Every finding on record at Sunrise Nursing Healthcare LLC

Based on observation, interview, and facility policy review, the facility failed to ensure the right to privacy and confidential medical records for 2 (Resident #45 and Resident #59) of 67 facility residents. Specifically, observations revealed the computer screen on two medications carts was left visible in a facility hallway, while Resident #45 and Resident #59's identification and personal health information (PHI) was displayed. Findings include: A facility policy titled, Confidentiality of Information and Personal Privacy, revised 04/2017, indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. The policy revealed, 4. Access to resident personal and medical records will be limited to authorized staff and business associates.On 08/25/2025 at 9:24 AM, an observation revealed a computer screen on top of a medication cart for the Peri/Primrose Hallway displayed Resident #45's PHI, including the resident's name, contact information, a list of medications and allergies, and progress notes. The nurse was in the room with a resident behind a closed door.During an interview on 08/25/2025 at 9:30 AM, Registered Nurse (RN) #3, who was a supervisor, stated that someone could come by and see the resident's personal information, which violated the resident's rights. RN #3 revealed she was able to see the resident's name, information about medications, progress notes, history, and physician's orders on the computer screen. RN #3 stated nurses must lock their computer screen when stepping away from their computer. On 08/25/2025 at 9:32 AM, Registered Nurse (RN) #4 returned to the Peri/Primrose Hallway medication cart from a resident room. RN #4 stated that computer screens should not be left unlocked, to protect residents' privacy. RN #4 stated that someone could read the resident's health information, and they did not want that to happen. On 08/25/2025 at 9:55 AM, an observation revealed RN #5 left the computer screen on the Peri Hallway medication cart unlocked with Resident #59's PHI displayed, including the resident's name, medications, ventilator status, date of birth , physician name, blood pressure, code status, and allergies. The nurse was behind a closed door, and the medication cart was located in the hallway between two resident rooms. On 08/25/2025 at 9:59 AM, RN #5 returned to the medication cart and stated the computer screen should have been locked to protect resident confidentiality. On 08/25/2025 at 10:00 AM, in a follow-up interview, RN #3 stated that the screen should not be left unlocked, and staff had a duty to protect resident information. On 08/27/2025 at 9:22 AM, the Director of Nursing (DON) revealed the expectation was for the staff to lock their computer screen when they were at the desk, nursing station, and between residents. On 08/27/2025 at 9:42 AM, the Administrator stated to protect personal health information, the expectation was for all staff to close out of their computer screen when they stepped away. The Administrator stated that he expected staff to follow the facility's privacy and safety policies to protect residents' personal information, which included ensuring staff locked computer screens.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff interviews and policy review, the facility failed to ensure staff smoked only in designated areas of the facility in accordance with the facilities smoking policy. This affected one (Resident #58) of three reviewed for oxygen usage. The facility census was 62. Findings include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses of traumatic subarachnoid hemorrhage, anoxic brain damage, metabolic encephalopathy and tracheostomy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had severe cognitive impairment and had range of motion impairment of bilateral upper and lower extremities. Resident #58 was non-communicative and dependent on staff for all Activities of Daily Living (ADLs). Review of the physician orders for July 2024 revealed Resident #58 had a tracheostomy with continuous oxygen and received nutrition through an enteral feeding tube. Observation of the video with date and time that was blurred and unable to be visualized provided by the family through a camera located in the room of Resident #58 revealed Registered Nurse (RN) #222 visibly lighting an unidentified smoking paraphernalia on two occasions in the room of Resident #58. Observation of Resident #58 on 07/09/24 throughout the survey in her room revealed continuous oxygen was in use and administered through a tracheostomy. Further observations of Resident #58's room door on 07/09/24 revealed signage in place stating, Oxygen in use / No-Smoking Permitted. Interview on 07/09/24 at 3:10 P.M. The Administrator and [NAME] President of Clinical Operations (VPCO) #333 confirmed smoking is not permitted inside any part of the facility and in any area where oxygen is being used or stored. The Administrator and VPCO #333 confirmed RN #222 was observed on video camera smoking in Resident #58's room on 06/25/24. The Administrator and VPCO #333 confirmed the facility became aware of RN #222 smoking in Resident #58's room on 06/25/24 and the police were called and RN #222 was immediately removed from duty. The Administrator and VPCO #333 stated they were unable to determine what RN #222 was smoking in Resident #58's room. Review of the Smoking Policy-Employees revised 05/2019 revealed employee smoking is permitted only in places where it is designated and this includes use of cigarettes, e-cigarettes, chewing tobacco, pipes, cigars and vaping. Smoking is prohibited in all other areas. Smoking is prohibited in any area where oxygen is being used or stored, in any area that bears a No-Smoking sign, or in any area that would create a hazardous or unsafe condition. The deficiency was corrected on 06/26/24 when the facility implemented the following corrective actions: On 06/25/24 at 10:40 P.M. the RN #222 was immediately relieved of duty and placed under the supervision of Licensed Practical Nurse (LPN) # 401 until law enforcement arrived at the facility. On 06/25/24 the RN #222 exited the facility with law enforcement and never returned. On 06/25/24 the RN #222 was replaced as the RN on duty by the Director of Nursing (DON). On 06/26/24 the DON completed a skin assessment on Resident #58 with no new skin impairments noted. On 06/26/26 the Administrator, a report with the Ohio Board of Nursing on the RN #222. The report # is 24-003334. On 06/26/24 the Administrator and/or his designee interviewed all Residents to ensure they felt safe in their environment and had no concerns. No concerns were noted. On 06/26/26 the Administrator interviewed staff working the evening/night of 06/25/24 to 06/26/24. On 06/26/24 the Administrator and/or his designee educated facility staff on the policies of Substance Abuse, Smoking, and Oxygen. On 06/26/24 the Administrator implemented an audit plan to audit five residents three times a week to ensure they feel safe in their environment and have no concerns. Audits will occur weekly for four weeks and then monthly for two months. Corrective action will be initiated for any noted non-compliance. On 06/26/24 the Administrator presented the results of the investigation to the Quality Assurance and Performance Improvement (QAPI) committee. Audit plan findings will be presented to Quality Assurance and Performance Improvement (QAPI) committee monthly for review and recommendations. This deficiency represents non-compliance investigated under Complaint Number OH00155153.

