Every finding on record at Stillwater Skilled Nursing and Rehabilitation

Based on observation, staff interview, and review of the facility policy, the facility failed to properly store the resident medications. This had the potential to affect the seven residents with medications stored in the [NAME] Hall cart. The facility census was 46 residents.Findings include: Observation 04/15/26 at 8:20 A.M. of [NAME] Hall medication cart with Licensed Practical Nurse (LPN) #160 revealed there were six loose pills of different sizes, shapes, and colors at the bottom of the cart drawer under the resident medication cards. Interview on 04/15/26 at 8:20 A.M. with LPN #160 confirmed the medication cart drawer had six loose pills at the bottom of the drawer. LPN #160 stated all medications should stored in their original containers and should be discarded if the medication fell to the bottom of the drawer. Review of the facility policy titled Storage of Medications revised April 2019 revealed all drugs and biologicals should be stored a safe, secure, and orderly manner and should be stored in packing, container, or other dispensing systems in which they were received. The nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a comprehensive person-centered care plan included the resident preferences and refusals of cares/services for laryngectomy tube. This affected one (Resident #8) of two residents reviewed for care plans. The facility census was 46 residents. Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/05/24 with diagnoses including malignant neoplasm of larynx, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/07/26 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and received tracheostomy care. Review of the care plan for Resident #8 dated 06/25/25 which stated the resident had laryngeal tube with a history of cutting edge/lip of the tube, stating it was too long. Interventions included the following: ensure tube ties were secured at all times, suction as necessary, monitor for skin breakdown. Further review of the care plan for Resident #8 revealed it did not include documentation of the resident's refusal of trach ties, the resident's preference to complete laryngeal tube care independently, nor of the resident's refusal to allow staff access to the tube at bedside. Observation on 04/14/26 at 11:37 A.M. of Resident #8 revealed the resident had a a laryngectomy tube in his neck stoma with no trach ties were noted around the tube. Observation revealed Resident #8 removed the laryngectomy tube out of his neck stoma and placed it back independently. There was no replacement tube at the resident's bedside. Interview on 04/14/26 at 11:39 A.M. with Resident #8 confirmed he completed his laryngectomy tube care independently and did not want trach ties around the tube, and he did not have a replacement tube at the bedside. Interview on 04/14/26 at 2:47 P.M. with the Director of Nursing (DON) confirmed Resident #8's care plan for the laryngectomy tube did not have documentation to support the resident completed laryngectomy tube care independently, that the resident refused to allow staff to apply trach ties or allow staff access to laryngectomy tube at bedside. Review of the facility policy titled Care planning- Interdisciplinary Team (IDT) revised September 2013 revealed the facility IDT was responsible for the development of an individual comprehensive care plan for each resident.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a replacement laryngectomy tube (used to keep neck stoma open and to provide a permanent, total airway separation) was at the resident's bedside or easily accessible for staff use. This affected one (Resident #8) of one facility-identified resident with laryngectomy tube. The facility census was 46 residents.Findings include: Review of the medical record for Resident #8 revealed an admission date of 01/05/24 with diagnoses including malignant neoplasm of larynx, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/07/26 revealed the resident was cognitively intact, required staff assistance with activities of daily living (ADLs), and received tracheostomy care. Review of the physician's orders for Resident #8 revealed an order dated 11/10/25 to remove the laryngectomy tube from the stoma and cleanse the stoma site with normal saline and to clean and replace the tube every shift and as needed. Observation on 04/14/26 at 11:37 A.M. of Resident #8 revealed the resident had a a laryngectomy tube in his neck stoma and the removed the laryngectomy tube out of his neck stoma and placed it back independently. There was no replacement tube at the resident's bedside. Interview on 04/14/26 at 11:39 A.M. with Resident #8 confirmed he completed his laryngectomy tube care independently and he did not have a replacement tube at the bedside. Interview on 04/14/26 at 11:16 A.M. with Licensed Practical Nurse (LPN) # 146 confirmed Resident #8 did not have a replacement laryngectomy tube at bedside nor did the staff have a tube available to use if needed. LPN #146 stated nursing staff assist the resident with setting up cleaning supplies for laryngectomy tube care and the resident was able to complete the task independently and refused to allow staff to complete the task. Interview on 04/14/26 at 11:40 A.M. with the Director of Nursing (DON) confirmed Resident #8 had a laryngectomy tube in his locked box at the bedside but staff were not able to get into the locked box. Review of the facility policy titled Tracheostomy Care revised August 2013 revealed a replacement tube must be available at the bedside at all times.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents did not receive unnecessary medications. This affected one (Resident #22) of five residents reviewed for unnecessary medications. The facility census was 46 residents.Findings include: Review of the medical record for Resident #22 revealed an admission date of 10/24/25 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and malignant neoplasm of bronchus and lung. Review of the physician's orders for Resident #22 revealed an order dated 10/27/25 for Azithromycin 250 milligram (mg) one tablet by mouth on Monday, Wednesday, and Friday for infection. Review of the care plan for Resident #22 dated 11/13/25 revealed the resident had signs and symptoms of respiratory infection/COPD exacerbation and was on long term antibiotic for COPD. The goal was for the resident to be free from signs and symptoms of pneumonia /respiratory infection after completion of antibiotics, administer antibiotics as ordered. Review of the pharmacist's recommendation for Resident #22 dated 11/23/25 revealed the pharmacist recommended a stop date on the Azithromycin. The physician's assistant refused the recommendation because the pulmonologist had written the order for the medication. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 02/13/26 revealed the resident was cognitively intact. Review of the progress note for Resident #22 dated 03/04/26 revealed the resident developed pneumonia and the physician gave orders start Augmentin and Doxycycline twice daily for five days and to hold Azithromycin for seven (7) days. Review of the after-visit summary for Resident #22 dated 03/10/26 revealed the resident saw the pulmonologist for mucopurulent chronic bronchitis and COPD and the pulmonologist gave an order to continue the Azithromycin tablet on Monday, Wednesday, and Friday. Interview on 04/14/26 at 2:45 P.M. with the Director of Nursing (DON) confirmed the facility staff had not called the pulmonologist to review the use of Azithromycin three times weekly for COPD and ask for a possible stop date for the medication. The DON also confirmed the facility Infection Preventionist (IP) had not monitored or evaluated the long-term use of Azithromycin for Resident #22 nor had the IP suggested a possible dose reduction or stop date for the medication to the attending physician or pulmonologist since the 11/23/25 pharmacy recommendation. Review of the facility policy titled Infection Prevention and Control Program dated December 2023 revealed the facility would monitor antibiotic use and evaluate. The facility would provide feedback to practitioners regarding review of antibiotic use. Review of the facility policy titled Antibiotic Stewardship dated December 2016 revealed the facility staff would monitor antibiotic use.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a medication error rate of five percent (%) or lower. The medication error rate was 7.4% based on two errors out of 27 medication opportunities. This affected one (Resident #34) of the four residents observed for medication administration. The facility census was 46 residents.Findings include: Review of the medical record for Resident #34 revealed an admission date of 07/26/24 with diagnoses including hypertension, atherosclerotic heart disease, asthma, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 01/31/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #34 dated April 2026 revealed orders for the following 12 morning medications: Eliquis, Claritin, Norco, Lasix- hold if blood pressure less than 120/80, Wellbutrin, amlodipine besylate-hold for blood pressure less than 120/80, allopurinol, clonidine-hold if systolic blood pressure less than 110, spironolactone, aspirin, pantoprazole. Observation on 04/15/26 between 8:02 A.M. of medication administration for Resident #34 per Licensed Practical Nurse (LPN) #160 revealed the nurse prepared 10 medications for administration: allopurinol, aspirin, Claritin, Lasix, pantoprazole, spironolactone, Wellbutrin, clonidine, Eliquis, and Norco. LPN #160 confirmed Resident #34's medication cup contained 10 medications. At 8:16 A.M. LPN #160 checked the resident's blood pressure and noted it was 150/88. LPN #160 administered the 10 medications to Resident #34, washed her hands, and exited the resident's room. Interview on 04/15/26 at 8:19 A.M. LPN #160 confirmed she had not administered Resident #34's amlodipine besylate or carvedilol as ordered. LPN #160 confirmed that Resident #34 should have had 12 medications administered with the morning medication pass. Review of the facility policy titled Administering Medications revised April 2019 revealed medications should be administered in a safe and timely manner, and as prescribed. The policy stated medications were to be administered in accordance with prescriber orders, including required timeframe.