Every finding on record at Stonespring of Vandalia

Based on observation, staff interview, and facility policy, the facility failed to ensure food brought in by family or visitors were stored or handled safely and in a sanitary manner. This affected 43 Residents (#3, #6, #8, #10, #11, #14, #15, #20, #21, #23, #28, #31, #36, #39, #40, #45, #46, #54, #56, #59, #62, #68, #71, #72, #75, #77, #80, #82, #83, #87, #88, #91, #93, #98, #99, #103, #105, #111, #119, #121, #123, #134, and #144) out of 140 residents reviewed for refrigerators in room.Findings include: Observation on 08/12/26 at 11:06 A.M. revealed refrigerators (with and without freezers) in the rooms of Residents (#3, #6, #8, #10, #11, #14, #15, #20, #21, #23, #28, #31, #36, #39, #40, #45, #46, #54, #56, #59, #62, #68, #71, #72, #75, #77, #80, #82, #83, #87, #88, #91, #93, #98, #99, #103, #105, #111, #119, #121, #123, #134, and #144) did not contain a temperature gauge, temperature log, or date labeling to ensure safe consumption. Contents observed included plastic containers with unidentified food items, yogurt, hard boiled eggs, Magic Cups, ice cream, cheese, ranch dressing, opened tomato juice, and various other snacks and beverages (opened and closed). During an interview on 08/12/26 at 2:20 P.M., the Administrator verified perishable food stored in resident room refrigerators were not labeled or dated in Residents (#3, #6, #8, #10, #11, #14, #15, #20, #21, #23, #28, #31, #36, #39, #40, #45, #46, #54, #56, #59, #62, #68, #71, #72, #75, #77, #80, #82, #83, #87, #88, #91, #93, #98, #99, #103, #105, #111, #119, #121, #123, #134, and #144) rooms. The Administrator also stated that no temperature gauges or temperature logs were in place because they were unaware these monitoring practices were required. Facility policy Food Brought by Family/Visitors, dated 11/24, revealed facility maintains professional standards for food service safety by having designated spaces and areas where outside food may be stored. Non-perishable food will be stored in plastic containers with tight-fitting lids. Perishable food will be stored in refrigerator/freezer labeled with resident name and dated to ensure consumption by date. Facility staff will monitor.

Based on staff interview and record review, the facility failed to ensure provider visit notes were written, signed and dated at each visit. This affected four Residents (#3, #10, # 40, and #42) of the four residents reviewed for provider visit notes. The facility census was 140.Findings include: 1) Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hemiplegia and hemiparesis, aphasia, dysphagia, and vascular dementia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #3 had moderately impaired cognition and psychotic disorder.Review of the provider progress note for Resident #3 revealed a date of service of 07/27/26 and the note was signed and dated 08/13/26.2) Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, immunodeficiency, spinal stenosis, and cognitive communication deficit.Review of the most recent MDS 3.0 assessment dated [DATE], revealed Resident #10 cognitively intact.Review of the provider progress note for Resident #10 revealed a date of service of 10/06/25 and the note was signed and dated 11/03/25.3) Record review for Resident #40 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: emphysema, sacroiliitis, benign prostatic hyperplasia with lower urinary tract symptoms and neuromuscular dysfunction of bladder. Review of MDS quarterly assessment dated [DATE], revealed Resident #40 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to be supervision with toileting, bathing and dressing. Resident ambulates in a wheelchair. Medications include antianxiety, depression, diuretic, and opioid.Review of the provider progress note for Resident #40 revealed a date of service of 11/11/25 and the note was signed and dated 11/24/25.4) Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, spinal stenosis, and major depressive disorder.Review of the provider progress note for Resident #42 revealed a date of service of 07/02/26 and the note was signed and dated 07/07/26.During an interview on 08/13/26 at 12:49 P.M., the Administrator confirmed the provider notes should be closed on the date of the service provided and confirmed all notes for the residents listed above were closed late and not at the time of service.

Based on staff interview and record review, the facility failed to ensure the Medical Director (MD) visited the residents once every 60 days. This affected four (#3, #11, #12, and #54) of four reviewed for physician visits. This had the potential to affect all the residents who resided in the facility. The census was 140.Findings include1) Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hemiplegia and hemiparesis, aphasia, dysphagia, and vascular dementia.Review of the medical record for Resident #3 revealed MD visits on 01/20/25, 08/11/25 and 07/27/26.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #3 had moderately impaired cognition and psychotic disorder.During an interview on 08/13/26 at 1:14 P.M, the Administrator confirmed that Resident #3 had documented physician visits on 01/20/25, 08/11/25 and 07/27/26. The Administrator confirmed no additional physician visits were documented for Resident #3. 2) Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included fibromyalgia, anxiety disorder, chronic obstructive pulmonary disease, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE], revealed Resident #11 had moderately impaired cognition, partial assistance with toileting and bathing.Review of the medical record for Resident #11 revealed MD visits on 02/16/26, 03/23/26 and 05/18/26. 3) Review of the medical record of Resident #12 revealed an admission date of 09/06/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia oropharyngeal phase, anxiety disorder, type II diabetes mellitus, major depressive disorder, cognitive communication deficit, and alcoholic hepatitis without ascites. Review of the most recent MDS assessment dated [DATE], revealed the resident was cognitively intact.Review of the medical record for Resident #12 revealed MD visits on 01/20/25, 12/20/25 and 04/22/26.During an interview on 08/13/26 at 1:14 P.M, the Administrator confirmed that Resident #12 had documented physician visits on 04/22/26, 12/20/25, and 01/20/25. Administrator confirmed no additional physician visits were documented for Resident #12 from 01/20/25 to today. 4) Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis, chronic respiratory failure, cardiac arrhythmia, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE], revealed Resident #54 cognitively intact.Review of the medical record for Resident #54 revealed the only MD visit on 03/31/25.During an interview on 08/13/26 at 9:58 A.M., the Administrator confirmed the MD visits for Residents (#3, #11, #12 and #54). The Administrator stated the MD was not required to visit the residents every 60 days.