Based on observations, staff interview interview, and review of the facility policy, the facility failed to ensure there were no expired tube feed formula bottles stored in the medication rooms and central supply room. The facility identified one resident (#26) who received Glucerna 1.5 (a specialized tube feed formula) and no residents currently who received Nephro 1.8 (a specialized tube feed formula). The facility identified 11 residents who receive tube feed formula. The facility census was 63. Findings include: Observation of medication room B with Registered Nurse (RN) #206 on [DATE] at 11:15 A.M. verified there were eight bottles of expired Glucerna 1.5 in the medication room. The eight bottles had expiration date of [DATE]. Subsequent observations of the central supply room with RN #206 verified there were eight bottles Glucerna 1.5 with the expiration date of [DATE]. RN #206 verified there were a total of 16 bottles of Glucerna 1.5 bottles with expired date [DATE] in medication room B and central supply room. Observation of medication room A with Licensed Practical Nurse (LPN) #709 on [DATE] at 11:58 A.M. verified there was one bottle of Nephro 1.8 and one bottle of Glucerna 1.5 with an expiration date of [DATE] in medication room A. Interview on [DATE] at 1:38 P.M. with Central Supply (CS) #215 stated she was educated recently on checking in central supply the expiration dates on the gastric tube feeds. CS #215 stated she recently got rid of many expired gastric tube feeds bottles with expired dates already. Review of the facility policy titled Storage of Medication, dated ,d+[DATE], revealed drugs and biologicals used at the facility are stored in a locked compartment. Discontinued, outdated, or deteriorated drugs or biologicals are returned to dispensing pharmacy or destroyed. This deficiency represents non-compliance investigated under Complaint Number OH00154163 and Complaint Number OH00153892.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, staff interview, and interview with contracted entity provider representative, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The facility census was 46. Findings include: 1) Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included Parkinsonism, dementia, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #01, revealed the resident had moderate cognitive impairment. Review of the Care Plan for Resident #01 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #01, revealed the resident was ordered to receive nutrition DRIPT IV (an entity who provides intravenous [IV] hydration and vitamin nutrient therapy) via IV one-time monthly 1000 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 1000 mLs an hour (hr.) with total additive volume of 27.4 mLs of the additive formula: Vitamin C (ascorbic acid) 5 grams (gms), Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 200 mgs, Dexpanthenol (Dex) 4 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin [Methyl]) 2 mgs, Magnesium Chloride (MagCl) 1000 mgs, Calcium Chloride (CaCl) 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine (Arg) 500 mgs, Ornithine ([NAME])150 mgs, Lysine ([NAME]) 250 mgs, Vitamin D2 (calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of Medication Administration Records (MARs) revealed Resident #01 received ordered Nutrition IV infusions on 05/09/23, 06/06/23, and 07/11/23. 2) Review of the medical record for Resident #09 revealed the resident was admitted on [DATE]. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia. Review of the MDS assessment dated [DATE] for Resident #09, revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23. 3) Review of medical record for Resident #11 revealed the resident was admitted on [DATE]. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia. Review of the MDS assessment dated [DATE] for Resident #11 revealed the resident was cognitively intact. Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. 4) Review of medical records for Resident #12 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses including traumatic brain injury, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care. Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions: On 09/22/23, the contract with DRIPT IV cessation was effective. On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review. On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by [NAME] President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing. Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148167.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, staff interview and contracted entity provider representative interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The census was 46. Findings include: 1) Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included Parkinsonism, dementia, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #01, revealed the resident had moderate cognitive impairment. Review of the Care Plan for Resident #01 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #01, revealed the resident was ordered to receive nutrition DRIPT (entity who provides intravenous (IV) hydration and vitamin nutrient therapy) IV one-time monthly 1000 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 1000 mLs an hour (hr.) with total additive volume of 27.4 mLs of the additive formula: Vitamin C (ascorbic acid) 5 grams (gms), Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 200 mgs, Dexpanthenol (Dex) 4 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin [Methyl]) 2 mgs, Magnesium Chloride (MagCl) 1000 mgs, Calcium Chloride (CaCl) 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine (Arg) 500 mgs, Ornithine ([NAME])150 mgs, Lysine ([NAME]) 250 mgs, Vitamin D2 (calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). 2) Review of the medical record for Resident #09 revealed the resident was admitted on [DATE]. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia. Review of the MDS assessment dated [DATE] for Resident #09, revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23. 3) Review of medical record for Resident #11 revealed the resident was admitted on [DATE]. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia. Review of the MDS assessment dated [DATE] for Resident #11 revealed the resident was cognitively intact. Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. 4) Review of medical records for Resident #12 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses including traumatic brain injury, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care. Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions. Interview with the Administrator on 12/06/23 at 10:20 A.M. revealed [NAME] President of Operations (VPO) #505 from the facility's corporate office notified them to stop administration of IV infusions from the ancillary provider (DRIPT IV) on 09/22/23. They were not made aware of any concerns related to the TDDD Ohio licensure for the ancillary provider. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions. On 09/22/23, the contract with DRIPT IV cessation was effective. On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review. On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by [NAME] President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing. Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148167.

Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The facility census was 46. Findings include: 1) Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnoses included Parkinsonism, dementia, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #01, revealed the resident had moderate cognitive impairment. Review of the Care Plan for Resident #01 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #01, revealed the resident was ordered to receive nutrition DRIPT IV (entity who provides intravenous [IV] hydration and vitamin nutrient therapy) via IV one-time monthly 1000 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 1000 mLs an hour (hr.) with total additive volume of 27.4 mLs of the additive formula: Vitamin C (ascorbic acid) 5 grams (gms), Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 200 mgs, Dexpanthenol (Dex) 4 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin [Methyl]) 2 mgs, Magnesium Chloride (MagCl) 1000 mgs, Calcium Chloride (CaCl) 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine (Arg) 500 mgs, Ornithine ([NAME])150 mgs, Lysine ([NAME]) 250 mgs, Vitamin D2 (calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of Medication Administration Records (MARs) revealed Resident #01 received ordered Nutrition IV infusions on 05/09/23, 06/06/23, and 07/11/23. 2) Review of the medical record for Resident #09 revealed the resident was admitted on [DATE]. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia. Review of the MDS assessment dated [DATE] for Resident #09, revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23. 3) Review of medical record for Resident #11 revealed the resident was admitted on [DATE]. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia. Review of the MDS assessment dated [DATE] for Resident #11 revealed the resident was cognitively intact. Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. 4) Review of medical records for Resident #12 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses including traumatic brain injury, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care. Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol - for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions. Interview with the Administrator on 12/06/23 at 10:20 A.M. revealed [NAME] President of Operations (VPO) #505 from the facility's corporate office notified them to stop administration of IV infusions from the ancillary provider (DRIPT IV) on 09/22/23. They were not made aware of any concerns related to the TDDD Ohio licensure for the ancillary provider. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions. On 09/22/23, the contract with DRIPT IV cessation was effective. On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review. On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by [NAME] President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing. Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148167.

