm in length by 1.0cm in width with dark pink scabbed tissue. The Stage I pressure area on the left big toe measured 1.0 cm in length by 1.0 cm in width of intact dark pink tissue. The left medial foot was categorized as a Stage I measuring 0.2 cm in length by 0.2 cm in width of intact dark pink tissue. Review of nurse's note dated [DATE] revealed the attending physician (Physician #100) was notified the wounds were worse and Resident #52 was lethargic. Orders were received to decrease the [MEDICATION NAME] 0.25 milligrams (anti-psychotic), consult the wound physician and change the dressing order from every third day to daily. Review of physician orders [REDACTED]. Review of nurse's notes dated [DATE] revealed a complete blood count (CBC) was drawn and Resident #52's white blood count was elevated. Physician #100 was notified and orders were obtained to collect culture and sensitivity of the left buttocks wound and start Doxycline (antibiotic) 100 mg by mouth for seven days. Review of Resident #52 lab results dated [DATE] revealed the resident's white blood count was 13.8 H (normal 4XXX,[DATE]). Review of wound culture results dated [DATE] revealed heavy Proteus Mirablis, rare Escherichia coli and occasional [MEDICATION NAME] species. Review of Resident #52's skin grid dated [DATE] by an unknown author revealed the area on the left buttocks had declined to a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling} measuring 8.0 cm in length by 5.0 cm in width x 2.0 cm in depth and was open dark purple/pink/brown/scant tan drainage. Left heel and left big toe revealed no noted changes from the [DATE] wound assessment. The left medial foot wound increased to 0.5 cm long by 0.5 cm wide intact dark pink tissue. Review of Resident #52's medical record revealed no evidence Physician #100 was notified of the decline in Resident # 52's left medial foot. Review of Resident #52's nurse ' s notes dated [DATE], revealed a urinary catheter was inserted per order to deter urine from the buttocks wound until it was healed. Review of Consulting Wound Physician #110's notes dated [DATE] revealed Resident #52 had a large Stage III possibly Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) ulcer of the left buttock with necrotic tissue in the wound. In addition there was peri-wound inflammation. Consulting Wound Physician #110 documented Resident #52 would require debridement of the area. Review of the appointment book revealed Resident #52 was scheduled for the wound debridement on [DATE] with the wound clinic at 3:30 P.M. Review of physician orders [REDACTED].#52 was ordered a new antibiotic, [MEDICATION NAME] 500 mg, for 10 days and on [DATE] an order was received for an alternating air mattress instead of the standard facility pressure reduction mattress. Review of the June, 2015 treatment administration record (TAR) revealed Resident #52's canoe mattress (a deep perimeter mattress, no pressure relieving qualities) and alternating air mattress both were signed off as in use from [DATE] to [DATE]. Registered Nurse (RN) #4 affirmed the canoe mattress was discontinued on [DATE] and was unable to provide evidence when the alternating air mattress was applied. Review of Resident #52's skin grid dated [DATE] by an unknown author documented the area on the left buttocks measured 8.0 cm in length by 5.0 cm in width by 2.5 cm in depth. The left buttocks remained a Stage III with an open pink/brown large amount of tan drainage. Review of nurse's notes and physician orders [REDACTED].#100 or consulting Wound Care Physician #110 was notified of the left buttock wound decline. Review of nurse's notes dated [DATE] revealed the left buttock measured 8.0 cm by 6.0 cm by 2.5 cm and was a Stage III ulcer. The ulcer had a large amount of foul smelling tan drainage. Further review revealed no evidence Physician #100 was notified of a decline in the wound. Observation of Resident ' s #52 left buttocks wound care on [DATE] at 1:46 P.M. with LPN #56 and RN #4 revealed the area on the left buttocks had 15 percent necrotic (black/grey dead tissue) tissue and the rest of the wound had red granulation tissue with strains of yellow/tan slough. The wound bed was pink and wound edges were approximated. The old dressing had a moderate amount of tan foul smelling drainage. LPN #56 applied the Calcium Ag but did not apply it to the entire wound bed. One to two centimeters around outer edge wound bed was not covered with Calcium Ag. LPN #56 applied the occlusive/foam dressing and a part of the wound was exposed on the bottom. RN #4 affirmed the Calcium Ag did not cover the entire wound bed and a part of the wound was exposed after the foam dressing was applied. Observation of Resident #52's mattress on [DATE] at 2:00 P.M. revealed the mattress was set on firm. The DON and RN #4 were not able to provide guidelines on the mattress and what the appropriate setting was for the wound. Observation of Resident #52's pressure areas on left foot on [DATE] at 2:05 P.M. with LPN #56 and RN #4 affirmed the pressure skin sheets were incorrect and the area was not on the left great toe it but was the left little toe; the left medial foot was incorrect and was actually the left outer foot. RN #4 affirmed the area on the left heel was a Stage II on [DATE] and then a Stage I on [DATE] and [DATE] according to the wound sheets. RN #4 affirmed the heel was staged incorrectly on [DATE] and [DATE] and was a Stage II. Review of nurse's note dated [DATE] revealed Consulting Wound Physician #110 was notified of Resident #52's left buttock wound having tan, foul smelling drainage. New orders were received to