Based on medical review, observation, staff interview, and facility policy, the facility failed to perform hand hygiene prior or after medication administration, as well as before donning or after donning gloves. This affected three Residents (#7, 96, and 103) out of four residents reviewed for infection control. The census was 144Findings include:1) Record review for Resident #7 revealed this resident was admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral region, unstageable, pressure ulcer of unspecified site, unspecified, dementia, inflammatory spondylopathies and neuromuscular dysfunction of bladder.Review of Minimum Data Set (MDS) significant change assessment dated [DATE], revealed Resident #7 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to be dependent on toileting, dressing and bathing. The resident was assessed with a Stage IV pressure ulcer and three deep tissue injury areas.Observation of wound care on 08/10/26 at 10:48 A.M. revealed Registered Nurse (RN) #120 and Nurse Practitioner (NP) #69 gathered wound supplies for Resident #7, donned gowns and gloves, and entered the resident's room without performing hand hygiene. During the wound care procedure to the resident's right foot, NP #69 changed gloves once without performing hand hygiene before donning new gloves or after removing contaminated gloves. RN #120 changed gloves three times without performing any hand hygiene before donning new glove or after removing the contaminated gloves. Upon exiting the resident's room, both RN #120 and NP #69 verified that hand hygiene had not been performed before new glove application or after contaminated glove removal.2) Observation of medication administration on 08/12/26 at 7:43 A.M., revealed Licensed Practical Nurse (LPN) #78 did not perform hand hygiene prior to preparing medications for Resident #96. LPN #78 donned gloves, opened the medication packet, doffed gloves, and continued the task without completing any hand hygiene at any point before or after glove use. LPN #78 and LPN #98 donned gloves to reposition Resident #96 in bed and doffed gloves afterward without performing hand hygiene before donning or after doffing gloves. Following this, LPN #78 proceeded to the medication cart and pulled medications for Resident #103 without completing any hand hygiene. LPN #78 and LPN #96 later repositioned Resident #103 in bed, again donning and doffing gloves without performing hand hygiene before or after glove use. LPN #78 then administered medications to Resident #103.During an interview on 08/12/26 at 8:14 A.M., LPN #78 and LPN #96 verified they did not complete any hand hygiene before donning or after doffing gloves.Facility policy Hand Hygiene, dated 03/26, revealed hand rubbing using alcohol-based hand sanitizers can be used besides completing hand hygiene before having direct contract with patients, before and after entering isolation rooms, and after removing gloves.

Based on observation, staff interview, facility policy and medication information insert, the facility failed ensure that it is free of medication error rates of five percent or greater. The medication error rate was 8 percent with 25 opportunities. This affected two Residents (#98 and 103) out of five residents reviewed for medication administration.Findings include: Observation of medication administration on 08/12/26 at 7:43 A.M., Licensed Practical Nurse (LPN #96) administered fluticasone propionate (allergy nasal relief) and salmeterol HFA (to control and prevent breathing problems from asthma or chronic obstructive pulmonary disease (COPD) inhalation 115-21 microgram (mcg) two puffs to Resident #98. LPN #96 did not offer Resident #96 to rinse her mouth out with water following the inhalation.Continued observation on 08/12/26 at 8:13 A.M., LPN #96 administered Breo Ellipta (inhaler for control and prevent respiratory symptoms) inhalation 100-25 mcg to Resident #103. LPN #96 did not offer Resident #96 to rinse her mouth out with water.During an interview on 08/12/26 at 8:28 A.M., LPN #96 stated she was unaware that a resident using a corticosteroid inhaler needed to rinse their mouth out afterwards. Review of the fluticasone propionate and Salmeterol HFA medication insert revealed a step by step of how to use: step seven stated rinse your mouth with water after breathing in the medication. Spit out the water. Do not swallow.Review of the Breo Ellipta Inhalation insert revealed a step by step of how to Use: step six states rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water.Facility policy Administer of Meter-Dose Inhaler, undated, revealed if using a corticosteroid, allow resident to gargle with water if desired, to remove medication from mouth and back of throat.

Based on record review, and staff interview, the facility failed to ensure a resident's medication was held when blood sugar readings were outside of perimeters based on the physician's order. This affected one (#14) of 28 residents reviewed for medications being administered per physician orders. The facility also failed to notify the physician of a resident's blood sugar that was outside of perimeters based on the physician's order. This affected one (#84) of 28 residents reviewed for quality of care. The facility census was 140. Findings include:1) Review of Resident #14's medial record revealed the resident was admitted to the facility 12/07/25. Diagnoses included anemia, type two diabetes mellitus with unspecified complications, gastrointestinal hemorrhage, chronic atrial fibrillation, metabolic encephalopathy, chest pain and hypotension. Review of the discharge return anticipated Minimum Data Set (MDS) assessment for Resident #14 dated 07/04/26, revealed the resident was moderately cognitively impaired. Review of the physician's order for Resident #14 dated 07/16/26, revealed Resident #14 was ordered Humalog KwikPen (fast acting insulin) subcutaneous solution pen injector 100 units per milliliter (ml) inject four units subcutaneously with meals for type two diabetes mellitus with unspecified complications and to hold for blood sugars under 150 milligrams per deciliter (mg/dl). Review of the July 20226 Medication Administration Record (MAR) for Resident #14 from 07/16/26 to 07/29/26, revealed Resident #14 was ordered Humalog KwikPen subcutaneous solution pen injector 100 units per ml inject four units subcutaneously with meals for type two diabetes mellitus with unspecified complications and to hold for blood sugars under 150 mg/dl. Further review of the MAR revealed Resident #14 had a blood sugar reading of 113 mg/dl on 07/20/26 at 8:00 A.M., a blood sugar reading of 120 mg/dl on 07/23/26 at 8:00 A.M., a blood sugar reading of 95 mg/dl on 07/25/26 at 5:30 P.M., a blood sugar reading of 116 mg/dl on 07/26/26 at 8:00 A.M., a blood sugar reading of 124 mg/dl on 07/26/26 at 12:30 P.M., and a blood sugar reading of 86 mg/dl on 07/28/26 at 8:00 A.M. Resident #14's MAR indicated that Resident #14 was administered his Humalog KwikPen subcutaneous solution pen injector 100 units per ml inject four units subcutaneously with meals for type two diabetes mellitus with unspecified complications on 07/20/26 at 8:00 A.M., on 07/23/26 at 8:00 A.M., on 