Based on record review, staff and resident interviews, review of personnel files, and review of facility policy, the facility failed to ensure residents were allowed to have visitors of their choice. This affected two residents (#11 and #16) out of six Residents reviewed for visitation. The facility census was 47. Findings included: 1) Review of the clinical record for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, but are not limited to, type II diabetes, cognitive communication deficit, major depressive disorder, hypertension, morbid obesity, and overactive bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #11, revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #11, addressed her being dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility. Interventions included encouraging ongoing family involvement and inviting the resident's family to attend special events, activities, and meals. Interview on 04/26/23 at 2:45 P.M. with Resident #11, revealed the resident indicated she would like to have one visitor and it was a former Activities Director from the facility. Resident #11 indicated she talked to former Activities Director #60 regularly on the phone. Resident #11 indicated she was told by former Activities Director #60 that she was not allowed to come and visit. 2) Review of the clinical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included, but are not limited to, schizoaffective disorder, sensorineural hearing loss bilaterally, major depressive disorder, intellectual disabilities,' mild cognitive impairment, type II diabetes, and cognitive communication deficit. Review of the quarterly MDS assessment dated [DATE], revealed Resident #16 had had a BIMS score of 11 indicating she had moderate cognitive impairment. She needed supervision for activities of daily living. Review of the care plan for Resident #16, revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Interview on 04/26/23 at approximately 2:50 P.M. with Resident #16, revealed the resident indicated she would like to have former Activities Director #60 visit her in the facility. Interview on 04/26/23 at 10:45 A.M. with Administrator and the Director of Nursing (DON), revealed former Activities Director#60 started in December 2021 and walked off the job in October 2023. The Administrator indicated former Activities Director #60 was aggressive and had emotional outbursts with other staff members prior to leaving. Administrator indicated the Corporate Policy was that when someone quit, they were not to be back in the building. Administrator indicated a friendly reminder was sent to former Activities Director #60 via text message on 03/09/23, after she came to visit residents on a weekend. Administrator displayed his phone to the surveyor, which revealed a text message to former Activities Director #30 stating, I was notified by residents that you were on Sunrise Manor premises visiting and as another reminder, you are not allowed on premises. This is a company policy. Administrator denied having any documented evidence that the Former Activities Director #60 had been verbally or physically abusive to the residents. Review of the personnel file for former Activities Director #60, revealed no disciplinary action against her prior to a 10/26/22 write up for misconduct when she had outbursts and unprofessional behavior during staff meetings. The personnel file revealed a 90-day evaluation dated 02/25/22, which indicated former Activities Director #60 was rated as working well with others, taking pride in her work, seeking improvement, was always concerned with safety and was always polite and willing to help. Review of the Employee Handbook effective 12/01/18, revealed the corporate employee policy page 35 and under a section titled Visitors stated personal visits to residents during working hours are prohibited. If you resign or (are) terminated from Sunrise Nursing Healthcare and wish to return to visit a resident, you may do so only after obtaining permission from the Administrator. Review of the facility's policy titled Visitation revised in September 2022, revealed the facility permitted residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. The Residents are permitted to have visitors of their choosing at the time of their choosing. This deficiency represents non-compliance investigated under Complaint Number OH00141089.

Based on bystander interview, staff interview, review of the facility policy, and medical record review, the facility failed to maintain a safe environment for a resident who had exit seeking behaviors and failed to follow their elopement policy. This affected one (Resident #25) of three residents reviewed for risk of elopement. The facility census was 49. Findings included: Review of Resident #25's medical record revealed an admitted [DATE]. Diagnoses included encephalopathy, chronic ulcer on the outer part of the left foot, difficulty walking, altered mental status, dementia, seizures, diabetes mellitus, schizophrenia, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had moderate cognitive impairment. Resident #25 required extensive one-person assistance for transfers, bed mobility, and toileting. Review of Resident #25's plan of care dated 12/12/22 revealed Resident #25 was at risk for elopement and wandering related to impaired safety awareness, dementia, and impaired cognitive function. The plan of care revealed Resident #25 wandered aimlessly and had exit seeking behaviors. Interventions included to distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Document diversional intervention in the resident's behavior log. Monitor for fatigue or weight loss and to monitor resident for tailgating. Review of the progress note dated 01/01/23 entered by Agency Registered Nurse (RN) #175 revealed Resident #25 was observed walking down the driveway. RN #175 walked back into the facility and notified State tested Nursing Assistant (STNA) #113. RN #175 and STNA #113 went to Resident #25. Resident #25 was with a bystander. Resident #25 was confused and not able to be redirected to the facility by either STNA #113 or the nurse. Resident #25 did not want to return to the facility. EMS had been called. The EMS did not want to transport Resident #25 to the hospital because the resident appeared to have no injuries. The police who were also present revealed the EMS could not take Resident #25 to the hospital unless there was a physician order to send the resident to the hospital. A physician order was received from the physician to transport Resident #25 to the hospital. The Director of Nursing (DON) and Resident #25's son were notified. The nurse was not able to complete an assessment, however no visible injuries were noted. Review of the facility's IDT (Interdisciplinary Team) Post Elopement Investigation Summary, dated 01/01/23, revealed on 01/01/23 at 1:15 P.M., Resident #25 was noted across the street from the facility. The incident report revealed a bystander was holding Resident #25's hand. The bystander had called Emergency Medical Services (EMS). The contributing factors included the resident had made comments to staff about looking for her son and the resident had anxiety related to her son with special needs. The staff reassured the resident her son was ok and at home and not to worry. The new intervention was to hang the son's name and the son's phone number in the resident's room and to prompt her to call her son. Review of Licensed Practical Nurse (LPN) #121's statement written on 01/01/23 revealed just before lunch trays were served, the door #1 alarm sounded (side door). LPN #121 revealed she responded to the alarm and saw Resident #25 walking away from the door. LPN #121 questioned Resident #25 and the resident replied she was looking for her son. LPN #121 led Resident #25 by her hand to STNA #113 and notified her of Resident #25's attempt to open the side door. LPN #121 advised STNA #113 to