discontinue skin prep to calloused areas on left outer aspect of foot and obtain a culture and sensitivity of the left buttocks. Debridement was scheduled for [DATE]. Nurse's notes revealed the original order for debridement of the wound received on [DATE] had been delayed. Observation was made of Resident #52's left buttocks pressure ulcer dressing change and measurement on [DATE] at 9:30 A.M. with RN #4 and the DON. RN #4 had measured 10 centimeter (cm) length by 6.0 cm width by 3.5 cm depth, and no tunneling noted. The DON reassessed the wound and affirmed there was undermining of 1.5 cm near the left trochanter and 1.5 cm undermining near the left labia. RN #4 applied the Calcium Ag to the wound bed with the Calcium Ag over lapping onto the good skin. The DON stepped in and re-educated RN #4 on the proper procedure to apply the Calcium Ag. RN #4 documented after the dressing change the wound bed was 75 percent pink/red tissue, 1.5 cm undermining toward the left trochanter and left labia, 23 percent necrosis in the upper part of the wound and 2.0 percent necrotic at the wound edge. Foul tan smelling drainage saturated the old dressing. The outer periphery edge was dark pink. RN #4 affirmed the wound had declined from the observation of [DATE] and a new necrotic area had developed on the lower part of the wound. Interview with the DON on [DATE] at 10:00 A.M. affirmed the skin grids on the left buttocks and left heel were not complete assessments of the wounds. The DON affirmed the areas on the left foot were not anatomically correctly documented on the skin grids or nurse's notes. The DON affirmed the treatment had not been changed for the areas on the left foot for five weeks, they had not improved and Physician #100 had not been notified of the wounds on left foot. The DON affirmed neither Physician #100 nor consulting Wound Care Physician #110 was notified of the decline of the left buttocks wound on [DATE] and [DATE]. The DON verified the treatment had not been changed on the left buttocks since [DATE] and the wound had declined. The DON affirmed consulting Wound Care Physician #110 had ordered debridement of the left buttocks on [DATE] and the area had not been debrided as of [DATE]. Interview with Physician #100 on [DATE] at 3:57 P.M. revealed he was unaware of Resident #52's wound decline. Review of the wound culture results that was collected on [DATE] revealed Resident #52's wound culture grew moderate proteus mirabilis and moderate diphtheroids. Review of nurse's noted dated [DATE] revealed a dressing change to the left buttocks wound revealed it was 80 percent black with a moderate amount of milky drainage. Borders were red with moderate sloth noted. Resident #52's temperature was 99.2 degrees Fahrenheit (F). Physician #100 was notified and new orders were obtained for a wound culture, laboratory studies and an antibiotic to be administered for 7 days. Interview with LPN #60 on [DATE] at 10:55 A.M. affirmed Resident #52 was transported to the hospital that morning due to a change in the wound and a fever of 103.2. LPN #60 reported around 10:00 A.M. Resident #52's temperature went up to 103.2 F and she appeared pale so he called Physician #100 and received new orders to send Resident #52 to the emergency room . Review of a hospital referral information form dated [DATE] revealed Resident #52 had a Stage IV ulcer with necrotic tissue on the left buttocks and dry specked tissue on the left foot. The temperature was 103.2 F, pulse 120, respirations 20 and blood pressure ,[DATE]. Interview with RN #132 on [DATE] at 4:45 P.M. revealed Resident #52 was admitted to the hospital on [DATE] [MEDICAL CONDITION] of the wound and an unstageable infected decubitus ulcer of the left buttocks. RN #132 revealed Resident #52 was currently on IV antibiotics and scheduled for debridement of the wound. Review of the facility Report to the Physician policy revealed the licensed nurse will report changes in the resident's condition, or accidents or incidents to the physician as soon as possible. Examples of changes in condition included skin conditions (bedsores) and change in general appearance. Review of in-service records revealed nurses were last in-serviced on wound care standards of practice on [DATE]. Further review revealed components of wound documentation include location, size, color, odor, necrotic tissue including percentage, tunneling/undermining, infection, healing, and surrounding skin. Pressure ulcers should be re-evaluated weekly and if the wound is deteriorating or no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. Review of the decubitus wound tracking policy and procedure dated [DATE] revealed the treatment nurse will chart weekly on residents with skin problems. Included on the chart will be dimensions, drainage, progress, color, etc. If area does not show improvement, a doctor will be notified. Review of the [MEDICATION NAME] Ag insert guidelines dated 2009 revealed to call the healthcare professional if signs of infection occur (increased pain, bleeding, wound drainage), if there is a change in wound color and/or odor, the wound does not begin to show signs of healing, and other unexpected symptoms occur. The wound dressing should overlap ½ inch onto the skin around the wound. Review of the Calcium Ag insert guidelines dated ,[DATE] revealed direction for use included select a size of alginate dressing that is slightly larger than the wound. Apply to wound bed directly. Loosely fill deep wounds, ensuring the dressing doses not overlap the wound margins, cover and secure with a non-occlusive secondary dressing. 