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to implement the antibiotic stewardship plan and failed to properly monitor antibiotic use. This affected one (Resident #22) of five residents reviewed for unnecessary medications. The facility census was 46 residents.Findings include: Review of the medical record for Resident #22 revealed an admission date of 10/24/25 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and malignant neoplasm of bronchus and lung. Review of the physician's orders for Resident #22 revealed an order dated 10/27/25 for Azithromycin 250 milligram (mg) one tablet by mouth on Monday, Wednesday, and Friday for infection. Review of the care plan for Resident #22 dated 11/13/25 revealed the resident had signs and symptoms of respiratory infection/COPD exacerbation and was on long term antibiotic for COPD. The goal was for the resident to be free from signs and symptoms of pneumonia /respiratory infection after completion of antibiotics, administer antibiotics as ordered. Review of the pharmacist's recommendation for Resident #22 dated 11/23/25 revealed the pharmacist recommended a stop date on the Azithromycin. The physician's assistant refused the recommendation because the pulmonologist had written the order for the medication. Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 02/13/26 revealed the resident was cognitively intact. Review of the progress note for Resident #22 dated 03/04/26 revealed the resident developed pneumonia and the physician gave orders start Augmentin and Doxycycline twice daily for five days and to hold Azithromycin for seven (7) days. Review of the after-visit summary for Resident #22 dated 03/10/26 revealed the resident saw the pulmonologist for mucopurulent chronic bronchitis and COPD and the pulmonologist gave an order to continue the Azithromycin tablet on Monday, Wednesday, and Friday. Interview on 04/14/26 at 2:45 P.M. with the Director of Nursing (DON) confirmed the facility staff had not called the pulmonologist to review the use of Azithromycin three times weekly for COPD and ask for a possible stop date for the medication. The DON also confirmed the facility Infection Preventionist (IP) had not monitored or evaluated the long-term use of Azithromycin for Resident #22 nor had the IP suggested a possible dose reduction or stop date for the medication to the attending physician or pulmonologist since the 11/23/25 pharmacy recommendation. Review of the facility policy titled Infection Prevention and Control Program dated December 2023 revealed the facility would monitor antibiotic use and evaluate. The facility would provide feedback to practitioners regarding review of antibiotic use. Review of the facility policy titled Antibiotic Stewardship dated December 2016 revealed the facility staff would monitor antibiotic use.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of Self-Reported Incident (SRI), review of the incident log, review of police statement, review of staff drug screening results, and policy review, the facility failed to ensure resident's controlled substances were not misappropriated. This affected four (#18, #31, #50 and #78) of five residents reviewed for misappropriation. The facility census was 49. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/29/23 with diagnoses including chronic obstructive pulmonary disease, type two diabetes, and vascular dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 is cognitively intact. Review of the physician orders revealed Resident #18 had an active order for Oxycodone. Review of the medical record for Resident #31 revealed an admission date of 12/26/24 with diagnoses including type two diabetes and inflammatory spondylopathy cervical region. Review of the MDS dated [DATE] revealed Resident #31 is cognitively impaired. Review of the physician orders revealed Resident #31 had an active order for Oxycodone. Review of the medical record for Resident #50 revealed an admission date of 09/26/25 with diagnoses including type two diabetes and chronic pain. Review of the MDS dated [DATE] revealed Resident #50 is cognitively intact. Review of the physician orders revealed Resident #50 had an active order for Oxycodone. Review of the medical record for Resident #78 revealed an admission date of 08/13/25 with diagnoses including chronic kidney disease and type two diabetes. Review of the MDS dated [DATE] revealed Resident #78 was cognitively intact. Review of the physician orders revealed Resident #78 had an active order for Oxycodone. Review of the incident log from 11/23/25 to 02/23/26 revealed Resident #18, #31, #50, and #78 had an alleged incident involving misappropriation of controlled substances on 02/05/26. Review of the facilities SRI dated 02/05/26 revealed on 02/05/26, Director of Nursing (DON) #100 noted an alteration in medication packaging involving controlled substances during a routine narcotic count. Bubble packaging had nicks and tears on the backside of the cards for multiple controlled substance. While popping the medications for waste, it was noted that the mediation was an unstamped white pill that was not consistent with manufacture markings of the pills in the rest of the narcotic pills. Each narcotic card with compromised packaging was identified as Oxycodone 5 milligrams (mg) tablets. Medication administration activities were immediately stopped and medication carts were secured. Audits of medication were started with 11 cards of Oxycodone being affected totaling 42 unstamped pills being identified. Four current residents were identified as potentially affected and were immediately assessed and interviewed. All nurses with access to the medication were directed to submit a urine drug screen and all nurses complied. The urine sample for Licensed Practical Nurse (LPN) #89 did not meet temperature requirements and was transported to complete a full-panel drug screen, that was pending at the time of the SRI investigation. Local law enforcement was notified of the incident. During an interview with LPN #89 she admitted to responsibility for the drug discrepancy and diversion of controlled substances. LPN #80 verified that she replaced Oxycodone 5 mg tablets with Melatonin 1 mg tablets in all 11 packages. LPN #89 verified that the diversion started within the last month. The facilities investigation revealed misappropriation was substantiated. Review of the police statement written by LPN #89 dated 02/05/26 verified that she was replacing narcotics with a medication that looked similar to imitate the narcotic. Review of the facilities drug screen for LPN #89 dated 02/05/26 at 9:00 A.M. revealed that the temperature of the urine sample was not between 90-100 degrees. Review of the observed drug screen completed on 02/05/26 revealed LPN #89 tested positive for cocaine, opiates, and oxycodones. Interview on 02/23/26 at 10:25 A.M. with DON #100 verified that she found the alterations int he narcotic packaging. DON #100 verified that LPN #89 confessed to diverting the narcotic medication. All residents were assessed with no concerns found. All residents had their medications replaced. DON #100 confirmed four (#18, #31, #50 and #78) residents were affected by the misappropriation. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, revealed residents have a right to be free from abuse, neglect, misappropriation and exploitation. The deficient practice was corrected on 02/05/25 when the facility implemented the following corrective actions: On 02/05/26 at from 7:43 A.M., DON #100 identified packages of narcotics with impaired package integrity. On 02/05/26 from 7:45 A.M. to 9:00 A.M. a full narcotic audit of all medication carts was conducted. 11 Oxycodone 5 mg cards for 5 residents with a total of 42 unstamped white pills were found in place of the oxycodone. On 02/05/26 between 9:00 A.M. and 7:00 P.M. drug testing of all nursing staff was completed. On 02/05/26 at 10:22 A.M the Medical Director, Chief Medical Director, Nurse Practitioner and Pharmacist were notified. On 02/05/26 at 10:56 A.M. the facility notified law enforcement and State Survey Agency of suspected drug diversion. On 02/05/26 at 11:00 A.M. DON #100 and Pharmacy Consultant completed the following audits: all current narcotics sheets, Electronic Medication Administration Records, Pyxis/Omnicell reports, shift-to-shift count documents, and waste documents. No additional discrepancies were found. On 02/05/26 at 11:00 A.M. the facility provided the following education to all staff: controlled substance handling, narcotic procedures, waste witnessing requirements, reporting discrepancies immediately, abuse/neglect and misappropriation policy. On 02/05/26 at 12:27 P.M. the facility had a QAPI meeting regarding narcotic discrepancy and abatement plan. On 02/05/26 at 7:40 P.M. the facility notified Ohio Board of Nursing suspected drug diversion. On 02/05/26 Social Services Director interviewed all cognitively intact residents. All residents denied concerns about receiving proper medication or knowledge of misappropriation. On 02/05/26 DON #100 interviewed all cognitively intact residents. All residents denied unmanaged pain or inadequate pain control. On 02/05/26 DON #100 assessed all cognitively impaired residents for presence of pain. All residents presented absent of abnormal findings. On 02/05/26 DON #100 began daily audits of medication storage and narcotic sheets. This deficiency represents non-compliance investigated under Complaint Number 2744451.