keep a close eye on Resident #25 so she did not go outside. The witness statement was silent for notification of the Director of Nursing regarding the attempt of the resident to exit the facility. Review of the Emergency Department (ED) discharge note dated 01/01/23 at 3:08 P.M. revealed Resident #25 was found wandering beside a busy road. The ED note revealed Resident #25 had no falls. Resident #25 had a Band-Aid on her forehead which was reported as old. The final impression revealed Resident #25 had severe dementia and was at baseline. Resident #25 had no complaints, and the physical examination revealed no concerns. Interview on 01/10/23 at 11:55 A.M. with STNA #132 confirmed she worked on 01/01/23. STNA #132 confirmed she was aware of Resident #25's elopement from the facility. STNA #132 revealed LPN #121 called out for a head count of all residents. STNA #132 revealed she was not the STNA who went with the nurse to get the resident. STNA #132 revealed she was aware Resident #25 had been antsy all day and staff had redirected Resident #25 most of the day. STNA #132 confirmed the police were present on 01/01/23 and she confirmed the Resident #25 had gone to the hospital. Telephone interview on 01/10/23 at 1:38 P.M. with Agency RN #175 confirmed she was an agency nurse and her first shift and only shift at the facility was on 01/01/23. RN #175 stated she was returning from her lunch break and saw a woman walking down the driveway near the road in front of the facility. RN #175 walked inside the facility and asked the receptionist if the woman was a resident and if she was allowed to be outside. RN #175 stated she hopped back in the car to drive to the resident across the street. RN #175 stated STNA #113 was already with the Resident #25 when she arrived. RN #175 stated Resident #25 was holding onto the man's hand who had stopped to help. RN #175 stated she tried to talk Resident #25 into sitting in her car because it was warm and more comfortable than standing in the cold. Interview on 01/10/23 at 1:45 P.M. with STNA #113 confirmed she worked on 01/01/23 and was assigned to Resident #25's hall. STNA #113 revealed Resident #25 had been crying intermittently and worried about her son. STNA #113 confirmed LPN #121 had alerted her Resident #25 had pushed on the side door which caused the door to alarm. STNA #113 stated she checked on Resident #25 at 1:00 P.M. when she went to her room to collect the resident's lunch tray. STNA #113 stated she collected a couple more lunch trays. STNA #113 stated not more than five minutes RN #175 approached her and asked if Resident #25 who was in the driveway was a resident at the facility and if she should be outside. STNA #113 stated she ran outside across the street to Resident #25. STNA #113 revealed she tried to redirect Resident #25 back to the facility, however Resident #25 refused. STNA #113 confirmed RN #175 drove her car to Resident #25 and encouraged Resident #25 to get into the car, however the resident refused. STNA #113 revealed she remained with Resident #25 until the resident was in the ambulance with the EMS personnel. STNA #113 confirmed Resident #25 was dressed and had shoes on. STNA #113 revealed she had not seen Resident #25 fall and denied seeing the resident lying on the road. Interview on 01/10/23 at 2:27 P.M. with the bystander revealed he was driving down State Route 132 in his tow truck and saw a woman (Resident #25) lying face down in the road. The bystander revealed he pulled his truck over and put on his warning lights. He got out of the truck and the aide with the glasses (STNA #113) was with Resident #25 as he was walking up to the resident. Interview on 01/11/23 at 8:25 A.M. with the Director of Nursing confirmed she was not present on 01/01/23 when Resident #25 eloped from the facility. The DON revealed she had been at the facility earlier prior to the incident and had gone home. The DON revealed the Administrator was also not present at the facility when the elopement had occurred. The DON confirmed both she and the Administrator did come into the facility after becoming aware of the elopement. The DON confirmed she was not notified of the earlier attempt of Resident #25's to exit the facility by the side door. The DON confirmed there was no Charge Nurse notified by the nurse of Resident #25's attempt to leave the facility. The DON confirmed the Elopement policy revealed staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Director of Nursing or Charge Nurse. The DON confirmed had she been notified she would have had the nurse contact the resident's son and put frequent checks in place. Review of the facility policy titled Elopements, dated 12/2007, revealed staff shall promptly report any resident who tries to leave the premises or is suspected of missing to the Director of Nursing or the Charge Nurse. This deficiency represents non-compliance investigated under Complaint Number OH00139090.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to timely discard expired medications. This affected two (#195 and #15) residents with expired medications observed in the medication carts and had the potential to affect all 41 residents residing in the facility who could potentially receive expired stock medications. The census was 41. Findings include: 1. Observation on 06/01/22 at 9:15 A.M. with Licensed Practical Nurse (LPN) #219 revealed the B Side medication room refrigerator contained two open vial of [MEDICATION(S)] testing solution dated upon opening with dates of 03/30/22 and 04/12/22. Interview on 06/01/22 at 9:15 A.M. with LPN #219 confirmed the TB test solution was expired and should have been discarded. 2. Review of the medical record for Resident #40 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the June 2022 monthly physician orders for Resident #40 revealed an order dated 02/08/21 for [MEDICATION(S)] Solution eye drops to left eye two times a day. Observation on 06/01/22 at 9:16 A.M. with LPN #219 revealed the B side medication room contained an unopened bottle of [MEDICATION(S)] eye drops for Resident #40 with a manufacturer's expiration date of 05/23/22. Interview on 06/01/22 at 9:16 A.M. with LPN #219 confirmed the B side medication room contained an unopened bottle of [MEDICATION(S)] eye drops for Resident #40 with a manufacturer's expiration date of 05/23/22. LPN #219 confirmed the medication was expired and should have been discarded. 3. Review of the medical record for Resident #15 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2022 monthly physician orders for Resident #15 revealed an order dated 02/08/21 for [MEDICATION(S)] tablet sublingual as needed for chest pain. Observation on 06/01/22 at 9:29 A.M. of the Primrose Unit medication cart with LPN #219 revealed the cart contained a bottle of [MEDICATION(S)] tablets for Resident #15 with a manufacturer's expiration date of February 2022. Interview on 06/01/22 at 9:29 A.M. with LPN #219 confirmed the Primrose Unit medication contained a bottle of [MEDICATION(S)] tablets for Resident #15 with a manufacturer's expiration date of February 2022. LPN #219 confirmed the [MEDICATION(S)] tablets for Resident #15 were expired and should have been discarded. 4. Observation on 06/02/22 at 7:35 A.M. of the Lilac Unit medication cart with LPN #258 revealed the cart contained a bottle of house stock [MEDICATION(S)] tablets with a manufacturer's expiration date of January 2022 and a bottle of [MEDICATION(S)] tablets with a manufacturer's expiration date of March 2022. Interview on 06/02/22 at 7:35 A.M. with LPN #258 revealed the cart contained a bottle of house stock [MEDICATION(S)] tablets with a manufacturer's expiration date of January 2022 and a bottle of [MEDICATION(S)] tablets with a manufacturer's expiration date of March 2022. Review of the facility policy titled Storage of Medications dated April 2019 revealed discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed.