07/25/26 at 5:30 P.M., on 07/26/26 at 8:00 A.M., on 07/26/26 at 12:30 P.M., and on 07/28/26 at 8:00 A.M. when Resident #14's blood sugar readings were below 150 mg/dl. Review of August 2026 MAR for Resident #14 from 08/01/26 to 08/12/26, revealed the resident #14 had a blood sugar reading of 119 mg/dl on 08/02/26 at 8:00 A.M., a blood sugar reading of 121 mg/dl on 08/02/26 at 12:30 P.M., a blood sugar reading of 140 mg/dl on 08/06/26 at 5:30 P.M., a blood sugar reading of 148 mg/dl on 08/07/26 at 8:00 A.M., a blood sugar reading of 140 mg/dl on 08/07/26 at 12:30 P.M., and a blood sugar reading of 138 mg/dl on 08/08/26 at 5:30 P.M. Resident #14's MAR indicated that Resident #14 was administered his Humalog KwikPen subcutaneous solution pen injector 100 units per ml inject four units subcutaneously with meals for type two diabetes mellitus with unspecified complications on 08/02/26 at 8:00 A.M., on 08/02/26 at 12:30 P.M., on 08/06/26 at 5:30 P.M., on 08/07/26 at 8:00 A.M., on 08/07/26 at 12:30 P.M., and on 08/08/26 at 5:30 P.M. when Resident #14's blood sugar readings were below 150 mgs/dl. Review of progress notes for Resident #14 from 07/16/26 to 08/12/26, revealed no documentation that Resident #14's Humalog KwikPen subcutaneous solution pen injector 100 units per ml inject four units subcutaneously with meals for type two diabetes mellitus with unspecified complications and to hold for blood sugars under 150 mg/dl was held on 07/20/26 at 8:00 A.M., on 07/23/26 at 8:00 A.M., on 07/25/26 at 5:30 P.M., on 07/26/26 at 8:00 A.M., on 07/26/26 at 12:30 P.M., on 07/28/26 at 8:00 A.M., 08/02/26 at 8:00 A.M., on 08/02/26 at 12:30 P.M., on 08/06/26 at 5:30 P.M., on 08/07/26 at 8:00 A.M., on 08/07/26 at 12:30 P.M., and on 08/08/26 at 5:30 P.M. when Resident #14's blood sugar readings were below 150 mg/dl. During an interview on 08/12/26 at 3:35 P.M., Assistant Director of Nursing (ADON) #67 verified Resident #14 had a blood sugar reading of 113 mg/dl on 07/20/26 at 8:00 A.M., a blood sugar reading of 120 mg/dl on 07/23/26 at 8:00 A.M., a blood sugar reading of 95 mg/dl on 07/25/26 at 5:30 P.M., a blood sugar reading of 116 mg/dl on 07/26/26 at 8:00 A.M., a blood sugar reading of 124 mg/dl on 07/26/26 at 12:30 P.M., a blood sugar reading of 86 mg/dl on 07/28/26 at 8:00 A.M., a blood sugar reading of 119 mg/dl on 08/02/26 at 8:00 A.M., a blood sugar reading of 121 mg/dl on 08/02/26 at 12:30 P.M., a blood sugar reading of 140 mg/dl on 08/06/26 at 5:30 P.M., a blood sugar reading of 148 mg/dl on 08/07/26 at 8:00 A.M., a blood sugar reading of 140 mg/dl on 08/07/26 at 12:30 P.M., and a blood sugar reading of 138 mg/dl on 08/08/26 at 5:30 P.M. ADON #67 verified Resident #14's MAR indicated Resident #14 was administered his Humalog KwikPen subcutaneous solution pen injector 100 units per ml inject four units subcutaneously with meals for type two diabetes mellitus with unspecified complications on 07/20/26 at 8:00 A.M., on 07/23/26 at 8:00 A.M., on 07/25/26 at 5:30 P.M., on 07/26/26 at 8:00 A.M., on 07/26/26 at 12:30 P.M., on 07/28/26 at 8:00 A.M., on 08/02/26 at 8:00 A.M., on 08/02/26 at 12:30 P.M., on 08/06/26 at 5:30 P.M., on 08/07/26 at 8:00 A.M., on 08/07/26 at 12:30 P.M., and on 08/08/26 at 5:30 P.M. when Resident #14's blood sugar readings were below 150 mg/dl. ADON #67 also confirmed the facility did not have any documentation that Resident #67's Humalog was held on 07/20/26 at 8:00 A.M., on 07/23/26 at 8:00 A.M., on 07/25/26 at 5:30 P.M., on 07/26/26 at 8:00 A.M., on 07/26/26 at 12:30 P.M., on 07/28/26 at 8:00 A.M., on 08/02/26 at 8:00 A.M., on 08/02/26 at 12:30 P.M., on 08/06/26 at 5:30 P.M., on 08/07/26 at 8:00 A.M., on 08/07/26 at 12:30 P.M., and on 08/08/26 at 5:30 P.M. 2) Review of the medical record for Resident #84 revealed an admission date of 07/29/24. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus due to underlying condition with diabetic autonomic polyneuropathy, immunodeficiency, hemorrhage of anus and rectum, angiodysplasia of colon without hemorrhage, chronic gout and Alzheimer's disease. Review of the physician order for Resident #84 dated 04/21/26, revealed Resident #84 was ordered insulin aspart (fast acting insulin) injection solution inject five units subcutaneously with meals for diabetes mellitus and to call the doctor if blood sugar is over 300 milligrams (mg) per deciliter (dl) or under 80 mgs/dl.Review of the progress notes for Resident #84 from 07/01/26 to 08/11/26, revealed no documentation that Resident #84's physician was notified of Resident #84's blood sugar readings under 80 mgs/dl on 07/01/26, 07/08/26, 07/10/26, 07/26/26, 08/04/26, 08/05/26 and 08/11/26. Review of annual Minimum Data Set for Resident #84 (MDS) assessment dated [DATE], revealed the resident was cognitively intact and Resident #84 required set up assistance with eating, oral hygiene, and personal hygiene. Resident #84 required maximal assistance with toileting and showering and supervision with upper body dressing and rolling left and right. Resident #84 required moderate assistance with lower body dressing, putting on and taking off footwear, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, and tub transfers.Review of the July 2026 medication administration record (MAR) for Resident #84 from 07/01/26 to 07/29/26, revealed the resident was ordered insulin aspart injection solution inject five units subcutaneously with meals for diabetes mellitus and to call the doctor if blood sugar is over 300 mgs/dl or under 80 mgs/dl. Further review of the MAR revealed Resident #84 had a blood sugar reading of 78 mgs/dl on 07/01/26 at 8:00 A.M., a blood sugar reading of 76 mgs/dl on 07/08/26 at 8:00 A.M., a blood sugar reading of 76 mgs/dl on 07/10/26 at 8:00 A.M., and a blood sugar reading of 75 mgs/dl on 07/26/26 at 8:00 A.M. Review the August 2026 MAR for Resident #84 from 08/01/26 to 08/12/26, revealed the resident had a blood sugar reading of 76 mgs/dl on 08/04/26 at 8:00 A.M., a blood sugar reading of 78 mgs/dl on 08/05/26 at 8:00 A.M., and a blood sugar reading of 68 mgs/dl on 08/11/26 at 8:00 A.M. During an interview on 08/12/26 at 3:35 P.M., Assistant Director of Nursing (ADON) #67 verified Resident #84 had a blood sugar reading of 78 mgs/dl on 07/01/26 at 8:00 A.M., a blood sugar reading of 76 mgs/dl on 07/08/26 at 8:00 A.M., a blood sugar reading of 76 mgs/dl on 07/10/26 at 8:00 A.M., a blood sugar reading of 75 mgs/dl on 07/26/26 at 8:00 A.M., a blood sugar reading of 76 mgs/dl on 08/04/26 at 8:00 A.M., a blood sugar reading of 78 mgs/dl on 08/05/26 at 8:00 A.M., and a blood sugar reading of 68 mgs/dl on 08/11/26 at 8:00 A.M. ADON #67 verified the facility had no documentation that the physician was notified of Resident #80's blood sugar readings below 80 mgs/dl as ordered by the physician on 07/01/26, 07/08/26, 07/10/26, 07/26/26, 08/04/26, 08/05/26 and 08/11/26. Review of the facility's administration of insulin policy dated March 2026 revealed the facility will administer insulin in a safe, consistent manner with the appropriate solution as prescribed by the physician. The facility will monitor the resident's blood sugar per physician orders, and the facility will document in the electronic medical record.