2. Review of Resident #62's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS 3.0 assessment dated [DATE] revealed Resident #62 was cognitively impaired and required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. Resident #62 required extensive assistance of one staff member for personal hygiene. The MDS indicated Resident #62 had a pressure ulcer present that was greater than a Stage I. Review of the Plan of Care for skin impairment dated [DATE] revealed Resident #62 had an unstageable pressure ulcer to the left heel and had a history of [REDACTED]. The care plan indicated Resident #62 required assistance to turn and reposition at least every two hours and weekly skin check as needed. Resident #62 was at risk for further impairment due to decreased mobility, protein malnutrition and incontinence. Interventions included up in a geriatric (Geri-chair) chair as needed, keep feet elevated, monitor nutritional status and monitor intake and record. Review of Resident #62's monthly physician's orders [REDACTED]. An order to elevate the resident's heels off of the bed and chair at all times was received on [DATE]. Review of the pressure risk assessment revealed it was not completed upon admission of [DATE]. The risk assessment was dated [DATE] and indicated Resident #62 was at moderate risk for pressure ulcers. Review of the Decubitus Flow Sheet dated [DATE] by an unknown author revealed an unstageable pressure ulcer was discovered on the Resident #62's left heel measuring 0.5 cm by 0.5 cm and described as a dark tan/brown scabbed area, dry and intact. Further review of the Decubitus Flow Sheet revealed the wound was measured weekly and no changes were noted. On [DATE] an order was received for an alternating air mattress to Resident #62's bed. On [DATE] at 12:32 P.M., Resident #62 was observed seated in a Geri- chair with the feet elevated by the foot rest of the chair. The resident's knees were bent and the bottoms of both feet were resting on the Geri-chair. Resident #62 was wearing shoes and no devices to off-load the pressure from the left heel were noted. On [DATE] at 12:47 P.M., interview with the DON verified the resident's pressure ulcer risk assessment was not completed on admission to the facility and no off-loading pressure relieving interventions had been implemented for Resident #62 as ordered. On [DATE] at 12:32 P.M., Resident #62 was observed with her feet elevated on the foot rest of the recliner with socks on both feet. No pressure relieving device was observed to be in place to off-load the resident's heels. This finding was verified with State-tested Nurse Aide (STNA) #75 at that time. On [DATE] at 3:20 P.M., Resident #62 was observed in her recliner chair with a pillow under her legs to elevate her heels. The resident was then observed to draw her knees up and rest the soles of her feet on the recliner chair. On [DATE] at 10:10 A.M., Resident #62 was observed lying in bed with both heels touching the mattress on her bed. This finding was verified with RN #4. 3. Review of Resident #22's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #22 was cognitively impaired and required extensive assistance of two staff members with bed mobility, dressing and toilet use and extensive assistance of one with personal hygiene. Review of the Nursing Admission Screening/History dated [DATE] revealed the resident did not have skin conditions on admission. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #22 was at high risk for pressure ulcers. Review of the Decubitus Flow Sheet dated [DATE] by an unknown author revealed Resident #22 had two Stage II pressure ulcers on her coccyx each measuring 0.1 cm by 0.1 cm by 0.1 cm open tissue, pink in color. On [DATE] the two areas became one area measuring 4.5 cm by 5.0 cm by 0.1 cm. On [DATE] a Stage II to left lower buttocks was discovered measuring 1.5cm by 1.5 cm by 0.1 cm open pink tissue no drainage. On [DATE] a Stage II pressure ulcer was discovered on Resident #22's left upper buttock measuring 2.0 cm by 1.0 cm by 0.1 cm described as open pink tissue. Review of the nurse's progress notes dated [DATE] at 2:42 A.M. revealed Resident #22 had an open area on her left lower buttock measuring approximately 1.5 cm by 1.5 cm. The coccyx had two small pinpoint areas. An order was received for Duoderm. The nurse's progress notes did not contain any further documentation related to pressure ulcers. No documentation regarding notification of the physician related to the decline in the resident's pressure ulcer to coccyx was noted in the medical record. Review of the Duoderm CGF (control gel formula dressing) manufacturer's guidelines revealed it is an adhesive [MEDICATION NAME] wound contact dressing. The [MEDICATION NAME] are contained within the dressing mass. The adhesive layer contains polymers which enhance the dressing's ability to contain wound exudate by forming a cohesive gel. The Duoderm CGF is not indicated for use as a treatment for [REDACTED]. Review of the medical record did not contain documentation for turning and repositioning of Resident #22 during the months of May and [DATE]. Review of the Medication Administration Record [REDACTED]. Resident #22 was admitted to the hospital on [DATE]. Review of the Referral Information Form dated [DATE] revealed Resident #22 had two open areas on her left buttock, one measuring 2.0 cm x 1.0 cm, without a depth measurement, and the other 0.5 cm x 0.5 cm without a depth measurement; an area to the coccyx measuring 4.5 cm by 5.0 cm with no depth measurement and an area on the right buttock which measured 1.0 cm x 1.4 cm. Review of the hospital records revealed