Based on observations, staff interviews, review of a meal spreadsheet and policy review, the facility failed to provide qualified staff to ensure meals were provided as ordered by the physician. This had the potential to affect all 41 residents residing in the facility. The facility census was 41. Findings include: Review of lunch menu spreadsheet dated 06/01/22 revealed a puree diet was to have a #16 scoop portion of puree bread. There was no diet planned for mechanical soft diets. Observation on 06/01/22 from 11:00 A.M. to 11:15 A.M. , revealed Cook #228 preparing puree foods, and no puree bread was prepared. The 06/01/22 lunch spreadsheet was observed on the counter. Cook #228 did not review the spreadsheet when pureeing the food. Interview on 06/01/22 at 11:15 A.M. Cook #228 stated she did not normally made puree bread and did not know the amount of meat portion or foods to prepared for mechanical soft diets. Cook #228 stated she just received new spreadsheets from the Interim Dietary Manger #275 and had not been trained on the spreadsheets. Cook #228 stated the Interim Dietary Manger #275 visits the facility one time a week to order food and has not seen Registered Dietitian, (RD) #271. Cook #228 states she works five to seven days a week as she is the only cook. Cook #228 stated she did not contact Dietary Manager #275 regarding meal and diet preparation, food substitutions, or portion control because she did not have time. Cook #228 stated she did not have RD #271's contact information. Interview on 06/01/22 at 1:18 P.M. RD #271 revealed she is contracted one day a month and a diet technician visits the facility for clinical duties one time a week. RD #271 verified the Dietary Manager #275 is not employed at the facility full time. RD #271 stated Dietary Manager #275 places food orders and was to provide new spreadsheets last week. RD #271 revealed her monthly audit, completed 05/21/22, recommended the cook to contact the RD before making substitutions, and to follow the spreadsheets for meal preparation. Observation during survey of dates 05/31/22, 06/01/22 and 06/02/22 from 8:00 A.M. through 4:00 P.M. revealed the Dietary Manger #275 and the RD #271 were not in the facility. Interview on 06/02/22 at 9:00 A.M. the Administrator verified the facility has had no full time employed RD and/or full-time certified Dietary Manager since 05/13/22. The Administrator stated current RD #271 is not employed full time and the Interim Dietary Manager #275 is not employed full time at the facility. The Administrator stated the current certified Dietary Manger #275 is at the facility one day a week to place the food order and verified the facility requires full time Dietary Manger. The facility confirmed all 41 residents residing in the facility receive their meals from the kitchen. Review of the policy titled Food and Nutrition Services, dated October 2017, revealed the Dietitian will assess the resident nutritional needs and a diet will be based on this assessment. Each resident will be provided a well-balanced diet that meets the national dietary needs.

Based on observations, staff and resident interviews, review of a spreadsheet and policy review, the facility failed to ensure sufficient and trained dietary staff to meet residents' dietary needs. This had the potential to affect all 41 residents residing in the facility who received meals from the kitchen. The facility census was 41. Findings include: Review of the dietary schedule revealed no dinner cook was scheduled on 05/31/22 and 06/01/22. Interview on 05/31/22 at 4:45 P.M. Housekeeper #231 revealed she was pulled to assist in the kitchen for the meal. Housekeeper #231 stated she had not worked in the kitchen for [AGE] years. Observation on 06/01/22 at 1:30 P.M. revealed the dishwasher washer was not meeting temperature standards and the Administrator instructed Dietary Aide #243 to clean and sanitize the dishes in the three-sink method. Interview on 06/01/22 at 3:30 P.M. with Dietary Aide #243 stated she was not going to clean the dishes by the three-sink method because she did not have enough time. Dietary Aide #243 stated there was no one else in the kitchen. Dietary Aide #243 stated there was no cook scheduled to cook dinner. Dietary Aide #243 verified there were many meals in which the menu was changed due to untrained staff asked to do dietary positions. Dietary Aide #243 verified there had been no Dietary Manager employed for several weeks. Observation on 06/01/22 at 4:30 P.M. revealed a dish rack of pots and pans in the dish machine and lunch plates in a rack on the clean side of the dish machine. Interview on 06/01/22 at 4:31 P.M. Dietary Aide #243 verified she had no time to wash the lunch plates and pans from lunch by the three-sink method and washed the pans and plates through the improper functioning dish machine. Dietary Aide #243 stated there had been no cook in the kitchen preparing dinner. Dietary Aide #243 verified dinner meals were to be delivered starting at 5:00 P.M. Observation at 5:45 P.M. on 06/01/22 revealed five staff in the kitchen plating food for residents. There was no qualified cook preparing or plating the resident meals. On the spread sheet, the meal was written as a chicken wrap, cucumber tomato salad and fruit cup. The observed meal served to the residents was a chicken wrap, cottage cheese, mandarin oranges, cookies, and yogurt. Activity Director #262 was observed to not follow the spreadsheet for portion control. The Administrator prepared puree food without following the spreadsheet for puree foods and did not use the correct scoop sizes per the spreadsheet. There was no Dietary Manager or Registered Dietitian present in the kitchen. Review of meal service times revealed the dinner meal was to begin service at 5:00 P.M. and at 5:15 P.M. for the Primrose unit. Interview on 06/02/22 at 8:30 A.M. with Residents #13 and #3, who resided on Primrose Unit, revealed the dinner meal on 06/01/22 had not been served until after 6:00 P.M. and were hungry. Residents #13 and #3 stated the meals are often late, especially on the weekends. Interview on 06/02/22 at 9:00 A.M. the Administrator verified the spreadsheet was not followed for the dinner meal on 06/01/22. The Administrator stated there was no substitution list completed and the Registered Dietitian was not contacted prior to the meal being planned or served. The Administrator verified the dietary staffing was being supplemented by staff who have not been recently trained. The Administrator verified the diner meal of 06/01/22 was served late. The facility confirmed all 41 residents residing in the facility receive their meals from the kitchen. Review of the policy titled, Prevention Foodborne Illness-Employee Hygiene and Sanitary Practices, dated October 2017, revealed all employees who handle, prepare or serve food will be trained in the practices of safe food handling. All employees will demonstrate knowledge prior to working with food or serving food to residents.