Based on staff interview, record review and policy review, the facility failed to ensure the resident care plan was accurate. This affected one (#16) of eight residents reviewed for care plans. The facility census was 140.Findings include Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dysphagia, and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #16 was cognitively intact, no broken or loosely fitting full or partial denture, and no dental issues.Review of a dental visit for Resident #16 dated 07/16/26, revealed a plan for denture replacement.Review of the active care plan for Resident #16 revealed no dental issues identified or addressed.During an interview on 08/10/26 at 11:03 A.M., Resident #16 stated he had a partial denture that did not fit correctly. Resident #16 stated they have been trying to fix the partial denture.During an interview on 08/12/26 at 9:20 A.M., MDS Coordinator #72 confirmed no dental issues for Resident #16 were in the care plan and they should be addressed in the care plan. Review of the policy titled, Quality of Care, Care Planning, dated 02/2026 revealed a care plan is developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level. This deficiency represents non-compliance investigated under Complaint Number 3028478.

Based on staff interview, record review, and policy review, the facility failed to ensure a comprehensive assessment was accurate. This affected one (#16) of the seven residents reviewed for assessments. The facility census was 140.Findings include:Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dysphagia, and cognitive communication deficit. Review of Resident #16's dental visits on 12/12/25, 01/08/26, 02/13/26 and 07/16/26 with a plan for denture replacement.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #16 cognitively intact, no broken or loosely fitting full or partial denture, and no dental issues.Review of the active care plan for Resident #16 revealed no dental issues identified or addressed.During an interview on 08/10/26 at 11:03 A.M., Resident #16 stated he had a partial denture that doesn't fit correctly. Resident #16 stated they have been trying to fix the partial denture.During an interview on 08/12/26 at 9:20 A.M., MDS Coordinator #72 confirmed no dental issues for Resident #16 are in the MDS assessment and they should be addressed in the assessment. Review of the policy titled, Quality of Care, Care Planning, dated 02/2026 revealed a care plan is developed to identify strengths or possible barriers to guide the resident in reaching their maximum functional level. Each discipline is responsible for implementing and providing input (based on patient/resident representative feedback) on any interventions to assist the patient in achieving their goals and desired outcomes. This deficiency represents non-compliance investigated under Complaint Number 3028478.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of hospital documentation, review of a death certificate, and policy review, the facility failed to ensure adequate care was provided to prevent an avoidable fall with injury. This resulted in Actual Harm when on [DATE] Certified Nursing Assistant (CNA) #315 rolled Resident #135 away from her in the bed during personal care. Resident #135 shifted and rolled out of the bed onto the floor and had immediate complaints of severe back pain. Resident #135 was sent to the hospital and had five rib fractures, admitted to the Surgical Intensive Care Unit (SICU) and died at the hospital. This affected one (Resident #135) of three residents reviewed for falls. The facility census was 133. Findings include: Review of the medical record revealed Resident #135 was admitted on [DATE]. The resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The resident was transferred to the hospital again on [DATE] and died at the hospital on [DATE]. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), adult failure to thrive, depression, and a history of falls.Review of a plan of care dated [DATE], revealed Resident#135 required extensive assistance of one staff for bed mobility and other activities of daily living (ADL). Review of the quarterly Minimum Data Set (MDS) assessment completed on [DATE], revealed Resident #135 had intact cognition. The resident required partial/moderate assistance with bed mobility and transfers.Review of the After Visit Summary (AVS) for Resident #135 dated [DATE], revealed the resident was hospitalized for acute hypoxic respiratory failure and congestive heart failure. The resident had highly impaired hearing and required extensive assistance with bed mobility and other activities of daily living (ADL). Review of the Fall Risk Scale dated [DATE], revealed Resident #135 was at an increased risk for falls. Review of the Nurse Practitioner (NP) progress note dated [DATE], revealed Resident #135 was seen for complaints of not feeling well. The resident was coughing, congested and had a history of frequent pneumonia. The resident's abdomen was distended and the resident voiced discomfort. The resident's last bowel movement was recorded on [DATE]; however, the small bowel sounds were hypoactive. NP #400 ordered for the resident to have a chest x-ray, kidneys, ureter and bladder (KUB) x-ray, urinalysis, and blood work completed the next day. Review of the fall occurrence progress note dated [DATE] and authored by Licensed Practical Nurse (LPN) #305, revealed CNA #315 reported Resident #135 rolled off the bed onto the floor. The resident was found on the floor on the left side of the bed and laying on her left side. The resident stated she was being changed and rolled out of the bed. The resident complained of constant pain rating a 10 on the pain scale, (where zero is no pain and 10 is severe pain) on the right side of her back and below the shoulder blade. The provider was called and ordered for the resident to be sent to the hospital. Review of the Hospital Trauma History and Physical dated [DATE], revealed Resident #135 presented to the emergency room (ER) after a ground level fall. The resident was diagnosed with right posterior lateral rib fractures of five through 10 with displacement, no pneumothorax and was admitted to the SICU related to rolling out of bed at her nursing facility onto the right side. Review of the Interdisciplinary Team (IDT) follow-up note dated [DATE] and authored by Assistant Director of Nursing (ADON) #300, revealed on [DATE] at 5:08 A.M., while CNA #315 was providing care to Resident #135, the resident was positioned in the bed on her left side while being changed. The resident continued to attempt to roll over more and CNA #315 advised her she did not need to continue to move; however, the resident continued to move and rolled off the bed and onto the floor. The resident was immediately assessed and verbalized pain on the right side of her back and below the shoulder blade. Ther resident was moved back into bed by two staff members. The provider was notified and ordered for the resident to be sent to the hospital. Root cause analysis/investigation revealed the resident was at risk for falls related to previous falls and malaise. The resident seen by NP #400 on [DATE] for complaints of not feeling well, cough, congestion and distended abdomen and ordered various tests. A chest x-ray showed mild interstitial edema, the KUB showed a non-obstructive bowel gas pattern, the urinalysis was still pending, and the labs showed a low potassium level and slightly elevated blood urea nitrogen (BUN)/Creatinine ratio (a calculated laboratory value that divides your BUN by your serum creatinine - both are waste products filtered by your kidneys, but they change differently based on hydration and protein intake ratio). The resident was noted with a decline in condition and could benefit from hospice care; however, the resident and family declined hospice. The staff reported Resident #135 often moved around in her bed and the CNA had applied a clean brief on the resident earlier in the shift; however, the brief had loosened and moved, allowing bowel to soil the bedding. The root cause of the fall