Based on medical record review, observations, staff interviews and policy review, the facility failed to implement their policy to ensure residents with enhanced barrier precautions (EBP) have clear signage and/or instruction on their doors indicating required personal protective equipment (PPE) and care activities that require PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy and what PPE to use. This affected nine (#13, #18, #20, #30, #34, #39, #42, #43 and #56) out of nine residents reviewed for EBP. The facility census was 57. Findings include: Medical record review for Resident #34 revealed an admission date of 12/19/24. Medical diagnoses included acute embolism and thrombosis of left femoral vein. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of Resident #34's care plan dated 10/06/25 revealed the resident required enhanced barrier precautions due to a complex wound/wound care. Review of Resident #34's physician orders dated 11/25/25 revealed there was no order for EBP. Medical record review for Resident #42 revealed an admission date of 01/05/24. Medical diagnoses included malignant neoplasm of the Larynx. Review of the quarterly MDS dated [DATE] revealed Resident #42 was cognitively intact but non-verbal. Review of the care plan for Resident #42 revealed Resident #42 required enhance barrier precautions due to a laryngostomy tube. Review of Resident #42's physician orders dated 11/25/25 revealed there was no order for EBP. Medical record review for Resident #18 revealed an admission date of 12/12/20. Medical diagnoses included non-traumatic brain dysfunction. Review of the care plan for Resident #18 dated 10/03/25 revealed Resident #18 was in enhanced barrier precautions due to urinary catheter. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was rarely or never understood. Review of physician orders dated 11/25/25 revealed there was no order for EBP. Medical record review for Resident #56 revealed an admission date of 11/14/25. Medical diagnoses included intracranial abscess and granuloma. Review of Resident #56's medical record revealed an admission MDS was in progress. Further review of an admission progress note dated 11/14/25 revealed resident was cognitively intact and was able to ambulate with assistance. Review of the care plan dated 11/25/25 revealed Resident #56 required EBP due to a peripheral inserted central catheter (PICC) line. Review of physician orders dated 11/25/25 revealed there wasn't one for EBP. Interview with Certified Nursing Aide (CNA) #111 on 11/25/25 at 6:36 A.M. revealed if someone was in a EBP room she would wear a gown, mask and gloves into the room. Interview with CNA #94 on 11/25/25 at 6:50 A.M. revealed if a resident was in EBP she would put on her gown, gloves and a mask while in the room before she talked to the resident. Observations and interview with the Director of Nursing (DON) on 11/25/25 from 7:19 A.M. to 7:35 A.M. revealed Residents #13, #18, #20, #30, #34, #39, #42, #43 and #56 rooms revealed there was a magnetic square that has EP written on it and no other information (i.e. instructing staff on what PPE to wear) was available. Further observation revealed Residents #18, #42, and #34 had no sign in the cart and Resident #56 had a droplet precaution sign in her cart that didn't apply to her. Interview on 11/25/25 at 7:35 A.M. with the DON revealed staff are educated on putting full PPE on for any high contact care for residents with EBP. The DON revealed the staff are trained on EBP monthly at staff meetings and when newly hired. The DON also stated if a staff does not know what to put on or to do for EBP they can ask a nurse in the building or look in a blue book at the nursing station that has the type of isolation a resident is in. The DON confirmed the PPE cart is placed inside the room and there is no distinction at the door for which resident in the room are in EBP. The DON stated the cart would be placed inside the room on the side the resident resided. The DON confirmed there is no additional signage at the door for a resident in EBP, staff would need to look in the cart inside of the room to determine what they would need wear for EBP or look in the resident's chart. The DON stated there is no order for EBP, it is only documented in the resident care plan. The DON confirmed there are currently nine (#13, #18, #20, #30, #34, #39, #42, #43 and #56) resident residing in the facility who are in EBP. Review of the facility policy named, Enhanced Barrier Precautions, dated 08/2022 revealed, staff are trained prior to caring for residents on EBP's and signs are posted on the door or wall outside the resident room to alert staff the resident requires EBP. EBP's employ targeted gown and glove use during high contact resident care activities. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, interviews with staff and Resident Representative, and facility policy review, the facility failed to ensure Resident Representative was notified of room change prior to a room change. This affected one resident (#54) out of the three residents reviewed for room change notification. The facility census was 55. Findings include: Review of the medical record for Resident #54 revealed an admission date of 10/19/23 with medical diagnoses of mild neurocognitive disorder due to known physiological condition with behavioral disturbances, degenerative disease of the nervous system, depression, dementia, and cerebral atherosclerosis. Review of the medical record for Resident #54 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, which indicated Resident #54 had moderate cognitive impairment and was dependent upon staff for all Activities of Daily Living (ADLs). Review of the medical record for Resident #54 revealed the resident had room moves on 01/01/25, 02/27/25 and on 04/14/25. Review of the medical record for Resident #54 revealed a nurses' note dated 02/28/25 which stated notified resident/family of room move. Review of the medical record revealed a late entry note on 06/06/25 at 12:48 P.M. for 01/01/25 at 12:46 P.M. which stated the resident was moved rooms due to bed reductions. The note stated Resident Representative aware of room moves and of bed reductions. Further review of the nurses' notes revealed a late entry note on 06/06/25 at 1:02 P.M. for 04/14/25 at 12:58 P.M. which stated the resident was moved from a rehab hall to a long-term private room where the resident would be more visible to staff to visualize due to the need for frequent checks and large space for family to visit. Discussed with Resident Representative in advance and in agreement with change. Physician Assistant was notified. Interview on 06/06/25 at 2:08 P.M. with Director of Nursing (DON) stated Resident #54's husband was aware of the room changes but the facility staff had not documented the room changes in the medical record until 06/06/25. DON confirmed the medical record for Resident #54 indicated on 02/28/25 that Resident #54's husband was notified of room change that occurred on 02/27/25. Interview on 06/06/25 at 2:53 P.M. with Resident #54's Representative stated the facility notified him of one of Resident #54's room changes but was not notified of the other recent room changes. Review of the facility policy titled, Transfer, Room to Room, revised December 2016 stated the purpose of the procedure was to provide guidelines for safely transferring residents from one room to another when such a transfer has been approved in accordance with facility policies. The policy stated the residents were to be oriented to the transfer in a form and manner that the residents could understand. The policy stated the information must include where the room is located, who the resident's new roommate, if any, would be, who will be providing the resident's care, that his/her family and visitors would be informed of the room change and why the transfer was taking place. The policy continued to state the following information should be recorded in the resident's medical record: date/time of room transfer was made, the names and titles of the individual(s) who assisted in the move, all assessment data obtained during the move, how the resident tolerated the move, if the resident refused the move and the resident why, and the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number OH00165133.

Based on observation, medical record review, staff interview and review of policies, the facility failed to ensure medications were administered according to physician's order, resulting in a medication error rate which exceeded 5 percent (%). Thirty-five opportunities were observed with four medications errors, resulting in 11.42% error rate. This affected three (#1, #33, #43) of three residents observed during medications administration. The census was 61. Findings included: 1. Review of the medical chart for Resident #1 revealed an admitted [DATE], with diagnosis included hyperlipidemia. Review of the physician's order dated 06/20/23, for Resident #1, revealed an order for Fish Oil 500 milligrams (mg) tablet to give two tablets, one time a day for supplement. Observation of medication administration with Licensed Practical Nurse (LPN) #151 on 08/22/23 at 7:15 A.M., to Resident #1, revealed LPN #151 gave Fish Oil 1000 mg 2 tablets by mouth. Interview with LPN #151 on 08/22/23 at 8:52 A.M., verified she gave Resident #1 Fish Oil 1000 mg two tablets by mouth. Interview with Director of Nursing (DON) on 08/22/23 at 8:23 A.M., verified Resident #1 was to be given Fish Oil 1000 mg total with two tablets of 500 mg, which was not given per physician's order. 2. Review of the medical record for Resident #33 revealed an admitted [DATE], with diagnosis included diabetes mellitus. Review of physician orders for Resident #33 revealed an order for Novolog Flex Pen 100 unit per milliliters (ml), to give six units with meals for diabetes mellitus. Observation of insulin injection on 08/22/23 at 7:40 A.M., revealed LPN #151 took out the Novolog Flex Pen, placed a new needle on and dialed up six units of insulin. She injected Resident #33 in the left abdomen. This surveyor did not observe the nurse prime the Flex Pen prior to dialing up the dosage amount. Interview on 08/22/23 at 7:40 A.M., with LPN #151 verified she did not prime the Flex Pen with two unit prior to dialing up the dosage of six unit for Resident #33. Interview with Unit Manager #107 verified the Flex Pen needle needs to be primed with two units before dialing up the dosage amount of insulin. 3. Review of the medical record for Resident #43 revealed an admitted [DATE], with diagnosis included hypertension. Review of the physician orders for Resident #43 revealed an order dated 08/14/23 for Metoprolol Tartrate 25 mg to give 0.5 tablet by mouth two times a day for hypertension hold for systolic blood pressure less than 100 or pulse less than 60 and a completed order dated 08/14/23 for Tetracycline HCI capsule 500 mg, to give one capsule two times per day for urinary tract infection for 14 administrations. Review of Resident #43's medication administration record revealed Tetracycline HCI capsule 500 mg, to give one capsule two times per day for urinary tract infection for 14 administrations was started on 08/14/23 at 8:00 P.M. and received her 14 th dose on 08/21/23 at 8:00 A.M. Observation of LPN #157's medication administration with Resident #43 on 08/22/23 at 7:03 A.M., revealed the resident received Metoprolol 25 mg one-half tablet orally and one Tetracycline 500 mg one tablet orally. The resident blood pressure was taken and was 89 systolic and 59 diastolic with a pulse of 64 beats per minute. Interview with LPN #157 on 08/22/23 at 8:58 A.M., revealed she gave Resident #43 the medications: Metoprolol Tartrate 25 mg to give 0.5 tablet by mouth and Tetracycline HCI capsule 500 mg, to give one capsule. LPN #157 verified the order for the Metoprolol does have perimeters to hold if systolic was less than 100 and the Tetracycline was not on the medication administration record for her to give for the date of 08/22/23 which she did administer. Review of the undated policy titled, Administering Insulin via a Flex Pen, revealed Step 6: Prime the insulin pen. Priming means removing the air bubbles form the needled and ensures the needle is open and working. The pen must be primed before each injection. Step 7: To prime the insulin pen, turn the dosage kob to 2 units indicator. With the pen pointing upward, push the knob all the way up. At least one drop of insulin should appear. Review of the policy titled, Administering Medications dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication will verify the right resident, right medication, right dosage. Right time and right method (route) of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Number OH00145373.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff primed the insulin Flex Pen prior to dialing up medication dose, thus resulting in significant medication error due to resident not receiving the correct amount of insulin. This affected one (#33) of one resident observed for insulin administration. The census was 61. Findings included: Review of the medical record for Resident #33 revealed an admitted [DATE], with diagnosis included diabetes mellitus. Review of physician orders for Resident #33 revealed an order for Novolog Flex Pen 100 unit per milliliters (ml), to give six units with meals for diabetes mellitus. Observation of insulin injection on 08/22/23 at 7:40 A.M., revealed Licensed Practical Nurse (LPN) #151 took out the Novolog Flex Pen, placed a new needle on and dialed up six units of insulin. She injected Resident #33 in the left abdomen. This surveyor did not observe the nurse prime the Flex Pen prior to dialing up the dosage amount. Interview on 08/22/23 at 7:40 A.M., with LPN #151 verified she did not prime the Flex Pen with two unit prior to dialing up the dosage of six unit for Resident #33. Interview with Unit Manager #107 verified the Flex Pen needle needs to be primed with two units before dialing up the dosage amount of insulin. Review of the undated policy titled, Administering Insulin via a Flex Pen, revealed Step 6: Prime the insulin pen. Priming means removing the air bubbles form the needled and ensures the needle is open and working. The pen must be primed before each injection. Step 7: To prime the insulin pen, turn the dosage kob to 2 units indicator. With the pen pointing upward, push the knob all the way up. At least one drop of insulin should appear. This deficiency represents non-compliance investigated under Complaint Number OH00145373.