Based on observations, staff interview, review of the dish machine log and policy review the facility failed to label foods, sanitize dishes and store ice machine scoop in a sanitary manner. This had the potential to affect all 41 residents residing in the facility who received food from the kitchen. The facility census was 41. Findings include: Observation on 05/31/22 at 8:45 A.M. revealed in the dry storage room, an undated bag of macaroni. In the refrigerator walk in, macaroni salad and two bags of chopped lettuce were undated. The lettuce appeared to be wet and had a brown colored appearance. In the reach in refrigerator, thawed meat was in an undated box. The ice machine scoop was directly on top of the ice machine, lying on the wet surface. The ice scoop holder was hanging onto the ice machine, attached on one side. The ice scoop had several cracked areas and had brown debris in the cracked areas. Interview on 05/31 at 8:50 A.M., Dietary Aide #202 verified the lettuce needed discarded and the macaroni salad was undated. Dietary Aide #202 verified the ice scoop holder had been broken, could not hold the ice scoop to drain and needed cleaned. Observation on 06/01/22 at 9:20 A.M. revealed the high temperature dish machine wash temperature peaked at 145 degrees Fahrenheit. The dish machine log dated 06/01/22, revealed the dish machine wash temperature was 150 degrees Fahrenheit during breakfast meal dish washing. The dish machine log dated May 2022 revealed the dish machine wash cycle was always above 150 degrees Fahrenheit. The dish machine log revealed the minimum wash temperature should be 150 degrees Fahrenheit. Interview on 06/01/22 at 9:22 A.M., Dietary Aide #202 stated the dish machine wash temperature runs low many days due to resident bathing times and laundry usage. Dietary Aide #202 verified the wash cycle should be 150 degrees Fahrenheit. Dietary Aide #202 stated she has not washed dishes in the three-sink when the wash cycle was below 150 degrees Fahrenheit. Observation on 06/01/22 at 11:15 P.M. revealed the dishwasher wash temperature was 140 to 145 degrees Fahrenheit. Interview on 06/01/22 at 11:20 A.M., the surveyor alerted the Administrator the dish machine wash temperature was 140 to 145 degrees Fahrenheit. Observation on 06/01/22 at 1:30 P.M. revealed the dishwasher was not meeting washing temperature standards and the Administrator instructed Dietary Aide #243 to clean and sanitize the dishes in the three-sink method. Interview on 06/01/22 at 3:30 P.M. with Dietary Aide #243 stated she was not going to clean the dishes by the three-sink method because she did not have enough time. Observation on 06/01/22 at 4:30 P.M. revealed a dish rack of pots and pans in the dish machine and lunch plates in a rack on the clean side of the dish machine. Interview on 06/01/22 at 4:31 P.M. Dietary Aide #243 verified she had no time to wash the lunch plates and pans from lunch by the three-sink method and washed the pans and plates in the improper functioning dish machine. The facility confirmed all 41 residents residing in the facility receive their meals from the kitchen. Review of the policy titled Dishwasher Machine Use, dated March 2010, revealed high temperature dish machine must maintain the wash solution temperature of 150 degrees Fahrenheit. Review of policy titled Sanitation dated October 2008, revealed ice machine storage containers will be clean, and in good repair. Review of policy titled Food Receiving and Storage dated October 2017 revealed, dry foods will be labeled, and foods stored in the refrigerator will be dated and discarded within seven days from preparation date.

Based on record review, observation and staff , the facility failed to provide puree and mechanical soft diets as planned by a Registered Dietitian. This had the potential to affect two (#19 and #245) residents with orders for a puree diet, and six (#8, #10, #24, #41, #44 and #195) residents with orders for a mechanical soft diet. The facility census was 41. Findings include: Review of the spreadsheet for lunch meal of 06/01/22 revealed there was no menu plan for mechanical soft diets. The puree diet was to include a puree bread portion of a number 16 scoop and the meat portion of a number eight scoop. Observation on 06/01/22 from 11:00 A.M. to 11:35 A.M., revealed Cook #228 preparing puree foods, and no puree bread was prepared. The 06/01/22 lunch spreadsheet was present on the counter. Cook #228 did not review the spreadsheet when pureeing the food. Cook #228 had the incorrect food portion number 16 scoop in the puree meat. There was a number eight portion scoop for the mechanical meat. Interview on 06/01/22 at 11:15 A.M. Cook #228 stated she did not normally make puree bread and did not know the amount of meat portion for the mechanical meat or foods to prepare for mechanical soft diet because it was not on the spreadsheet. Cook #228 stated she received new spreadsheets from the Interim Dietary Manger #275 and had not been trained on the spreadsheets. Cook #228 stated she had no reference sheet available to convert measurements and weights of food into scoop portion sizes. Cook #228 confirmed there are currently two (#19 and #245) residents with orders for a puree diet, and six (#8, #10, #24, #41, #44 and #195) residents with orders for a mechanical soft diet. Review of policy titled Kitchen Weights and Measures dated April 2007, revealed the staff will be trained in weights and measures, utensil use and size conversions of weight measures. Signs and posters explaining utensil measurement will be displayed for reference.

Based on record review, observation, staff interview, and review of manufacturers guidelines, the facility failed to properly clean and sanitize blood glucose meters after use. This affected four (#22, #19, #7, and #14) of four residents observed for blood glucose monitoring. The census was 41. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #196 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #7 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #14 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 06/01/22 at 11:44 A.M. revealed Licensed Practical Nurse (LPN) #258 checked Resident #22's blood sugar with a glucose meter. After the procedure, LPN #258 wiped the meter with an alcohol pad. Continued observation at 11:49 A.M. revealed LPN #258 proceeded to check Resident #196's blood sugar with the same portable glucose meter used for Resident #22. After the procedure, LPN #258 wiped the meter with an alcohol pad. Interview on 06/01/22 at 11:52 A.M. LPN #258 confirmed she cleansed the glucose meter with an alcohol pad after use for Resident #22 and #196. LPN #258 further confirmed if she did not have bleach wipes available, she used alcohol pads instead. Observation on 06/01/22 at 12:01 P.M. revealed Registered Nurse (RN) #223 checked Resident #7's blood sugar with a portable glucose meter. After the procedure, RN #223 wiped the meter with an alcohol pad. Continued observation at 12:10 P.M. revealed RN #223 checked Resident #14's blood sugar with the same portable glucose meter used for Resident #7. After the procedure, RN #223 wiped the meter with an alcohol pad. Interview on 06/01/22 at 12:10 P.M. RN #223 confirmed she cleansed the glucose meter with an alcohol pad after use for Resident #7 and #14. RN #223 confirmed she usually used alcohol pads to clean the glucose meter. Review of manufacturer's guidelines for the glucose meter, undated, revealed the meter should be cleaned and disinfected with a commercially available Environmental Protection Agency (EPA)-approved disinfectant detergent or germicidal wipe.

Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were dressed in a dignified manner. This affected one (Resident #195) of 12 residents reviewed for dignity. The census was 41. Findings include: Review of the medical record for Resident #195 an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of admission nursing note dated 05/26/22 revealed Resident #195 was admitted to the facility for a five-day respite stay. Review of the admission nursing assessment dated [DATE] revealed Resident #195 was alert and oriented to person but was not checked as oriented to place, time, or situation. The resident was able to express herself verbally in an appropriate manner. Review of baseline care plan dated 05/26/22 revealed Resident #195 preferred to choose which clothes she would wear for the day. Review of nursing note dated 05/30/22 revealed Resident #195's daughter reported the clothes brought into the facility on the day of admission were missing. Observation on 05/31/22 at 10:40 A.M. revealed Resident #195 was sitting in her wheelchair, with her door open. Resident #195 could be seen from the hallway and was wearing a short nightshirt, which barely covered her peri area. Resident #195 was tugging at the bottom of the nightshirt trying to cover herself. Interview on 05/31/22 at 10:40 A.M. with Resident #195 confirmed she didn't have any pants and she was embarrassed because the nightshirt did not cover her upper thighs. Resident #195 further confirmed she was new to the facility, and thought her family had brought in some clothes for her to wear but they hadn't been provided to her yet. Interview on 05/31/22 at 12:18 P.M. with State tested Nursing Assistant (STNA) #261 confirmed she assisted Resident #195 with getting dressed that morning but the only clothing available was nightshirts. STNA #261 further confirmed Resident #195 was wearing a nightshirt which barely covered her peri area. Interview on 05/31/22 at 12:19 P.M. with Licensed Practical Nurse (LPN) #245 confirmed Resident #195 was wearing a nightshirt which did not appropriately cover her. LPN #245 further confirmed he heard the resident's clothes were missing and he thought management was conducting a search for them. Interview on 06/01/22 at 3:58 P.M. with the Director of Nursing (DON) confirmed Resident #195 was initially admitted for a respite stay but the resident and her family decided she would stay at the facility long-term. The DON further confirmed the facility had a supply of clothing available in the lost and found which could have been used for Resident #195 so she could have had appropriate clothing to wear. The DON further confirmed it was not appropriate for the resident to be uncovered and exposed when her preference was to wear clothing. Review of the facility policy titled, Quality of Life - Dignity, dated August 2009, revealed residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns.

Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were bathed according to their preference. This affected one resident (#7) of 12 residents reviewed for bathing preferences. The census was 41. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of the Minimum Data Set (MDS) for Resident #7 dated 05/16/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs). Review of MDS for Resident #7 dated 09/02/21 revealed resident was coded as very important for the question in section F of the MDS: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Review of the care plan for Resident #7 dated 04/19/21 revealed the resident had an ADL self-care performance deficit related to tibial plateau fracture, fibula fracture, diabetes, weakness, and non-weight bearing status. The resident required staff assistance to complete ADL tasks daily. Fluctuations were expected related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the resident should be bathed/showered two times per week, staff should avoid scrubbing and should pat dry sensitive skin, and provide a bed bath when a shower cannot be tolerated. Review of bathing records for Resident #7 for May 2022 revealed resident was out of the facility on 05/06/22 through 05/09/22. Further review of records revealed the resident received a bed bath on 05/02/22, 05/11/22/, 05/19/22, and 05/31/22. Observation on 05/31/22 at 9:35 A.M. revealed Resident #7 had a functioning shower in his room. Interview on 05/31/22 at 9:35 A.M. Resident #7 confirmed he preferred to take a shower, but the aides told him he wasn't allowed to take a shower and they gave him regular bed baths instead. Interview on 05/31/22 at 9:45 A.M. with State tested Nursing Assistant (STNA) #253 confirmed Resident #7 had a functioning shower in his room but the facility used the central shower room for residents who got showers. STNA #253 confirmed Resident #7 was not permitted to take showers and the nightshift aides gave him bed baths. Interview on 06/01/22 at 12:00 P.M. with Registered Nurse (RN) #223 confirmed there was no clinical contraindication to Resident #7 receiving showers as opposed to bed baths. Review of the facility policy titled, Shower-Tub Bath, dated October 2010, revealed the facility would provide showers or tub baths to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on record review, observations and staff interview, the facility failed to implement a physician ordered intervention for a speciality cushion to a residents wheelchair to promote healing of a pressure ulcer. This affected one (#44) of three residents reviewed for pressure ulcers. The facility census was 41. Findings include: Medical record review for Resident #44 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 received hospice services. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively impaired and required extensive assistance of two staff for transfers and bed mobility. Review of nurse note date 05/22/22 at 1:15 P.M. revealed Resident #44 was noted to have a open area/pressure ulcer to right inner coccyx measuring 1.0 centimeter by 0.5 centimeter. New orders included [MEDICATION(S)] dressing for three days and monitoring of wound on weekly wound rounds. Review of nurse's notes dated 05/26/22 at 6:06 P.M. revealed the physician ordered a specialty wheelchair cushion. Review of nurse's notes dated 06/01/22 at 12:35 P.M. revealed the family representative was notified of the specialty wheelchair cushion to assist with skin healing. The family representative was in agreement to implement the specialty wheelchair cushion. Observation on 05/31/22 from 12:22 P.M. through 4:30 P.M., Resident #44 was observed sitting in a wheelchair in the hallway near the unit nurse station. The wheelchair did not have the specialty wheelchair cushion in place. Observation on 06/01/22 at 8:55 A.M. revealed the resident in the wheelchair in her room with no specialty wheelchair cushion in place. Interview on 06/01/22 at 9:00 A.M., State tested Nurse Aide, (STNA) #217 verified Resident #44 did not have the specialty wheelchair cushion in the wheelchair. STNA #217 stated the specialty wheelchair cushion was delivered earlier in the week. STNA #217 stated the cushion was too thick and would not fit in the resident's wheelchair. STNA #217 did not report the concern to the nurse managers. STNA #217 went to the resident's closet and showed the surveyor the specialty cushion. STNA #217 returned the specialty cushion to the resident's closet. Interview on 06/01 at 2:20 P.M., Licensed Practical Nurse (LPN) #219 verified Resident #44 should have had the specialty wheelchair cushion to prevent further skin breakdown. Observation on 06/02/22 at 8:00 A.M. revealed Resident #44 was in bed. The wheelchair was at bedside with no specialty wheelchair cushion in the wheelchair. Interview on 06/02/22 at 8:05 A.M. with STNA #217 verified the specialty wheelchair cushion was not in the wheelchair.