was identified as the resident continued to roll while on her left side while CNA #315 was preparing the bedding and CNA #315 informed the resident she did not need to move any further. The interventions implemented following the fall included fall mats at the bedside, a low bed, and bed mobility assistance was changed from one staff to two staff. Review of the death certificate for Resident #135, revealed the resident passed away on [DATE] with the immediate cause of the death as blunt force trauma of the chest caused by a ground level fall. During an interview via telephone on [DATE] at 11:22 A.M., CNA #315 stated she was completing incontinence care and a full bed change for Resident #135. CNA #315 stated she rolled the resident away from her and the resident was lying on her left side with her right leg on top of her left and facing the wall. CNA #315 stated she was folding the flat (draw) sheet when the resident swung her right leg over the side of the bed and rolled out of bed onto the floor. During an interview on [DATE] at 1:17 P.M., Occupational Therapist (OT) #405 stated on [DATE], the resident stated she was not feeling well; however, participated in therapy. OT #405 stated the resident refused all therapy on [DATE] because she was not feeling well. During an interview via telephone on [DATE] at 4:26 P.M., CNA #310 stated, the CNAs would always try to have another CNA in Resident #135's room to assist with bed mobility and incontinence care because the resident was shaky and nervous with turning to the side. CNA #310 stated many staff, especially the newer staff, did not feel comfortable having just one person assisting Resident #135 and would ask other staff for help to prevent the resident from falling. During an interview on [DATE] at 2:24 P.M., the Director of Nursing (DON) stated Resident #135's bed mobility was not reassessed following her hospitalization on [DATE] to [DATE] and the resident's change in condition on [DATE]. The DON verified the resident fell out of the bed on [DATE] during care by CNA #315 and was admitted to the hospital with rib fractures. During an interview on [DATE] at 2:57 P.M., ADON #300 stated CNA #315 rolling Resident #135 away from her during care, was not a safe practice. Review of the facility policy titled Peri Care, dated 04/2026, revealed, safety should be ensured when assisting the resident to a side-lying position. Review of the facility policy titled, Fall and Accident Management, dated 06/2019, revealed resident would be evaluated for fall risk on admission, with a change in condition and at least quarterly.The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions:On [DATE] at approximately 5:08 A.M., Resident #135 was immediately assessed by Registered Nurse (RN) #500 and LPN #305. Resident #135 rolled off the left side of the bed, complained of pain and was noted with malaise and tremors to bilateral hands. The physician and the responsible party were notified, and the resident was ordered to be sent to the ER for evaluation. The resident never returned to the facility. On [DATE] at 3:00 P.M., CNA #315 returned to the facility to demonstrate the details of the incident. ADON #300 and RN #501 provided one-on-one (1:1) education and coaching to CNA #315 on proper positioning of a resident in bed during incontinence care, care plan assistance, safety interventions, turning and repositioning a resident while in bed (bed mobility), peri-care and appropriate changing of an occupied bed. CNA #315 demonstrated proper techniques back to ADON #300 and RN #501. There were no disciplinary actions for CNA #315 that followed. On [DATE], the DON reviewed Resident #135's medical record. There were no additional concerns identified. On [DATE], the IDT meeting consisting of ADON #300, DON, Administrator, RN #501, Physical Therapist (PT) #505 reviewed Resident #135's fall. The review consisted of the resident's fall history, fall risk, current interventions and recommendations The teams RCA indicated the resident continued to roll while on her left side despite the CNA informing the resident she did not need to move any further as CNA was preparing bedding. New interventions implemented included fall mats at bedside, low bed, bed mobility assistance change from one person to two person assist. On [DATE], education to all care staff by DON and ADON #300 was initiated. Subjects consisted of accidents, care plan/Kardex, review of appropriate assistance and safety interventions. The education was completed with all staff on [DATE]. On [DATE], the DON completed a facility wide audit on all current residents to ensure all residents care plan assistance (transfer, toileting and mobility assistance), safety interventions (including but not limited to side rails, cushions, fall mats, assistance devices and mattresses) were assessed correctly, remain appropriate, were in place and implemented per the plan of care. There were no additional concerns identified. On [DATE], a Quality Assurance (QA) meeting was held with Medical Director #510, Administrator, DON, ADON #300, QA RN #515, and Corporate RN #520. During this meeting, a review of the falls, change of condition, per-care and fall and accident policies were reviewed. There were no changes.Beginning on [DATE], Performance Improvement (PI) /Audit Worksheets were initiated by the DON and/or designee to ensure that adequate care (positioning, bed mobility, safety interventions, and level of assistance is appropriate) was provided to prevent a fall with injury. The audits would be daily for seven days, then twice weekly for four weeks, then weekly for four weeks, the monthly. If issues are noted, the DON will take appropriate action at the time the concerns are noted. The results of the audits will be reported to the QA committee for a determination of the need for further ongoing formal monitoring. This deficiency represents noncompliance in Complaint Number 3067829.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration. This affected one (Resident #40) of the three residents reviewed for medication administration. The facility census was 130. Findings include: Review of the medical record for Resident #40 revealed an admitted [DATE] with medical diagnoses of local infection of skin, diabetes mellitus, morbid obesity, Chronic Obstructive Pulmonary Disease (COPD), hypothyroidism, and hyperlipidemia. Review of the medical record for Resident #40 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #40 was cognitively intact and was independent with eating and bed mobility, required partial/moderate staff assistance with toilet hygiene, and supervision with transfers. Review of the medical record for Resident #40 revealed physician orders dated 07/09/24 for apixaban 5 milligram (mg) one tablet by mouth two times per day and metformin 500 mg give 0.5 tablet by mouth two times per day, an order dated 07/16/24 for lactobacillus one tablet two times per day, an order dated 07/26/24 for metoprolol 25 mg one tablet by mouth two times per day, and an order dated 08/06/24 for Lasix 40 mg one tablet by mouth daily. Review of the medical record for Resident #40 revealed a Medication Administration Record (MAR) for August 2024 which revealed documentation to support Resident #40 had received the morning doses of apixaban, Lasix, lactobacillus, metformin and metoprolol on 08/09/24. Observation and interview on 08/09/24 at 9:56 A.M. of Resident #40 revealed Resident #40 sitting in a wheelchair with bedside table in front of his chair. The observation revealed a medication cup with five pills in the cup. Resident #40 stated the nurse had brought his morning medications in a while ago and he had not taken them yet. Interview on 08/09/24 at 10:10 A.M. with Registered Nurse (RN) #212 confirmed Resident #40 had a medication cup with medications in the cup sitting on his bedside table. RN #212 stated she had left Resident #40's morning medications sit at the bedside and had not watched Resident #40 consume the medications. Review of the facility policy titled, Administration Oral Medications, revised June 2015 stated the facility would ensure patients are given medication per the physician orders. The policy stated the nurse/medication aide administering the medication remains with the resident until the medicine is swallowed.