Based on observation and staff interview, the facility failed to ensure there was sufficient dietary staff to carry out functions of the nutrition services. This affected four (Residents #46, #23, #19, and #31) and had the potential to affect all residents residing in the facility, as all residents received their meals from the facility's kitchen. The facility's census was 56. Findings include: Interview on 03/13/23 at 9:05 A.M. with Dietary Manager (DM) #24 stated there were two aides and one cook working in the facility's kitchen, which was not enough staff to serve residents in the main dining room and halls. DM #24 verified the dining room was closed due to insufficient kitchen staffing. DM #24 reported she requested additional staff, and the facility did hire one new cook who started training on 03/13/23. Observations on 03/13/23, 03/14/23, 03/15/23, and 03/16/23 during mealtimes revealed the main dining room was closed to residents, and meals were served via hall trays to resident rooms. Interview on 03/13/23 at 10:47 A.M. Resident #46 verified the dining room was closed and the resident's preference was to be able to eat their meals in the dining room instead of their room. Interview on 03/13/23 at 11:50 A.M. Resident #23 verified the dining room was closed and the resident's preference was to be able to eat their meals in the dining room instead of their room. Interview on 03/14/23 at 9:54 A.M. Resident #19 verified the dining room was closed and the resident's preference was to be able to eat their meals in the dining room instead of their room. Interview on 03/14/23 at 1:19 P.M. Resident #31 verified the dining room was closed and the resident's preference was to be able to eat their meals in the dining room instead of their room. Observation and interview on 03/15/23 at 11:00 A.M. of the lunch meal service revealed DM #24 was not present. Director of Dietary (DD) #180 reported she worked for a sister facility and was helping the facility during the annual survey. DD #180 reported DM #24 and the new cook who started training on 03/13/23, both quit on 03/13/23. DD #180 verified when DM #24 and the cook quit, the kitchen was left with only two aides for dietary staff. DD #180 reported she was only scheduled to work in the facility until 03/17/23, the end of the annual survey. Interview on 03/15/23 at 11:30 A.M. with Dietary Aide (DA) #104 verified after 03/17/23, there would be only two aides working in the kitchen, herself and DA #104. DA #112 verified the facility was not serving meals in the dining room due to there not being enough aides to serve the residents in the dining room and prepare and deliver the hall trays. DA #112 appeared rushed, stressed, and sorrowful throughout the interview as evidenced by looking as if she was about to cry, and she never stopped working plating food, throughout the interview. DA #112 also reported DA #104 was a newer staff member, so she was also juggling training DA #104 at the same time. Interview on 03/16/23 at 3:30 P.M. [NAME] President (VP) of Operation #36 verified the insufficient staffing levels for the dietary department. Per VP #36, the plan was to hire a new director. VP #36 stated after 03/17/23, the facility's administrator would be cooking and serving meals, however when requested to provide the administrator's dietary credentials, nothing was provided. A kitchen staffing schedule was requested on 03/13/23 and 03/15/23 and was not provided.

Based on medical record review, observations, resident and staff interviews, review of facility water temperature logs and review of invoices, the facility failed to ensure comfortable water temperatures were maintained for residents bathrooms and shower room. This affected three (#31, #45, and #46) of three residents reviewed for the physical environment and had the potential to affect 13 (#2, #6, #9, #11, #14, #23, #31, #32, #38, #45, #46, #118, and #309) residents residing on the West-hall. The current census is 56. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses include conversion disorder with seizures, bipolar disorder, autism, and adjustment disorder. Review of Resident #45's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed there was no assessment completed for the mental score. Review of Resident #45's assessments dated 03/08/23 revealed a mental score assessment was conducted and Resident #45 was scored at a 10, indicating cognitive impairment. Review of Resident #45's care plans dated 02/2023 revealed a focus for activities of daily living (ADL) performance in refusal of showers. Interventions include encourage resident to participate, make ADL routine consistent, provide necessary equipment, and notify of complaints and discomfort. Interview and observation on 03/13/23 at 10:53 A.M. of Resident #45 revealed the resident was ambulating through the hallways. Resident #45 had a full facial beard and appeared unkept. Resident #45 answered simple questions and stated he did not know when the last time he showered. Resident #45 did not respond when asked about his bathroom sink water. Observation and interview on 03/13/23 at 2:30 P.M. of Resident #45 revealed the resident was clean shaven and well groomed. Resident #45 stated he had to walk to the other hall to get a shower and it 'bothered' him. 2. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses include paraplegia, bipolar disorder, chronic obstructive pulmonary disease, post-traumatic stress disorder, neuromuscular dysfunction, and chronic pain. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition and was an extensive two-person assist for ADL. Review of Resident #46's care plans dated 01/26/22 revealed a focus for ADL decline and requiring an extensive assist for ADL's. Interventions include preventative skin care, monitor skin, bed mobility with two assist, transfers with lift, turning and repositioning and peri-care after incontinence. Interview on 03/13/23 at 10:37 A.M. with Resident #46 revealed the resident stated there was no hot water in his bathroom. Resident #46 stated there was also no hot water in the shower room on the West-hall, the hall where he resides. Resident #46 stated the hot water has been gone for about a month. Resident #46 stated he is unable to ambulate down to the other shower room in the East-hall due to his paralysis. Resident #46 stated due to his mobility he has to have bed baths. Resident #46 stated due to there being no hot water in his bathroom his bed baths are often cold and uncomfortable because the aide will use the water out of the bathroom to fill the basins for his baths. Resident #46 stated he has reported the issues to the Maintenance Manager many times with no repairs being made. Observation on 03/13/23 at 10:44 A.M. of Resident #46's water temperature in the bathroom revealed the sink water was turned on to 'hot' and did not warm up to touch. The water temperature never reached a comfortable warm temperature and stayed lukewarm during the observations. 3. Record review of Resident #31 was admitted to the facility on [DATE]. Diagnoses include fracture of left humerus, heart failure, dwarfism, hemiplegia, abnormal posture, and depression. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition and was a two-person assist for ADL. Review of Resident #31's care plans dated 09/2017 revealed a focus for ADL required assistance due to hemiplegia. Interventions include assist resident with showers twice a week and as needed upon request, if resident refuses care re-approach at later time, and allow time for a task do not rush. Interview on 03/14/23 at 1:22 P.M. with Resident #31 revealed the resident was alert and oriented and able to recall details of past days. Resident #31 stated it had been over a month since the hot water had been functional in her bathroom and on the West-hall. Resident #31 stated the aides will tell her she is refusing to take a shower or bed bath if she tells them she wants warm or hot water brought to her room for her bed bath. Resident #31 stated she is tired of ambulating to the other hall's shower room to take a hot shower. Resident #31 stated the other hall has a lot of residents waiting to take showers and she feels uncomfortable ambulating back from the shower room. Resident #31 stated she will accept bed baths but only when the aides get hot water from some other area and bring it to her room to wash her up. Resident #31 stated she has not refused any baths, but stated she request hot water to bath with. Interview on 03/13/23 at 12:40 P.M. during an environmental tour with Director of Maintenance (DM) #16 stated the plumber repaired a cartridge for the West-hall on 03/10/23 and was to return on 03/15/23. DM #16 stated he has received reports from residents and staff regarding the cold temperatures of the water in the West-hall and stated the only rooms affected were Resident #7, Resident #46, and the shower room. DM #16 stated most residents are able to ambulate down to the East-hall shower room but stated he understood there were residents unable to bath in the other hall's shower room. DM #16 stated the West-hall water supply has been affected by the broken cartridge since 02/2023. DM #16 stated he was told by the plumber the valves and cartridges needed replaced but they would have to wait until the facility's warranty was checked and the new parts would be sent after replacement parts were available. DM #16 stated he had to wait for approval for the replaced old parts instead of new parts being purchased. Observation of the water temperature in the West-hall shower room revealed the water temperature did not rise above 100 degrees Fahrenheit (F). DM #16 stated the normal range for water temperatures is 105 degrees F to 115 degrees F. DM #16 verified Resident #46, #45, and Resident #31's bathrooms were affected by the cold-water temperature issue and stated he scheduled the plumber to return on 03/15/23 to repair the hot water supply. Interviews on 03/13/23 and 03/14/23 throughout the survey with Licensed Practical Nurse (LPN) #58 and State tested Nurse Aide (STNA) #82 revealed all residents on the