a wound/dressing tool dated [DATE] indicating Resident #22 was admitted to the hospital with [REDACTED]. No measurements were indicated. Necrotic tissue was present in the wound beds. Review of the Hospital Discharge instructions dated [DATE] revealed an order for [REDACTED]. The order did not indicate the site of application. Further review of the re-admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On [DATE] at 1:35 P.M. interview with the DON revealed Resident #22 did not have pressure ulcers on admission but did develop two stage two pressure ulcers on [DATE] that worsened into one area on [DATE]. Further interview confirmed the pressure ulcer assessment was not completed on admission and was not completed until seven days after admission. The DON stated if Resident #22 was assessed as high risk for pressure, interventions for pressure relief would be initiated. The DON indicated all mattresses in the facility were pressure relieving mattresses. The DON was asked to provide documentation related to the manufacturer's guidelines for the mattresses in the facility, however, the DON was unable to provide the documentation. The DON verified the facility implemented a low air loss mattress on [DATE] for Resident #22. The DON indicated if a wound declines the physician is to be notified and orders are to be given for interventions, the facility does not have standing orders related to pressure relieving interventions to put into place as a nursing intervention. The DON verified the [MEDICATION NAME] was ordered to apply BID as directed but did not indicate where and the treatment was not documented. The DON verified she was unable to locate documentation related to Resident #22 being turned and repositioned as ordered for the month of May, 2015. On [DATE] at 2:25 P.M. interview with Licensed Practical Nurse (LPN) #80 verified Resident #22 was admitted to the hospital on [DATE] and the treatment for [REDACTED]. LPN #80 verified the hospital records indicated the pressure ulcers on her natal cleft/coccyx and buttocks were unstageable with necrotic tissue in the wound bed and were present on admission to the hospital. On [DATE] at 3:49 P.M. interview with Physician #100 revealed he was unaware of Resident #22's decline in pressure ulcers. Physician #100 stated he would expect to be notified of a decline in a resident ' s pressure ulcer. Resident #22 expired on [DATE]. 4. Review of the closed medical record revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS admission assessment dated [DATE] revealed Resident #65 was cognitively intact, required extensive assistance of two staff for bed mobility and transfers, and was at risk for development of pressure ulcers. The MDS revealed Resident #65 was admitted with one Stage I pressure ulcer and two Stage II pressure ulcers. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #65 was at risk for pressure ulcers. Review of the plan of care dated [DATE] revealed Resident #65 was admitted with impaired skin integrity and was at further risk for skin breakdown due to decreased mobility and poor appetite. The interventions included the nurses were to assess and document the status of the wound perimeter, the wound bed, and the healing progress. The plan of care had been updated on [DATE] to include the provision of treatment to an open area to the left buttock and on [DATE] to include the provision of treatment to an open area to the right upper back. The plan of care did not reveal any intervention in place to utilize for Resident #65 to reduce pressure in an attempt to prevent further decline. Review of the Decubitus Flow Sheet dated [DATE] revealed Resident #65 was admitted to the facility with a deep tissue injury (DTI) to the left heel t

Based on observation, interview and record review, the facility failed to ensure pain control was maintained during a dressing change to a pressure ulcer. This affected one of two residents observed for a dressing change (Resident #52). The census was 49. Actual harm occurred while Resident #52 who was receiving a dressing change to a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer yelled out in pain it hurts and get out of there. Findings include: 1. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #52's Physician order [REDACTED]. On 06/18/15 at 1:46 P.M., observation of a dressing change to Resident #52's Stage III pressure ulcer of the left buttock completed by Licensed Practical Nurse (LPN) #56 and Registered Nurse (RN) #4, revealed during cleansing of the wound and applying the new dressing, Resident #52 yelled out twice it hurts and get out of there. State-tested Nurse Aide (STNA) #1 asked the resident if she was OK once during the dressing change. Resident #52 responded yes. During the dressing change, neither LPN #56 or RN #4 made any effort to further medicate or stop the dressing change. This surveyor asked LPN #56 if the resident had been medicated for pain. LPN #56 reported she gave Resident #52 Tylenol for pain around 11:30 A.M. The wound was deep in appearance and had an odor. Review of Resident #52's Medication Administration Record (MAR), nursing notes, and the 24 hour Nurses Report dated 06/18/15, revealed no evidence that Tylenol had been administered on 06/18/15 to Resident #52 as reported by LPN #56. Interview with LPN #56 on 06/18/15 at 2:15 P.M. revealed she had forgotten to document that she gave Resident #52 Tylenol 650 milligrams (mg) around 11:30 A.M. LPN #56 affirmed the Tylenol was not documented on the MAR, the 24 hour shift report or the nurses' notes. Review of the skin sheet dated 06/19/15 revealed Resident #52's pressure ulcer measured 10 centimeters (cm) length by 6 cm width by 5.5 cm depth. Review of the MAR dated 06/15/15 revealed Resident #52's only pain medication was Tylenol 650 milligrams (mg) by mouth every 4 hours as needed for pain. Further review revealed Resident #52 had Tylenol given only six times from 06/02/15 to 06/04/15. Review of Resident #52 pain care plan initiated 06/10/15 revealed Resident #52 was at risk for pain due to impaired skin and generalized discomfort. Interventions included to administer [MEDICATION NAME] as per orders, anticipate the resident's needs for pain relief and respond immediately to any complaint of pain, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.