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gastrostomy tube (g-tube) feedings were administered in a safe and proper manner. The affected one (Resident #86) of seven facility-identified residents with g-tubes. The facility census was 134. Findings include: Review of medical record for Resident #429 revealed an admitted [DATE] with diagnoses including hemiplegia, hemiparesis, type two diabetes, cognitive deficit, and hypertension. Review of plan of care for Resident #429 dated 04/12/24 revealed the resident was at nutritional risk. Interventions included the following: administer tube feeding and flush per orders, maintain the head of the bed elevated 30 degrees during and thirty minutes after tube feeding, monitor and report signs and symptoms of aspiration. Review of plan of care for Resident #429 dated 04/12/24 revealed the resident required tube feeding related to dysphagia. Interventions included the following: administer tube feed and flush per orders, head of bed elevated 30 degrees during and thirty minutes after tube feed, verify tube placement, monitor for signs and symptoms of aspiration. Review of physician's orders for Resident #429 revealed an order dated 04/12/24 for the resident to have nothing by mouth. Review of physician's orders for Resident #429 revealed an order dated 04/17/24 for Glucerna 1.2 per g-tube via continuous pump at 60 milliliters (ml.) per hour. Observation on 04/17/24 revealed Resident #429 was lying flat in the bed and receiving care with the g-tube pump continuously running at 60 ml per hour. Interview on 04/17/24 at 11:20 A.M. with Unit Manager (UM) #240 confirmed Resident #429 was lying flat with the tube feeding running. UM #240 confirmed the tube feeding should have been placed on hold while the resident was receiving care which required the head of the bed to be lowered. Review of facility policy titled Gastric Tube dated March 2012 revealed that a resident who had a gastric tube should have the head of bed elevated at least 30 degrees while the tube feeding was infusing. Staff should turn the pump to the hold position while providing care that required the head of bed to be lowered.

Based on medical record review, observation, and staff interview, the facility failed to ensure non-edible products were secured and not accessible to residents with cognitive impairments. This affected one (Resident #94) of two residents reviewed for accidents. The facility census was 134. Findings include: Review of the medical record for Resident #94 revealed an admitted [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 04/02/24 revealed the resident had severely impaired cognition and required supervision for eating, moderate assistance for oral hygiene, maximal assistance for personal hygiene, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfer. Review of the plan of care for Resident #94 dated 10/26/22 revealed the resident had impaired cognition and decision-making skills related to dementia. Interventions included the following: administering medications as ordered, ask yes/no questions to determine the resident's needs, cue, reorient, and supervise as needed. Review of the progress note for Resident #94 dated 03/24/24 revealed the nurse was alerted by the aide that Resident #94 had ingested about two fluid ounces of no-rinse foam cleanser for cleansing and conditioning hair and skin. The facility staff contacted Poison Control and were informed the cleanser was non-toxic, but could cause gastrointestinal issues. Observation on 04/15/24 at 11:39 A.M. of Resident #94 revealed the resident was lying in bed. There was a bedside table next to the bed, and on the top of the table were various personal care items, including clinical no-rinse foam cleanser. Interview on 04/15/24 at 11:39 A.M. with Licensed Practical Nurse (LPN) #169 confirmed clinical no-rinse foam cleanser was on the bedside table next to Resident #94.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed physician's orders for treatment of pressure ulcers. This affected one (Resident #429) of 17 facility-identified residents with pressure ulcers. The facility census was 137. Findings include: Review of medical record for Resident #429 revealed an admitted [DATE] with diagnoses including hemiplegia, hemiparesis, type two diabetes, and hypertension. Review of physician's order for Resident #429 dated 04/12/24 revealed an order for State tested Nursing Assistant (STNA) to apply Remedy barrier cream after each incontinent episode. Review of physician's orders for Resident #429 dated 04/17/24 revealed an order to cleanse the pressure ulcer to the resident's sacrum with normal saline, pat dry with sterile gauze, cover with collagen, cover with gauze or abdominal pad, then secure with tape every day and night shift. Observation on 04/17/24 at 11:10 A.M. revealed Unit Manager (UM) #240 removed an old dressing that was saturated with urine and blood from Resident #429's sacral pressure ulcer. UM #240 performed hand hygiene, then donned gloves and used a peri wipe to clean the peri wound area to sacral pressure ulcer. UM #240 did not clean the wound bed. UM #240 then performed hand hygiene, donned clean gloves and applied Remedy barrier cream to a border gauze dressing which she placed over the resident's sacral pressure ulcer. Interview on 04/17/24 at 11:12 A.M. with UM #240 confirmed Resident #429 had an order to cleanse the sacral pressure ulcer with normal saline, pat dry with sterile gauze, cover with collagen, cover with gauze or abdominal pad, then secure with tape every day and night shift. UM #429 confirmed she cleansed the peri wound to the resident's sacrum with a peri wipe and she applied Remedy barrier cream to the peri wound and covered the pressure ulcer with a gauze dressing. UM #240 confirmed she did not follow Resident #429's physician's orders for care of the resident's sacral pressure ulcer. Review of the facility policy titled Skin Integrity Team-Skin Monitoring Process dated January 2023 revealed the facility team would provide care and services to promote healing of pressure ulcers or other skin related issues in accordance with professional standards of care.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure carpet in resident rooms was maintained in a clean and sanitary manner. This affected one (Resident #421) of 28 sampled residents. The facility census was 134. Findings include: Review of medical record for Resident #421 revealed an admitted [DATE] with diagnoses including skin cancer, atrial fibrillation, and post-traumatic stress disorder (PTSD.) Review of the Minimum Data Set (MDS) assessment for Resident #421 dated 03/26/24 revealed the resident was cognitively intact and was dependent on staff for assistance with activities of daily living (ADLs.) Observation on 04/15/24 at 11:00 A.M. of Resident #421's room revealed there were six large dark red stains on the carpet next to television and dresser stand. Interview on 04/15/24 at 11:00 A.M. with Resident #421 confirmed the stains on the carpet were made when he had fallen, and his blood had dripped all over the floor. Interview on 04/15/24 at 2:30 P.M. with State tested Nursing Assistant (STNA) #250 confirmed Resident #421's carpet had six large stains due to the resident had bled on the floor when he fell . Observation on 04/16/24 at 1:40 P.M. revealed the stains to Resident #421's carpet were present and unchanged from the observation on 04/15/24. Interview on 04/18/24 at 1:40 P.M. with the Administrator confirmed Resident #421 had bled from a skin tear on 03/30/24 which had resulted in the blood stains to the resident's carpet. The Administrator further confirmed the facility had not removed the blood stains from Resident #421's carpet. Review of the facility policy titled Residents Rights dated 1987 revealed that residents at a nursing home had the right to provide a safe, and clean-living environment.