West-hall have reported the issues with the cold water. Per the staff the residents who are able to ambulate are taken down the other hall for their showers. Per the staff the showers are often given when the other hall residents are not using the shower room and the schedule does get hectic. The staff stated the staff are to get hot water from the other halls bathrooms in the basins and bring it to the rooms of the residents on the West-hall who are to receive bed baths. Per STNA #82 there have been resident complaint regarding bed bath water being uncomfortable due to the temperatures. The staff stated they have reported to DM #16 about the water temperatures and are told it is being worked on. The facility confirmed there were 13 (#2, #6, #9, #11, #14, #23, #31, #32, #38, #45, #46, #118, and #309) residents residing on the West-hall that could potentially be affected. Review of the facility's water temperature logs dating from 02/2023 to 03/2023 revealed the facility was not testing the West-hall resident rooms or the West-hall shower room. Review of the facility's work invoices from the plumber and emails regarding the repairs revealed on 02/06/23 the facility sent an email requesting a replacement Mixing Valve-Flow be sent to the facility. The response dated 02/09/23 revealed the plumbing company requested the facility send back the broken valve for warranty and replacement. The facility was informed the process to replace the valve could take 10 business days. On 02/16/23 the facility was notified by email the replacement part would arrive in five to seven business days. Review of the facility's invoices revealed on 03/10/23 the plumber installed a new mixing valve. Per the invoice on 03/15/23 the plumber returned and stated he found more issues with the cartridge and other elements on the hot water heater. This deficiency represents non-compliance investigated under Complaint Number OH00140630.

Based on record review, staff and resident interviews, review of Resident Assessment Instrument Manual (RAI) 3.0, the facility failed to conduct care plan review meetings quarterly and failed to include the resident, members of the facility interdisciplinary team (IDT), or resident representative in the care plan review meetings. This affected four (#26, #31, #41, and #48) of the six residents reviewed for quarterly care plan meetings. Additionally, the facility failed to remove a hospice care plan when the services were discontinued. This affected one (#4) of one residents reviewed for hospice services. The facility census was 56. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE] with medical diagnoses of schizoaffective disorder, major depression, diabetes mellitus, and psychotic disorders with delusions. Review of the medical record for Resident #26 revealed a quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/23/23, which indicated Resident #26 was severely cognitively impaired and required supervision with bed mobility, transfers, ambulation, dressing, and toileting. Review of the medical record for Resident #26 revealed a care planning meeting note, dated 11/30/22, which did not have documentation to support the resident, resident representative or guardian were invited or attended the meeting. The care plan meeting note had signatures of two staff members that attended the meeting. Further review of the medical record for Resident #26 revealed a late entry note for a care plan review meeting dated 02/17/22. The note stated the IDT was present and guardian was notified. The note did not have documentation to support the names or disciplines of the members of the IDT that were present for the meeting or if the guardian attended in person or via phone. Interview on 03/15/22 at 3:02 P.M. with [NAME] President of Operations (VPO) #36 confirmed the medical record for Resident #26 did not contain documentation to support the Resident #26 or the resident's guardian attended the care plan review meeting. VPO #36 also confirmed the documentation did not include the disciplines or the names of the members of the IDT that were present for the meeting on 02/17/23. 2. Review of the medical record for Resident #41 revealed an admitted [DATE] with medical diagnoses of benign paroxysmal vertigo, chronic obstructive pulmonary disease (COPD), chronic kidney disease stage III, and protein calorie malnutrition. Review of the medical record for Resident #41 revealed a quarterly MDS, with an ARD of 01/04/23, which indicated Resident #41 was severely cognitively impaired and required supervision with bed mobility, transfers, ambulation, toileting and extensive assistance with bathing. Review of the medical record for Resident #41 revealed a care plan meeting note, dated 10/12/22 which indicated members of the IDT were present but did not include the IDT member disciplines or names and stated the guardian was notified. The care plan meeting note did not have documentation to support the resident or guardian attended in person or via phone. Further review of the medical record for Resident #41 revealed no documentation to support the facility conducted a care plan review meeting since 10/12/22. Interview on 03/15/22 at 3:02 P.M. with VPO #36 confirmed the medical record for Resident #41 did not contain documentation to support the facility conducted a quarterly care plan review meeting since the meeting on 10/12/22. 3. Review of the medical record for Resident #48 revealed an admitted [DATE] with medical diagnoses of hypertension, COPD, adjustment mood disorder, dementia with behavioral disturbances and major depression. Review of the medical record for Resident #48 revealed a quarterly MDS, with an ARD of 01/06/23 which indicated Resident #48 had severe cognitive impairment and required limited assistance with bed mobility and transfers and extensive assistance with toileting and bathing. Review of the medical record for Resident #48 revealed a care plan review meeting was conducted on 10/12/22. The care plan meeting note indicated the IDT was present and the guardian was updated. Further review of the medical record for Resident #48 revealed no documentation to support the facility conducted a care plan review meeting since 10/12/22. Interview on 03/15/23 at 3:02 P.M. with VPO #36 confirmed the medical record for Resident #48 did not contain documentation to support the facility conducted a care plan review meeting since 10/12/22. 4. Record review for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #31 include fracture of the left humerus, obesity, dwarfism, cerebral infarction, heart failure, chronic obstructive pulmonary disease, hemiplegia, osteoarthritis, convulsion, and fibromyalgia. Review of Resident #31's comprehensive MDS assessment dated [DATE] revealed Resident #31 had intact cognition. Review of Resident #31's social work progress notes revealed a care conference dated 08/06/22 was the last document entered into the resident's medical record for care conferences. Interview on 03/14/23 at 1:17 P.M. with Resident #31 revealed the resident was alert and oriented and able to recall dates and details. Resident #31 stated the facility has not invited her to a care conference since 08/2022. Per the interview with Resident #31, she has requested a care conference recently to discuss with the team her recent injury and the plan to get her back into her motorized wheelchair. Resident #31 stated the staff are not updating her on her care plans or the changes of care. Resident #31 denied being invited to any care conferences within the last two quarters. Review of Resident #31's most recent care conference document, not located in the resident's electronic or paper chart, was dated 11/16/22 revealed only two staff members attended a care conference for Resident #31. Per the document the resident nor a representative was present at the conference. Interview on 03/15/23 at 3:00 P.M. with Regional Quality Assurance (QA) Nurse #34 verified Resident #31 had not had a care conference in 2023. Per the QA Nurse #34 there was no evidence Resident #31 was invited to the care conference on 11/16/22. Interview on 03/15/23 at 3:15 P.M. with Resident #31 revealed the resident did not recall being invited to the care conference held on 11/16/22. Per the resident if she were invited, she would have attended to discuss her care. 5. Medical record review for Resident #4 revealed an admission on 11/20/21 with diagnoses including but not limited to schizophrenia, history of Coronavirus Disease 2019 (COVID-19), neuromuscular dysfunction bladder, insomnia, urine retention, cognitive communication deficit, type two diabetes mellitus, anxiety, memory deficit following cerebrovascular disease. Review of the annual MDS dated [DATE] for Resident #4 revealed resident is rarely or never understood. Verbal behaviors towards others occurred one to three days during the assessment period. Resident #4 required extensive assist with two staff members for bed mobility, transfers, and extensive assist from two staff members for toileting. Resident #4 required extensive assist for eating. No hospice was coded. Review of the plan of care dated 03/07/23 for Resident #4 revealed the resident received hospice services related to failure to thrive due to schizophrenia and anxiety. Resident #4 is followed by hospice. Interventions included contact Hospice for changes in resident condition, hospice services as ordered, hospice to collaborate care with facility staff, inspect skin during care, provide emotional support and comfort measures, and provide oral hygiene frequently. Interview on 03/14/23 at 9:30 A.M. with Licensed Practical Nurse (LPN) #129 stated Resident #4 was on hospice services but it has been discontinued last month. Interview on 03/15/23 at 10:14 A.M. with Regional MDS/Registered Nurse (RN) #176 stated Resident #4 was only receiving palliative services from hospice from 02/04/21 through 02/20/23. Interview on 03/15/21 at 3:17 P.M. with RN #34 verified Resident #4 was no longer receiving palliative hospice services. RN #34 further stated the hospice plan of care was added in error and would be deleted. Interview on 03/16/23 at 2:36 P.M. with VPO #36 stated the facility did not have a policy for review of care plans or care plan review meetings and was advised the facility follows the RAI manual for procedures for care plan reviews. Review of the RAI Manual 3.0 page 4-11 states the residents care plan must be reviewed after each assessment and revised based on changing goals, preferences and need of the resident and in response to current interventions.