Based on observation, record review, and staff interview, the facility failed to ensure appropriate fall interventions were implemented for a resident with a known fall risk. This affected one of four residents reviewed for accidents (Resident #63). The facility also failed to ensure hazardous chemicals were properly secured. This had the potential to affect four residents the facility identified as cognitively impaired and independently mobile. (Residents #35, #37, #43 and #72). The census was 49. Harm occurred when Resident #63 was unsupervised in a common area, and fell sustaining a laceration to his head requiring 13 sutures. Findings include: 1. On 06/21/15 at 10:43 A.M. State-tested Nurse Aide (STNA) #20 was observed in the dining room pushing Resident #63 in his wheel chair. A six to eight inch gap was observed between the resident and his lap buddy (a soft padded cushion applied to a wheelchair to remind the resident to ask for assistance to get up). Interview with STNA #20 revealed the lap buddy was incorrectly applied but the resident had not been cooperative when she tried to apply the lap buddy and that was the only way the lap buddy could be applied. STNA #20 stated sometimes the lap buddy was purposely applied incorrectly to make sure the resident had it in place for positioning. On 06/22/15 at 10:05 A.M., the resident was observed walking from his wheelchair to his recliner. The resident had removed his lap buddy and the chair alarm was sounding. The resident was incontinent of urine. STNA #13 entered the resident's room to assist the resident and stated the resident removes the lap buddy. On 06/22/15 at 4:21 P.M. Resident #63 was observed in bed and the personal alarm was not on the resident's clothing as indicated in his plan of care (POC). This finding was verified with STNA #52. On 06/23/15 at 10:27 A.M. observation revealed Resident #63 did not have his call light on his clothing or pad alarm in his recliner chair. This finding was verified with Licensed Practical Nurse (LPN) #60. Further interview verified the resident should have an alarm in place. On 06/23/15 at 10:32 A.M. interview with STNA #49 verified the resident was to have an alarm in place at all times due to his risk for falls. Review of Resident #63's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the monthly physician's orders [REDACTED]. while in recliner, gripper socks while in bed, keep resident in common area with supervision while up in the wheelchair, canoe mattress and scheduled toileting program Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not cognitively intact and required extensive assistance of two staff with bed mobility, transfers, dressing and toilet use and extensive assist of one staff with personal hygiene. Review of the fall risk assessment dated [DATE] indicated the resident was a high risk for falls. Review of the Fall Care Plan dated 07/08/14 with target date of 09/07/15 revealed interventions to include every 30 minute visual checks, anticipate and meet the resident's needs, canoe mattress to the resident's bed, clip the call light to the resident's clothing, gripper socks when in bed, high-low bed in the lowest position to keep the resident safe, if not sleeping keep in area of activity, toileting program, keep alarm out of reach, keep in common area with supervision 03/12/15, keep personal items within reach, keep resident in wheelchair in common area and re-educate staff on 04/09/15, pad alarm at all times and check placement and function every shift, physical therapy to evaluate and treat as ordered or as needed (prn), the resident needs a safe environment Review of the incident and accident report dated 01/08/15 at 8:30 P.M. revealed the STNAs heard the resident's pad alarm sounding and then shut off. When they went in to check on the resident, the resident appeared to have slid out of the recliner chair and fell on to the floor in his room. The resident had an abrasion to the left side of head. Ice and neurological (neuro) checks were initiated. Ice was to be applied to the left side of the head as needed and neuro checks every four hours for 48 hours. New intervention to clip the call light to the resident's clothes while he is in the chair. Review of the neurological assessment revealed checks were completed on 01/08/15 at 8:30 P.M., 01/09/15 at 12:30 A.M., 01/09/15 at 6:30 A.M. and 01/09/15 at 10:00 A.M. No further documentation of neurological assessments were able to be located. Review of the Incident and Accident Report dated 01/16/15 at 4:30 A.M., revealed the STNAs went to check on the resident and the resident was found sitting on his buttocks in front of a chair in his room. The resident stated he slid out of the chair trying to get the cookies. The resident had an abrasion to his lower mid back and a skin tear to his left arm. The intervention was to keep personal items within reach. Review of the Incident and Accident