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure call lights were accessible to two (Residents #428 and #439) of 28 sampled residents. The facility census was 134. Findings include: 1. Review of medical record for Resident #428 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, dementia, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #428 dated 08/19/23 revealed that the resident was cognitively impaired and was dependent on staff assistance for activities of daily living (ADLs.) Review of plan of care for Resident #428 dated 04/13/24 revealed the resident was at risk for an ADL self-care performance deficit related to atrial fibrillation, COPD, chronic kidney disease, glaucoma, and DM. Interventions included the following: assist with positioning to help maintain proper body alignment, encourage rest periods, keep call light within reach while in room. Observation on 04/17/24 at 7: 40 A.M. revealed Resident #428 was lying in bed and was awake. Resident #428's call light was on the right side of the bed on the floor, covered in the blanket and falling off the bed. Interview on 04/17/24 at 7:47 A.M. with Registered Nurse (RN)#154 confirmed Resident #428's call light was not in reach. RN #154 further confirmed Resident #428 was able to use her call light and the resident's call light should be kept within the resident's reach at all times. 2. Review of the medical record for Resident #429 revealed an admitted [DATE] with diagnoses including hemiplegia, hemiparesis, DM, cognitive deficit, and hypertension. Review of plan of care for Resident #429 revealed the resident was at risk for an ADL self-care performance deficit related to hemiplegia, left side weakness, gastric tube, pulmonary embolism, DM, dysphagia, and dysarthria. Interventions included the following: assist with ADLs, encourage rest periods, provide privacy, keep resident's call light within reach while in room. Observation on 04/17/24 at 8:14 A.M. of Resident #429 revealed the resident was up in her reclining geri chair in her room with the call light on the bed and out of the resident's reach. Interview on 04/17/24 at 8:14 A.M. with RN #154 confirmed Resident #429 was able to use the call light to summon assistance but the call light was out of reach. RN #154 confirmed Resident #429's call light should be accessible to the resident while in the room. Review of the facility policy titled Call Lights dated August 2016 revealed the facility maintained a functioning communication system that registered residents' calls from rooms, toilet, and bathing facilities. It was the responsibility of each nurse to ensure the residents' call lights were working and within reach.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#134) out of the three residents reviewed for medications. The facility census was 129. Findings included: Review of the medical record for Resident #134 revealed an admitted [DATE] with medical diagnoses of hypothyroidism, end stage renal disease, dependence on dialysis, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/17/23 which indicated Resident #134 was cognitively intact. The MDS indicated Resident #134 required limited staff assistance with bed mobility and extensive staff assistance with transfers, toileting, dressing, and bathing. Review of the medical record for Resident #134 revealed a physician order, dated 08/16/23, for ipratropium-albuterol inhalation aerosol 20-100 microgram (mcg) per actuation (act), one inhalation by mouth three times per day on Monday, Wednesday, and Fridays for COPD. Review of the medical record for Resident #134 revealed a Medication Administration Record (MAR) for October 2023 which did not contain documentation to support Resident #134 received ipratropium-albuterol inhalation aerosol as ordered on 10/02/23, 10/04/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/23/23, and 10/27/23. Review of the MAR for November 2023 revealed no documentation to support Resident #134 received ipratropium-albuterol inhalation aerosol as ordered on 11/03/23, 11/06/23, 11/08/23, 11/13/23, 11/15/23, 11/17/23, and 11/20/23. Interview on 11/20/23 at 11:05 A.M. with Resident #134 confirmed the nursing staff administer her medications and that she had not received her ipratropium-albuterol inhalation medication as ordered. Resident #134 stated she was told by the nursing staff that the medication had not been delivered by the pharmacy. Resident #134 denied any medical concerns related to not receiving the ipratropium-albuterol inhalation medication as ordered. Interview on 11/20/23 at 3:00 P.M. with Director of Nursing (DON) confirmed Resident #134 had the ipratropium-albuterol aerosols ordered Monday, Wednesday and Friday routinely and an as needed medication for use other days/times. The DON confirmed Resident #134 did not receive the ipratropium-albuterol aerosol as ordered on 11/03/23, 11/06/23, 11/08/23, 11/13/23, 11/15/23, 11/17/23, and 11/20/23. DON stated the pharmacy changed the medication from an inhaler administration to nebulizer administration and some of the nursing staff were not aware of the change. DON confirmed nursing staff documented the ipratropium-albuterol aerosol as not available from pharmacy as the reason the medication was not given. DON was not able to determine the date in which the pharmacy changed to administration of the medication from an inhaler to via nebulizer. Interview on 11/21/23 at 1:04 P.M. with DON confirmed Resident #134 did not receive the ipratropium-albuterol aerosol as ordered on 10/02/23, 10/04/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/23/23, and 10/24/23. Review of the policy titled, Administration Oral Medications, revised June 2015, stated the facility wound ensure patients are given medication per the physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00147589.