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications were properly stored. This affected one (Resident #46) with the potential to affect five (Residents #50, #32, #37, #22, and #27) identified by the facility as cognitively impaired and ambulatory. The facility's census was 56. Findings include: Medical record review for Resident #46 revealed an admitted [DATE] with diagnoses including chronic pain, low back pain, bipolar disorder, chronic obstructive pulmonary disease, depression, migraine disorder, chronic insomnia due to mental disorder, chronic constipation, pressure ulcer, hypertension, obesity, osteomyelitis, type two diabetes, and Coronavirus 2019 (COVID-19). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition. Resident #46 required extensive assistance to total assistance for bed mobility, transfers, and toileting. Resident #46 was supervised for meal consumption. Review of the active physician orders for Resident #46 revealed orders for Humalog (insulin) solution 100 unit/milliliter (ml) inject per sliding scale at 6:00 A.M., 11:00 A.M. and 4:00 P.M., and oxycodone (pain medication) oral tablet 5 milligrams (mg) one tablet by mouth every six hours as needed for pain. Observation on 03/13/23 at 11:53 A.M. revealed Licensed Practical Nurse (LPN) #58 set a medication administration cup with one small white pill, a bottle of Flonase, a glucometer with a testing strip in the device, an alcohol pad, and artificial eye drops on top of a three drawer cart outside of Resident #46's room. LPN #58 turned her back and walked back to the medication cart, sitting in front of the nurse's station, leaving the medication unattended, to retrieve an insulin vial. Resident #7 was observed ambulating past the unattended medication. Interview on 03/13/23 at 11:55 A.M. with LPN #58 verified she forgot the resident's insulin and left medication on the three-drawer cart outside of the room unattended, while she went to the medication cart by the nurse's station. LPN #58 verified she should not have left medications unattended. During the time of the interview, LPN #58 did not know what the medication was in the medication administration cup. Review of the Medication Administration Record (MAR) revealed Resident #16 was administered oxycodone on 03/13/23 at 11:46 A.M. indicating the white pill was the oxycodone. Review of the staff education dated 03/13/23 revealed Clinical Operations Specialist Registered Nurse (RN) #32 educated LPN #58 to the proper storage and administration of medications. Document was physically signed by LPN #58 and RN #32. Review of a highlighted list provided by the facility revealed Residents #50, #32, #37, #22, and #27 were cognitively impaired and mobile. Review of the facility policy titled, Storage of Medication, dated 04/2019 revealed drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.

Based on medical record review, observation, staff interview, review of facility policy, and of Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure a urinary catheter bag was appropriately secured off the floor. This affected one (Resident #4) of one resident reviewed for urinary catheter bag infection control. The facility failed to follow proper isolation procedures for a resident positive with Coronavirus 2019 (COVID-19). This affected one (Resident #46) of one resident reviewed for COVID-19 isolation procedures. The facility failed to ensure staff utilized appropriate Personal Protective Equipment (PPE) when interacting with residents, while the facility had an outbreak of COVID-19 and the community transmission rate was high. This affected one (Resident #15) observed during a staff interaction. Additionally, the facility failed to administer medications following infection control procedures. This affected one (Resident #48) of one resident observed for infection control procedures during medication administration. The facility's census was 56. Findings include: 1. Medical record review for Resident #4 revealed an admission on [DATE] with diagnoses including schizophrenia, history of COVID-19, neuromuscular dysfunction bladder, and type two diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 was rarely or never understood. Resident #4 required extensive assistance of two staff members for bed mobility, transfers, and toileting. Resident #4 required extensive assistance with eating. Resident #4 was coded as having an indwelling catheter. Review of the plan of care dated [DATE], revealed Resident #4 was at risk for urinary tract infections secondary to use of a Foley catheter due to neurogenic bladder. Interventions included change Foley catheter as needed for obstruction, plugging or displacement, administer antibiotics as ordered/when ordered, change Foley catheter bag per policy and as needed, encourage leg strap, flush catheter as ordered, if change in urine color, consistency output or signs of infection are noted notify the physician, provide catheter care as ordered, and if resident becomes symptomatic, take vital signs and notify physician. Review of the active physician orders for Resident #4 revealed an order dated [DATE] for a urinary catheter, as needed, for neuromuscular dysfunction of bladder. Observation on [DATE] at 2:10 P.M. revealed Resident #4 resting in bed with a catheter bag attached to the metal bed frame. The catheter bag was resting on the floor and did not have a barrier bag between the floor mat and the bag. A dignity bag was placed over the top of the bag only and did not cover the bottom. Interview on [DATE] at 2:10 P.M. with Licensed Practical Nurse (LPN) #129 verified Resident #4's catheter bag was resting on the floor and did not have a barrier between the floor mat and the bag. LPN #129 verified the bag should not be touching the floor. Observation on [DATE] at 8:49 A.M. revealed Resident #4 resting in bed with catheter bag attached to the metal bed frame. The catheter bag was resting on the floor and did not have a barrier bag between the floor mat and the bag. A dignity bag was placed over the top of the bag only and did not cover the bottom. Interview on [DATE] at 9:01 A.M. with LPN #48 verified the catheter bag was resting on the floor and did not have a barrier between the floor mat and the bag. LPN #48 verified the bag should not be touching the floor. Review of the facility policy titled, Catheter Care, Urinary, dated ,d+[DATE] revealed under the section titled, Infection Control, under letter b, the policy stated, Be sure the catheter tubing and the drainage bag are kept off the floor. 2. Medical record review for Resident #46 revealed an admitted [DATE] with diagnoses including chronic pain, low back pain, bipolar disorder, chronic obstructive pulmonary disease, depression, migraine disorder, chronic insomnia due to mental disorder, chronic constipation, pressure ulcer, hypertension, obesity, osteomyelitis, type two diabetes, and COVID-19. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had intact cognition. Resident #46 required extensive assistance to total assistance for bed mobility, transfers, and toileting. Resident #46 required supervision for meal consumption. Resident #46 did not have any behaviors or rejection of care during the look back period. Resident #46 did not have a diagnoses of claustrophobia coded. Review of the plan of care dated [DATE] revealed Resident #46 required isolation due to testing positive for COVID-19. Interventions included educate resident on droplet isolation procedure, encourage resident to keep door shut, encourage resident to practice stress relief techniques to help with anxiety from door being closed, isolation maintained by staff during acute infections period, isolation to be discontinued as soon as infections no longer exists, resident will be served every meal in room on disposable dinnerware, and staff to monitor resident for signs and symptoms of depression. An intervention was added on [DATE] after surveyor intervention to reflect the resident's preference to keep his door open. The facility would honor the resident's preferences. Review of the plan of care dated [DATE] revealed no goals and interventions in place related to claustrophobia. Further review of the medical record, including progress notes from [DATE] to [DATE] revealed no documentation related to diagnoses or assessments related to Resident #46 suffering from claustrophobia. Observation on [DATE] at 7:40 A.M. revealed Resident #46's door was open to the hallway, and there was no barrier in place. Resident #46's door had signage posted stating the resident was on droplet precautions due to COVID-19. Resident #46 was in the first bed, closet to the doorway to the facility hallway. Interview on [DATE] at 7:45 A.M. with State tested Nursing Assistant (STNA) #88 revealed Resident #46's door was left open due to the resident being claustrophobic. STNA #88 stated Resident #46's room door was always open. Interview on [DATE] at 5:00 P.M. with Infection Control Licensed Practical Nurse (LPN) #6 and Clinical Operation Specialist/Interim Director of Nursing Registered Nurse (RN) #32 revealed Resident #46 was claustrophobic and could not have his door closed. Additionally, LPN #6 and RN #32 reported a health care association had advised facilities they were not allowed to utilize any barriers related to COVID-19 positive residents, as the wavier had expired. RN #32 verified Resident #46's door did not have any kind of respiratory barrier in place during the isolation period, at any time, during his isolation for COVID-19 from [DATE] through [DATE]. Review of the facility's infection control policy titled, Coronavirus