Report dated 02/13/15 at 2:30 A.M., revealed the resident stood to get out of bed and the bed controller fell to the floor. The resident slipped on the bed controller trying to get to the chair. The resident stated he fell on to his buttocks first and he hit the back of his head. The resident's pad alarm was sounding. The resident complained of right hip and left wrist pain. The physician was notified and orders were received for X-rays which showed a contusion (bruise). The intervention was gripper socks while in bed to prevent slipping when getting out of bed. No neurological assessments could be located. Review of the Incident and Accident Report dated 03/12/15 at 7:30 A.M., revealed Resident #63 was found sitting next to his wheelchair with the personal alarm sounding, on the floor in the dining room. The resident sustained [REDACTED]. The intervention was to keep the resident in common area when up in his wheelchair. Review of the Incident and Accident Report dated 03/16/15 at 10:30 A.M., revealed the resident was found on the floor lying on his right side. The resident stated he rolled from his left side to his right side. The resident complained of soreness in his left hip. Resident #63 was able to perform range of motion to his bilateral lower extremities, was incontinent of urine and had a bruise to his left hip. The resident had an X-Ray of his left hip and was placed on a toileting plan and 15 minute visual checks. Review of the Incident and Accident Report dated 03/18/15 (no time indicated) revealed the resident was found on the mat next to his low bed. A hematoma was found on the resident's left forehead and the resident complained of left hip pain. The intervention was to clip the alarm out of the resident's reach. No neurological assessments were completed. Review of the Incident and Accident Report dated 04/09/15 at 10:00 A.M. revealed Resident #63 was toileted per his request and assisted into his recliner at the bedside. A personal alarm was placed and the call light attached to the resident's shirt. At 9:45 A.M. the resident's call light and alarm were sounding and the resident was found sitting on the floor next to his bed and chair. The resident obtained a skin tear to his right forearm. The intervention implemented was to keep the resident in common areas in his wheelchair with personal alarm at all times while awake. Review of the Incident and Accident Report dated 04/09/15 at 10:20 P.M. revealed the resident was found lying on his left side in the television room. The resident obtained a 5.0 centimeter by 1.0 centimeter by 0.5 centimeter laceration to his head. The resident was sent to the emergency room and 13 sutures were placed to treat the laceration. The intervention was to change the clip alarm to a pad alarm. No neurological assessments or fall investigation was completed. There was no evidence Resident #63 was supervised as ordered and care planned. Review of the Nurses' Progress Note dated 04/09/15 at 11:30 P.M. revealed the resident was found on the floor in the television room facing the nurses' station. The resident was lying on his left side with blood around his head. His alarm was not sounding. The resident was wearing slippers and had a laceration above his left eye measuring 5.0 cm x 1.0 cm x 0.5 cm. Pressure was applied to the wound, the physician was notified and the resident was transferred to a local emergency room for evaluation and treatment. Review of the Hospital emergency room Report dated 04/09/15 revealed Resident #63 presented to the emergency room after a fall from his wheelchair at the nursing home and sustained a large laceration on the left side of his forehead. The resident had a large five centimeter laceration that was Y-shaped on the left side of the forehead. On 06/22/15 at 4:37 P.M. interview with the Director of Nursing (DON) verified the resident was to be in common area and supervised to prevent falls. The DON verified the resident was a high fall risk and had a history of [REDACTED]. The DON stated the resident should have had neurological assessments completed with this head injury as well as other head injuries obtained. 2. During initial tour on 06/15/15 at 10:36 A.M. revealed the maintenance closet in the west hall across from Room 103 was locked but not latched. The door was able to be opened by the surveyor and inside was a furnace, opened electrical panel and six containers with labeling stating each product was poison and to keep out of reach of children. The Material Safety Data Sheets (MSDS) for the six containers contained the following information: a. For the container labeled Neutra- Stat HD, MSDS number DMN0333. The product was a liquid detergent with the health hazard listed as an irritant. The concentrate is very irritating to the eyes and moderately irritating to the skin. b. For the container labeled Glass XT MSDS number DMN0813. The product was a concentrated glass cleaner with the health hazard listed as a possible irritant. The liquid is mildly irritating to the eyes. c. For the container labeled D-C Plus, MSDS number DMN 0219. The product was a liquid multipurpose detergent with the health hazard listed as an irritant. The liquid is mildly irritating to the eyes d. For the container labeled Ultra-Gloss Restorer, MSDS number DMN0207. The product was a floor finish restorer with the health hazard listed as an irritant. The liquid is irritating to the eyes and may be irritating to the skin. e. For the container labeled Stress Relief Odor Eliminator, MSDS number DMN0252. The product was a deodorizer with the health hazard listed as a possible irritant. The concentrate may be irritating to the eyes. f. For the container labeled Ultimet Neutral Cleaner, MSDS number DMN-354. The product was a neutral pH detergent with the health hazard listed as a possible irritant. The concentrate may be irritating to the eyes. The above findings were verified with the Maintenance Supervisor at 11:10 A.M. on 06/15/15. The Director of Nursing verified on 06/16/15 at 10:40 A.M. the unlocked chemicals had the potential to affect Residents #35, #37, #43 and #72 who were cognitivley imparied but independently ambulatory and resided in that area.