Based on observation, medical record review, resident and staff interview, and review of a policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected one (#10) of one residents observed for medications. The census was 130. Findings include: Review of the medical record of Resident #10 revealed an admitted [DATE]. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side, anxiety, and depressive disorder. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #10 was assessed with severely impaired cognition. Review of the October 2023 medication administration record (MAR) revealed Resident #10 was ordered the pain medication aspirin 81 milligrams (mg) one tablet, the supplement levothyroxine 137 micrograms (mcg) one tablet, the supplement selenium 200 mcg one tablet, the supplement vitamin D3 125 mcg one tablet, the antianxiety medication alprazolam 0.25 mg one tablet, the supplement magnesium 500 mg two tablets, the blood pressure medication metoprolol succinate 50 mg one capsule, the supplement sodium chloride one (1) gram one tablet, and the antidepressant venlafaxine 25 mg one tablet. Observation on 10/18/23 at 9:15 A.M. revealed a small plastic medication cup with 10 unidentified tablets and capsules sitting on Resident #10's breakfast tray. Further observation revealed Resident #10 was eating in her room. Interview on 10/18/23 at 9:15 A.M. with Resident #10 revealed the resident could not identify any of the medications in the medication cup on her breakfast tray, but stated she thought she was supposed to take them. Observation and interview on 10/18/23 at approximately 9:30 A.M. with Registered Nurse (RN) #200 verify the medications that were left at Resident #10's bedside. Review of the facility policy titled, Administration Oral Medications, dated December 2021, revealed the nurse administering the medication must remain with the resident until the medicine was swallowed. This deficiency represents non-compliance investigated under Master Complaint Number OH00147406.

Based on record review and interview, the facility failed to ensure a resident had the right to refuse treatment and failed to ensure the resident understood the intent of an advanced directive. This affected one (Resident #200) of three residents reviewed for advanced directives. The census was 128. Findings Include: Resident #200 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of her Minimum Data Set (MDS) assessment, dated 08/01/23, revealed she was cognitively intact. Review of Resident #200 physician orders revealed she had an advanced directive of full code status from admission until 08/01/23. On 08/01/23, it was changed to Do Not Resuscitate Comfort Care (DNRCC) status. Review of Resident #200 progress notes, dated 08/01/23, revealed a note written by Nurse Practitioner #300 that stated, She is satting [oxygen saturation dropping] in the 50's. Put her on Cpap and told her that she needed to keep that on to hopefully bring oxygen level up. Spoke about being sent to the hospital for evaluation and treatment. She refused. Explained that with her being a full code that we would need to send her. She is alert and oriented. Discussed code status with the resident. Explained that a DNRCC would allow her to stay here and would keep her comfortable. Nurse Practitioner #300 also wrote in the same note, The unit manager and nurse was at the bedside also through the conversation. DNRCC paperwork completed, and the resident signed without difficulty. During interview on 08/25/23 at 11:05 AM, Nurse Practitioner #300 stated she told Resident #200 that the facility would need to send her to the hospital if she remained a full code status. She also confirmed they spoke to Resident #200 about the DNRCC status, and they would not need to send her to the hospital if she changed her code status to a DNR. During interview on 08/25/23 at 2:10 PM, Registered Nurse (RN) #301 stated she was in the room when Nurse Practitioner #300 talked to Resident #200 about her current code status. She confirmed that it was relayed to Resident #200 that they would have to send her out to the hospital if she had respiratory distress, and if she remained a full code status. This deficiency represents non-compliance investigated under Complaint Number OH00145348.

Based on medical record review, staff interview, and review of facility policy, the facility failed to complete a pressure ulcer treatment as ordered. This affected one (#92) of three residents reviewed for skin breakdown. The census was 144. Findings include: Review of Resident #92's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #92 was assessed as being cognitively intact and requiring extensive assistance with activities of daily living (ADL's) in a quarterly Minimum Data Set (MDS) dated [DATE]. Review of a Weekly Wound Progress Note dated 11/26/21 revealed Resident #92 had a stage III pressure ulcer to the sacrum. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of treatment administration records (TAR's) revealed Resident #92's sacrum pressure ulcer treatment was not documented as being completed on 10/26/21, 10/27/21, 11/15/21, 11/19/21, 11/21/21, and 11/27/21. Interview with the Administrator and Director of Nursing (DON) on 12/01/21 at 11:24 A.M. confirmed Resident #92's sacrum pressure ulcer treatment was not documented as being completed on 10/26/21, 10/27/21, 11/15/21, 11/19/21, 11/21/21, and 11/27/21. The DON confirmed completed pressure ulcer treatments should be signed in the TAR by the nurse completing the treatment. Review of the facility's policy titled Infection Control-Dressings, Dry/Clean dated July 2019 revealed once a dressing treatment is completed it should be documented in the medical record. This deficiency substantiates Complaint Number OH 826 and Complaint Number OH 731.

Based on record review, observations and staff interviews, the facility failed to provide appropriate incontinence care for a resident. This affected one (#1) out of three residents reviewed for incontinence care. Facility census was 131. Findings include: Review of the medical record for the Resident #1 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimal Data Set (MDS) assessment, dated 05/28/21, revealed the resident had intact cognition. The resident was extensive assistance of two staff for all activities of daily living (ADL) except eating and she is a supervise, set up only. The resident was identified to be always incontinent of bowel and bladder. Resident #1 has a indwelling urinary (Foley) catheter in place to promote healing of moisture associated skin damage (MASD) on her buttocks. The MDS also revealed Resident #1 had a right trochanter surgical wound. Review of the care plan dated 05/28/21 revealed Resident #1 has bladder incontinence related to activity intolerance, confusion, impaired mobility, physical limitations, weakness. Interventions included monitor/document for signs and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Clean peri-area with each incontinence episode. Monitor and document intake and output as per facility policy. Provide protective barrier after incontinent episodes, as well as other appropriate interventions. Observation on 07/26/21 at 10:50 A.M. of incontinence care for Resident #1 with State tested Nursing Assistant (STNA) #101 and Registered Nurse (RN) #150 revealed the resident had a bowel movement. STNA #101 cleaned back and front of the resident's bottom and then started to place the incontinence product on the resident and finish. STNA #101 failed to move Resident #1's legs apart, the resident could no move her own legs and stool was not cleaned from between the resident's legs. At that time, this surveyor asked STNA #101 about the incontinence care technique being used for Resident #1 and that point STNA #101 needed several additional cleaning cloths due to additional bowel movement being left between the resident's legs. Interview on 07/26/21 at 10:50 A.M. with STNA #101 verified she forgot to clean in the folds of Resident #1's legs which left bowel movement behind. She also revealed she checks Resident #1 every two hours to see if she needs changed. Interview on 07/26/21 at 10:50 A.M. with the Director of Nursing (DON) revealed all nursing staff have been trained on the proper procedures for incontinence care. The observation involving Resident #1 was described to the DON and the DON confirmed this was not the appropriate procedure for incontinence care. This deficiency substantiates Complaint Number OH 047.