Disease (COVID-19)- Identification and Management of Ill Residents, dated ,d+[DATE] revealed residents with suspected or confirmed SARs-CoV-2 (COVID-19) infections are placed in a single person room. The door will be kept closed (if safe to do so) and ideally the resident will have a dedicated bathroom. Review of the CDC guidance titled, Infection Control Guidance, dated [DATE] revealed a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room and the door should be kept closed if safe to do so. 3. Medical record review for Resident #15 revealed an admitted [DATE] with diagnoses including hypertension, pain, anemia, hemiplegia, and hemiparesis following a stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 required extensive assistance for bed mobility, transfers, and toileting. Resident #15 was supervised for meal consumption. Observation on [DATE] at 10:15 A.M. revealed Social Services Designee (SSD) #10 was sitting in her office with Resident #15 sitting in his wheelchair, close to the right side of SSD #10's desk. Further observation revealed SSD #10 had her surgical mask below her chin, exposing her mouth and nose. SSD #10's face shield was pulled over the top of her head, exposing her nose and mouth during conversation with the resident. SSD #10 and Resident #15 were within six feet of each other for longer than 15 minutes. Resident #15 did not have a mask on at the time of the observation. Interview on [DATE] at 10:25 A.M. SSD #10 stated she did not have to wear a mask when she was in her office, regardless if residents were in the office with her, as it was considered a private space. Interview on [DATE] at 5:00 P.M. with Infection Control LPN #6, Clinical Operation Specialist/Interim Director of Nursing Registered Nurse (RN) #32 stated staff were educated on the use of face masks and face shields. When the facility community transmission rate was red (high), all staff were required to wear surgical masks. When the facility had an outbreak (one of more residents test positive for COVID-19, face shields are implemented by all staff). RN #32 verified staff were not to be in offices with residents without face shields and masks in place. Review of the CDC COVID Data Tracker revealed on [DATE] the county in which the facility resides in had a community transmission level of red, indicating the transmission level was high. Review of the CDC guidance titled, Infection Control Guidance, dated [DATE] revealed when SARS-CoV-2 (COVID-19) Community Transmission levels are high, source control was recommended for everyone in a health care setting when they could encounter patients. 4. Medical record review of Resident #48 revealed an admitted [DATE] with diagnoses including COVID-19, kidney failure, dementia, hypokalemia, and post laminectomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition. Resident #48 required limited assistance for bed mobility and transfers, extensive assistance with toileting, and supervision for eating. Review of the plan of care for Resident #48 dated [DATE] revealed Resident #48 was at risk for elopement/wandering related to dementia. Interventions include involve in activities of choice, one-on-one (1:1) allow to vent feelings, assess risk factors per facility procedures, follow facility elopement procedures, monitor, and report changes in behavior: restlessness, pacing, etc, provide diversional activities of interest as needed, redirect as needed, resident resides on secured unit for safety. Review of the physician orders for Resident #48 revealed orders for Flonase Suspension 50 micrograms (MCG), one spray in both nostrils in the morning for allergies dated /,d+[DATE], Loratadine Tablet Give 10 mg by mouth in the morning for allergies dated [DATE] and house liquid protein in the morning for nutritional supplementation for nutritional support dated [DATE]. Observation on [DATE] at 8:09 A.M. revealed License Practical Nurse (LPN) #48 preparing medications for administration to Resident #48. LPN #48 poured nutritional support 30 milliliters (ml) into a medication administration cup and set it on the top of the medication cart. LPN #48 then retrieved Flonase nasal inhaler from the medication cart and set it on the top of the medication cart. LPN #48 then prepared allergy relief one 10 milligram (mg) tablet in a second medication cup, setting it on the medication cart. LPN #48 picked up the nutritional liquid and set it inside of the second medication administration cup with the allergy relief tablet so the bottom of the medication cup that was previously sitting on the medication cart was directly on top of the tablet and touching. LPN #48 proceeded into Resident #48's room and administered the medication to the resident. Interview on [DATE] at 8:13 A.M. with LPN #48 verified she did not clean the top of the medication cart prior to preparing the medication. LPN #48 verified she stacked the medication administration cups on top of each other, allowing the bottom of one cup to touch the medication inside the second cup and should not have. Review of the nurse education dated [DATE] revealed Clinical Operation Specialist RN #32 educated LPN #48 that it was never acceptable to place medication cups, that have been placed on an un-sanitized surface, on anything ingestible such as medication. Review of the facility policy titled, Administering Medication, dated ,d+[DATE] revealed staff will follow established facility infection control procedures for the administration of medication.

Based on medical record review, observation, staff interview and review of the policy, the facility failed to ensure incontinence care was provided in a dignified manner. This affected one (#4) of one resident reviewed for infection urinary catheter care. The facility census was 56. Findings include Medical record review for Resident #4 revealed an admission on 11/20/21 with diagnoses include Schizophrenia, history of Coronavirus Disease 2019 (COVID-19), neuromuscular dysfunction bladder, insomnia, urine retention, cognitive communication deficit, type two diabetes mellitus, anxiety, memory deficit following cerebrovascular disease. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #4 revealed the resident is rarely or never understood. Resident #4 required extensive assist with two staff members for bed mobility, transfers, and extensive assist from two staff members for toileting. Resident #4 requires extensive assist for eating. Resident #4 was coded as having an indwelling Foley catheter. Review of the plan of care dated 7/18/22 for Resident #4 revealed the resident at risk for urinary tract infection secondary to the use of a Foley catheter due to diagnoses of neurogenic bladder. Interventions include change Foley catheter as needed for obstruction or displacement as ordered, change Foley catheter bag per policy, encourage leg strap, flush catheter as ordered, position catheter bad and tubing below the level of the bladder and ensure that tubing is not resident under the resident and provide Foley catheter care as ordered. Observation 03/14/23 at 3:49 P.M. of incontinent care for Resident #4 with Licensed Practical Nurse (LPN) #129 and State tested Nursing Assistant (STNA) #86 revealed LPN #129 positioned the bed away from the wall to allow for staff to assist on both sides of the bed. The bed was positioned with the headboard in the corner of the room. Resident #4 was uncovered to expose perineal area for incontinent care. Resident #4 was rolled from side to side for task and replacement of incontinent products, exposing bare body from the perineal region to her feet for Resident #4 on three occasions. The privacy curtain was not pulled around Resident #4 side of the room and this allowed roommate to see completion of incontinent care and exposure of perineal regions of Resident #4. Interview on 03/14/23 at 4:04 P.M. with STNA #86 verified she did not pull the curtain and should have to prevent exposure of Resident #4. Review of the facility policy titled Catheter Care, Urinary dated 09/2014, revealed staff will provide privacy during care. This deficiency represents non-compliance investigated under Complaint Number OH00141216.

Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to complete a comprehensive Minimum Data Set Assessment (MDS) within the required time frame. This affected two (#58 and #259) of two residents reviewed for comprehensive assessments. The facility census was 56. Findings include: 1. Review of the medical record for Resident #259 revealed an admitted [DATE] with medical diagnoses of Alzheimer's disease, unspecified psychosis, hypertension, chronic obstructive pulmonary disease (COPD), and depression. Review of the medical record for Resident #259 revealed an admission comprehensive MDS, with assessment reference date (ARD) of 02/23/23, which indicated Resident #259 had moderate cognitive impairment and required supervision with bed mobility, transfers, toileting, ambulation and eating. Review of the MDS revealed a completion date of 03/08/23. 2. Review of the medical record for Resident #58 revealed an admitted [DATE] with medical diagnoses of rhabdomyolysis, hyperlipidemia, obesity, diabetes mellitus with neuropathy, and hypertension. Review of the medical record for Resident #58 revealed an admission comprehensive MDS, with ARD 01/10/23, which indicated Resident #58 was cognitively intact and required extensive assist with bed mobility, transfers, toileting, and dependent for bathing. Review of the MDS revealed a completion date of 01/17/23. Interview on 03/15/23 at 9:37 A.M. with Regional Nurse #34 stated the facility utilized the RAI manual for their MDS policy and followed the RAI guidelines for MDS completion date requirements. Interview on 03/15/23 at 3:12 P.M. with Regional MDS Nurse #176 confirmed Resident #259 and #58's comprehensive MDS assessments were not completed on the 14th day of the resident's admission to the facility as per the RAI guidelines. Review of the RAI manual revealed an admission comprehensive MDS must be completed on the 14th day of the resident's admission to the facility.

Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set Assessment (MDS) within the required time frame. This affected one (#52) of two residents reviewed for Hospice services. The facility census was 56. Findings include: Review of the medical record for Resident #52 revealed an admitted [DATE] with medical diagnoses of diverticulitis of intestine, atherosclerotic heart disease (ASHD), major Depression, schizophrenia, unspecified psychosis, and dementia. Review of the medical record for Resident #52 revealed a SCSA MDS with assessment reference date (ARD) 02/28/23 which indicated Resident #52 had severely cognitive impairment and required extensive assistance with bed mobility, transfers, toileting, and was dependent for bathing. The MDS indicated Resident #52 received Hospice services. The completion date for Resident #52's SCSA MDS was dated 03/14/23. Review of the medical record for Resident #52 revealed a physician order dated 02/24/23 for Hospice services. Interview on 03/15/23 at 9:37 A.M. with Regional Nurse #34 stated the facility utilized the RAI manual for their MDS policy and followed the RAI guidelines for MDS completion date requirements. Interview on 3/15/23 at 3:12 P.M. with Regional MDS Nurse #176 confirmed Resident #52's SCSA MDS was not completed per RAI guidelines. Review of the RAI manual, hospice election is an automatic requirement for a significant change in status assessment. The ARD must be within 14 days from the effective date of the hospice election and the SCSA MDS completion date can be no later than the 14th calendar day after determination date (hospice election date).

Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to complete quarterly Minimum Data Set Assessment (MDS) within the required time frame. This affected three (#24, #26, and #52) of three residents reviewed for quarterly assessments. The facility census was 56. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with medical diagnoses of schizoaffective disorder, hypertension, Intellectual disabilities, major Depression, bipolar disorder, and anxiety. Review of the medical record for Resident #24 revealed a quarterly MDS, with ARD 02/23/23, which indicated Resident #24 was cognitively intact and required extensive assistance with bed mobility, transfers, toileting and bathing. Review of the MDS revealed a completion date of 03/09/23. 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with medical diagnoses of schizoaffective disorder, major depression, diabetes mellitus, and psychotic disorders with delusions. Review of the medical record for Resident #26 revealed a quarterly MDS, with ARD 01/23/23, which indicated Resident #26 was severely cognitively impaired and required supervision with bed mobility, transfers, ambulation, dressing, and toileting. Review of the MDS revealed a completion date of 02/07/23. 3. Review of the medical record for Resident #52 revealed an admitted [DATE] with medical diagnoses of diverticulitis of intestine, atherosclerotic heart disease (ASHD), major Depression, schizophrenia, unspecified psychosis, and dementia. Review of the medical record for Resident #52 revealed a quarterly MDS, with ARD of 01/22/23, indicated severe cognitive impairment and required extensive assist with bed mobility, transfers, dressing, toileting, and was dependent upon staff for bathing. Review of the MDS revealed a completion date of 02/06/23. Interview on 03/15/23 at 9:37 A.M. with Regional Nurse #34 stated the facility utilized the RAI manual for their MDS policy and followed the RAI guidelines for MDS completion date requirements. Interview on 3/15/23 at 3:12 P.M. with Regional MDS Nurse #176 confirmed Residents #24, #26, and #52 quarterly MDS assessments were not completed timely as per the RAI guidelines. Review of the RAI manual revealed a quarterly MDS completion date must be no later than 14 days after the ARD.

Based on record review, observation, staff interview, review of hospital record, review of employee personnel record and review of facility policy the facility failed to ensure a resident who was at risk for falls received continuous supervision while in the shower. This affected one Resident (#54) of five reviewed. This resulted in actual harm to Resident #54 who fell from a shower chair while unsupervised, Resident #54 sustained a [MEDICAL CONDITION] femur (thigh). Facility census was 55. Findings include: Review of the medical record for the Resident #54 revealed an admission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #54 was currently in the hospital. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately impaired in making decisions and required supervision. The MDS identified Resident #54 as having hallucinations, verbal behaviors as well as having behaviors directed toward others. Resident #54 was assessed with [REDACTED]. Resident #54 was assessed to be a two person transfer and required total dependence on one staff member for personal hygiene. Her balance during transitions from surface to surface was identified as not steady and she was only able to stabilize with staff assist. The MDS identified Resident #54 as always being incontinent of bowel and bladder. Review of the fall plan of care dated 06/24/18 revealed the resident was at risk for falls due to weakness, dementia, impaired balance, pain, mental health disorders, and behaviors of placing self on the floor. Interventions included reminding resident to request assistance before ambulation or transfers. Review of the fall risk assessment dated [DATE] identified Resident #54 as being a high risk for falls due to balance problems, intermittent confusion, incontinence, medications and predisposing disease. Review of the nurses notes dated 07/18/18 at 1:30 P.M., revealed the resident was in the shower when she slid out of the shower chair onto her knees. Resident #54 was observed with her legs turned outward. The resident's range of motion was assessed and the resident complained of pain to her right knee. The physician was notified and orders were received to transfer the resident to the emergency room for evaluation and treatment. Review of the nurses notes dated 07/18/18 at 6:00 P.M., revealed the hospital called and indicated Resident #54 was being transferred to a higher level of care hospital due to a fracture. Review of the hospital emergency records dated 07/18/18 identified Resident #54 arrived to the emergency room with complaints of right knee pain. Resident #54 stated she accidentally slipped while getting out of her shower chair. The x-ray results identified a closed displaced oblique [MEDICAL CONDITION] of the right femur. The hospital documentation revealed due to the additional assistance needed for femoral shaft repairs, Resident #54 was going to be transferred to a higher level of care facility. Review of the STNA #1's personnel record revealed a warning form dated 07/18/18. STNA #1 documented on the form she was the only STNA on the floor, the nurse was busy and STNA #1 went to get a bath blanket. STNA #1 indicated she was alone and what else could she have done. Interview on 07/19/18 at 8:20 A.M., with STNA #1 confirmed on 07/18/18 she provided a shower to Resident #54. STNA #1 revealed Physical Therapist Assistant (PTA) #3 assisted her in getting Resident #54 up into the shower chair and into the shower room. STNA #1 gave the shower to Resident #54 and she left the shower room to retrieve a bath blanket. A loud noise was heard by PTA #3, Resident #54 had fallen on the floor onto her knees. STNA #1 revealed there was no seatbelt on the shower chair. Resident #54 told STNA #1 she was trying to lean over to wipe her bottom and just fell out of the chair onto her knees. On 07/19/18 at 8:30 A.M., an observation of the shower room was made with Licensed Practical Nurse (LPN) #2. LPN #2 pointed out the shower chair sitting in the shower room. LPN #2 confirmed this was the only shower chair used on the secured unit. LPN #2 confirmed there was no seat belt on the shower chair to help keep residents from falling out. On 07/19/18 at 12:06 P.M., interview and review of the facilities post fall investigation report was completed with the Director of Nursing (DON). The DON read the report to the surveyor as follows: Resident #54 fell on the floor, the resident needed two staff members to transfer. Resident #54 was left alone and did not have on any foot wear due to being in the shower room. Resident #54 was alert and her vitals were normal. Staff were interviewed and asked to recreate the incident. The recreation of the incident revealed STNA #1 left the resident unattended to retrieve a bath blanket and upon returning to the shower room, Resident #54 was found on the floor. The resident was yelling and complaining of pain. The DON revealed Resident #54 should have never been left in the shower room alone. On 07/19/18 at 12:15 P.M., interview with PTA #3 revealed he was giving therapy to Resident #54 on 07/18/18 around 1:00 P.M. During the session she wanted to be approved to use the sit to stand lift and STNA #1 was ready to give her a shower. The sit to stand mechanical lift was used to place her in the shower chair. PTA #3 assisted STNA #1 in getting the resident into the shower room. Once in the shower he left the room. He was standing at the nurses desk, which was on the other side of the wall to the shower room. PTA #3 was talking to the nurse when he heard a loud thud. He observed STNA #1 running back to the shower room and he followed. Once in the shower room he observed Resident #54 on her knees, her face against the wall and her feet were both spread outward, in an odd position. Resident #54 was screaming and yelling, so he called for the nurse. PTA #3 assisted STNA #1 in getting the resident out of the shower onto a blanket on the floor. Resident #54 was complaining of pain to her right knee. Once the nurse completed assessing Resident #54, PTA #3 assisted STNA #1 to get Resident #54 off the floor, with the use of a mechanical lift. Resident #54 was then removed from the shower room and placed into her bed. Review of the facilities policy for providing showers dated 06/2017, revealed a safety belt should be applied if using a shower chair. This deficiency substantiates Complaint Number OH 957.