Based on closed record review, hospital record review, interview and policy review, the facility failed to ensure residents received adequate fluids to prevent dehydration. This affected one of three residents reviewed for hospitalization (Resident #22). The census was 49. Harm occurred when the facility failed to ensure Resident #22 received adequate hydration to prevent hospitalization for severe dehydration and subsequently required intravenous (IV) hydration. Findings include: Review of Resident #22's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) 3.0 dated 05/04/15 revealed the resident was not cognitively intact and required extensive assistance of two staff members with bed mobility, dressing and toilet use. The resident required extensive assistance of one staff member with eating and personal hygiene. Review of the Nursing Admission Screening/History dated 04/20/15 revealed the resident was alert and oriented to person and spoke softly. General appearance was thin and had upper and lower dentures. Review of the physician's telephone orders revealed: · On 04/23/15 an [MEDICATION NAME] pureed diet was ordered. · 04/29/15 health shake twice a day with lunch and dinner due to weight loss. · 05/12/15 speech recommendation for downgrading liquids to nectar consistency was ordered. · 05/13/15 Prostat 30 milliliter (ml) twice a day due to a wound. · 05/17/15 send to local hospital emergency room for evaluation. Review of the Dietitian's Progress Note dated 04/23/15 at 11:07 A.M. revealed the resident was a new admit to the facility with [DIAGNOSES REDACTED]. Her hydration needs were identified as1797 milliliters (ml) of fluid per day. Review of the Nurses' Progress Notes dated 05/12/15 at 6:56 P.M. revealed an order from speech therapy to downgrade the resident's liquids to nectar consistency. Further review of the Nurses Progress Notes did not reveal physician or dietitian notification related to the resident's poor fluid intakes. Review of the medical record did not reveal laboratory values from 04/20/15 to 05/17/15. Review of the meal fluid intakes for May 2015 revealed the following: · 05/01/15: The resident consumed 120 ml of fluids for supper. No documentation of substitutions or supplements offered. · 05/02/15: 120 ml of fluid at breakfast; 120 ml of fluid for lunch; zero fluids for supper. · 05/03/15: 240 ml of fluid; The resident consumed 120 ml of the physician prescribed health shake; 80 ml of fluid and zero with a line documented for the health shake. · 05/04/15: 120 ml fluid; 240 ml of fluid with 120 cc of health shake consumed for lunch; 360 ml of fluid with supper. · 05/05/15: 120 ml of fluid, and 90 ml of supplement; no documentation of the supper meal, fluid intake, supplement or substitution offered. · 05/06/15: 240 ml of fluid for breakfast; 240 ml of fluid and 120 ml of health shake consumed for lunch; 120 ml of fluid and 60 ml of health shake for supper. · 05/07/15: 240 ml of fluid no documentation of a substitute or supplement; 120 ml of fluid without documentation of supplement or substitute; 120 ml of fluid without documentation of supplement or substitute. · 05/08/15: 120 ml for breakfast; consumed 120 ml of fluid and 60 ml of health shake without documentation of a substitute; 240 ml of fluid without documentation of health shake or a substitute or supplement offered. · 05/09/15, 05/10/15 and 05/11/15: no fluid documentation-the resident was not listed on the printed meal intake record · 05/12/15: 120 ml of fluid; 60 ml of fluid without documentation of the supplement; and no documentation of supplements offered. · 05/13/15: 120 ml of fluid; 60 ml of fluid without documentation of supplement; 240 ml of fluid and 60 ml of health shake. · 05/14/15: 30 ml of fluid without a substitution or supplement offered; 60 ml of fluid no documentation for health shake; , 60 ml of fluid without documentation of supplement or substitute · 05/15/15: 120 ml of fluid without documentation of a substitute or supplement offered; zero fluid without documentation of the supplement or a substitute; no documentation for supper, substitute or supplement · 05/16/15: no fluids documented; zero fluids for lunch without documentation of supplement or substitute; 120 ml of fluid without documentation of supplement or substitute. · 05/17/15: 240 ml of fluid; 30 ml of fluid and 60 ml of health shake; 60 ml of fluid and no documentation of supplement or substitute. Review of the Referral Information Form dated 05/17/15 at 7:00 P.M. revealed the resident was noted at 4:00 P.M. to be lethargic, pale and pocketing food and refused to take oral fluids. Milky, bloody drainage was noted from her vagina. Her blood pressure and body temperature were low with very poor skin turgor. The resident's blood pressure was 50's over palpation (systolic blood pressure normal of 120 millimeters of mercury; palpation means blood pressure can only be felt, not heard with a stethoscope). Further review of the Nurses' Progress Notes revealed no documentation from 05/12/15 at 6:56 P.M. when speech therapy recommended nectar thickened liquids until 05/18/15 at 12:22 A.M. when the resident was admitted to a local hospital with dehydration, altered mental status [MEDICAL CONDITION]. Review of the Hospital emergency room Report dated 05/17/15 revealed the resident presented to the emergency department with lethargy. The resident had dementia but staff noted increasing lethargy over the past couple days. Staff stated she was non-verbal today. The physical examination documentation revealed the resident was lethargic with a pulse of 102 (normal 60-90 beats per minute) and her mucus membranes were dry. The resident' s white blood cell count was elevated at 28,000 (normals 4500- per microLiter); sodium was elevated at 151 (normals are 135-145 milliEquifilant per Liter (mEq/L), potassium elevated at 6.1 (normals are 3.7-5.2 mEq/L and her blood urea nitrogen (a test for kidney function) was elevated at 148 (normal values are 7 to 20 milligrams per deciliter). The resident was admitted with severe dehydration, [MEDICAL CONDITION] (high potassium) and [MEDICAL CONDITION]. Review of the Hospital Nutritional assessment dated [DATE] completed by Dietary Technician (DTR) #200 revealed the resident was admitted to the hospital with [REDACTED]. The resident was having bloody stools with clots per the registered nurse. The resident was receiving intravenous fluids. Review of the Hospital Nutritional assessment dated [DATE] completed by DTR #200 revealed the resident remained 'nothing by mouth' for four days, since 05/18/15. The labs indicated improved dehydration since admission. The DTR was planning to recommend the IV fluid be discontinued and Clinimax E, total [MEDICATION NAME] nutrition (TPN) 2.75/5 at 60 ml per hour if family agreed. The TPN was ordered by a physician. Review of the Observations to Report to the Physician policy dated March 2015 revealed licensed nurses will report changes in the resident's condition due to illness, exacerbation of existing condition, or accidents or incidents to the physician as soon as possible. The physician would be notified of a change in the resident's condition to include loss of appetite and/or failure to eat a meal. On 06/19/15 at 9:20 A.M. interview with the DON confirmed the DON shared the physician should have been notified of the resident's intakes. The DON verified the medical record did not reflect the condition of the resident from 05/12/15 to 05/17/15 when she was sent to the hospital and admitted for severe dehydration and malnutrition. The DON verified the resident returned to the facility with Total [MEDICATION NAME] Nutrition (TPN) due to malnutrition and had a [DIAGNOSES REDACTED]. On 06/19/15 at 3:49 P.M. interview with Physician #100 (who was also the Medical Director) revealed he was unaware of the resident's decreased meal and fluid intakes and his expectation would have been to be notified of the intakes. Further interview revealed the hospitalization may have been avoided had he been made aware of the decreased intakes. On 06/19/15 at 4:30 P.M. interview with Dietitian #62 verified she was not aware of the resident's food and fluid intake. Dietitian #62 shared had she been aware of the resident's poor intakes, she may have been more aggressive with the resident's nutritional and fluid status. She shared the elevated BUN, potassium, sodium, chloride and creatinine in the hospital did indicate the resident was dehydrated and an acute kidney injury was usually related to dehydration. If she had been notified of the resident's poor intake, she would have notified the physician and requested a laboratory testing to look at the resident's status. The Dietitian also stated she obtains her information related to the resident's condition from the staff and review of the resident's medical record. The Dietitian stated she does not observe the resident as part of her assessment. On 06/21/15 at 10:43 A.M. interview with State-tested Nurse Aide (STNA) #20 revealed she was unaware of what an [MEDICATION NAME] diet was but the meal intake records are used to notify the staff of what supplements a resident was to receive and if it wasn't listed on the record, she would be unaware the resident was to have the supplement. Further interview revealed changes in a resident's condition would be reported immediately to the nurse. An additional interview on 06/21/15 at 12:52 P.M. revealed low food and fluid intakes during her shift would be reported to the nurse. On 06/23/15 at 8:20 A.M. interview with Registered Nurse (RN) #1 revealed weight loss should be reported to the dietitian and the physician. Further interview revealed after 24 to 48 hours of a resident with poor fluid intake, she would notify the physician. She would offer fluids, supplements and monitor for signs and symptoms of dehydration to include low urine output, parched tongue, decreased skin elasticity and a change in the resident's neurological status. On 06/23/15 at 8:20 A.M. interview with Licensed Practical Nurse (LPN) #60 revealed dietary and the physician would be notified of a weight loss and poor food and fluid intake. He would monitor for signs and symptoms of dehydration such as a fast heart rate, decreased output and a change in the resident's neurological status. On 06/24/15 at 8:34 A.M. interview with Dietitian #62 revealed she does not notify the physician of a weight loss until the interventions she has implemented are ineffective for the resident. On 06/24/15 at 2:30 P.M. interview with Dietitian #62 revealed the resident's decline to result in a hospitalization did not occur quickly and would have occurred over a few days' time.