Based on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to ensure residents oxygen tubing was dated when changed. Additionally, the facility failed to ensure a resident had physician's orders for oxygen administration. This affected two (#7 and #44) of three residents reviewed for oxygen administration. The census was 41. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #7 revealed resident was cognitively impaired and required extensive assistance of two staff with activities of daily living. Review of the May 2022 monthly physician orders for Resident #7 revealed there were no orders for oxygen administration. Review of the care plan for Resident #7 initiated 08/26/21 revealed it contained no documentation regarding the use of oxygen. Review of the May 2022 Treatment Administration Record (TAR) and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/31/22 at 10:04 A.M. revealed Resident #7 had an oxygen concentrator in his room with oxygen tubing with a nasal cannula which was not dated. Resident #7 was not receiving oxygen. Interview on 05/31/22 at 10:04 A.M. with Resident #7 confirmed he occasionally used oxygen when he felt short of breath. Resident #7 confirmed he was unsure how often the tubing was changed or how much oxygen he was supposed to receive. Interview on 05/31/22 at 10:06 A.M. with State tested Nursing Assistant (STNA) #253 confirmed Resident #7's oxygen tubing was undated and tubing was supposed to be changed every Friday. Observation on 06/01/22 at 12:01 P.M. revealed Resident #7 was receiving oxygen per nasal cannula with the oxygen concentrator set at three liters. The oxygen tubing was not dated. Interview on 06/01/22 at 12:01 P.M. with Registered Nurse (RN) #223 confirmed Resident #7's oxygen tubing was not dated. RN #223 further confirmed Resident #7 did not have a physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Oxygen Administration dated October 2010 revealed prior to oxygen administration the nurse should verify that there is a physician's order for the procedure. The facility would ensure oxygen was administered in accordance with professional standards of practice. 2. Record review revealed Resident #44 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 received hospice services. Review of the Significant Change Minimum Data Set, (MDS), dated [DATE] revealed Resident #44 was cognitively impaired and required extensive assistance of two staff for care. Review of current physician orders revealed continuous oxygen at 3.5 milliliters via nasal cannula and change oxygen tubing every week on Sunday night shift and as needed. Observation on 05/31 22 at 12:24 P.M. and on 06/01/22 at 2:49 P.M. revealed Resident #44 was receiving oxygen via nasal cannula and the oxygen tubing was not dated. Interview on 06/01/22 at 2:50 P.M. with Licensed Practical Nurse (LPN) #219 verified Resident #44 oxygen tubing was not dated and was unable to determine when the oxygen tubing was last changed. LPN #219 stated the oxygen should have been changed and dated on Sunday, 05/29/22.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure proper documentation of administration of controlled substances and accounting for controlled substance medications. This affected two (#15 and #20) of nine facility-identified residents with controlled substances stored on the Primrose Unit medication cart. The facility also failed to administer a residents medications ([MEDICATION(S)] and [MEDICATION(S)]) as ordered. This affected one (#195) out of three residents reviewed for medication administration. The census was 41. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with a diagnoses of generalized anxiety disorder and chronic pain syndrome. Review of the June 2022 monthly physician orders for Resident #15 revealed an order dated 01/19/22 for [MEDICATION(S)] twice daily at 9:00 A.M. and 9:00 P.M. Resident #15 also had an order dated 05/03/21 for [MEDICATION(S)] twice daily at 9:00 A.M. for pain. Review of the controlled substance sheets for Resident #15's [MEDICATION(S)] and [MEDICATION(S)] revealed the 9:00 A.M. doses of the medications for 06/01/22 had not been signed out by the nurse. Observation on 06/01/22 at 9:40 A.M. with Licensed Practical Nurse (LPN) #219 of the Primrose Unit medication cart controlled substance medication drawer revealed there were five [MEDICATION(S)] tablets in the cart for Resident #15 but the controlled substance sheet for Resident #15's [MEDICATION(S)] indicated there should be six [MEDICATION(S)] tablets remaining. Interview on 06/01/22 at 9:40 A.M. with LPN #219 confirmed she had administered tablet #6 to Resident #15 on 06/01/22 at approximately 9:00 A.M. but had not signed when she pulled the medication for administration. Observation on 06/01/22 at 9:41 A.M. with LPN #219 of the Primrose Unit medication cart controlled substance medication drawer revealed there was an empty card of [MEDICATION(S)] tablets for Resident #15 with no tablets remaining. The controlled substance sheet for Resident #15's [MEDICATION(S)] indicated there should be one [MEDICATION(S)] tablets remaining. Interview on 06/01/22 at 9:41 A.M. with LPN #219 confirmed she had administered tablet #1 to Resident #15 on 06/01/22 at approximately 9:00 A.M. but had not signed when she pulled the medication for administration. 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with a diagnosis of panic disorder. Review of the June 2022 monthly physician orders for Resident #20 revealed an order dated 12/08/21 for [MEDICATION(S)] twice daily at 9:00 A.M. and 9:00 P.M. Review of the controlled substance sheets for Resident #20's [MEDICATION(S)] revealed the 9:00 A.M. doses of the medication for 06/01/22 had not been signed out by the nurse. Observation on 06/01/22 at 9:42 A.M. with LPN #219 of the Primrose Unit medication cart controlled substance medication drawer revealed there were 20 [MEDICATION(S)] tablets remaining for Resident #20 with no tablets remaining. The controlled substance sheet for Resident #20's [MEDICATION(S)] indicated there should be 21 [MEDICATION(S)] tablets remaining. Interview on 06/01/22 at 9:42 A.M. with LPN #219 confirmed she had administered tablet #21 to Resident #20 on 06/01/22 at approximately 9:00 A.M. but had not signed when she pulled the medication for administration. Review of the facility policy titled Controlled Substance undated revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Review of the facility policy titled Administering Medications dated April 2019 revealed the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate spot after giving each medication and before administering the next one. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered, the dosage, the route of administration, the signature and title of the person administering the drug. 3. Review of the medical record for Resident #195 revealed an admitted [DATE] with diagnoses including heart failure and anxiety disorder. Review of the admitting physician orders for Resident #195 dated 05/26/22 revealed orders for resident to receive a routine dose of [MEDICATION(S)] at 9:00 P.M. and a routine dose of [MEDICATION(S)] at 9:00 P.M. Review of the May 2022 MAR for Resident #195 revealed resident's [MEDICATION(S)] and [MEDICATION(S)] were not documented as administered or refused on 05/28/22 at 9:00 P.M. Review of the controlled substance sheets for Resident #195 for [MEDICATION(S)] and [MEDICATION(S)] revealed medications were not signed out for 05/28/22 at 9:00 P.M. Review of nurse progress notes for Resident #195 dated 05/28/22 revealed the notes were silent regarding rationale for [MEDICATION(S)] and [MEDICATION(S)] not being administered as ordered. Interview on 06/01/22 at 5:00 P.M. with Regional Nurse (RN) #268 confirmed Resident #195's MAR, controlled substance sheets and nurse progress note dated 05/28/22 showed resident was not administered her 9:00 P.M. doses of [MEDICATION(S)] and [MEDICATION(S)] on 05/28/22. Review of the facility policy titled Administering Medications dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed.

Based on medical record review, staff interview, and review of facility policy, the facility failed to timely report allegations of sexual abuse for two Residents (#52 and #55). This had the potential to affect seven residents residing on the memory care unit. The facility census was 54. Findings Include: Medical record review for the Resident #52 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53 resided on the memory care unit and was assessed to be severely cognitively impaired. Resident #53 received hospice services and had no history of sexual offenses. Medical record review for Resident #55 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 resided on the memory care unit and was assessed to be severely cognitively impaired. Resident #55 had no history of sexual offenses. Review of facility investigation dated 02/25/22 and timed 7:00P.M., revealed on 02/25/22 at 6:45 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) entered Resident #52's room and found Resident #52 kneeling at bedside, undressed below the waist with Resident #55 lying in bed, undressed below the waistline. Resident #52's hand touched Resident #55's vaginal area. The residents were separated, assessed, and a thorough investigation was completed. Review of State Agency Hearing Officer document dated 03/22/22, Facility Representative #100 verified, at Resident #52's discharge hearing on 03/16/22, the facility had not filed a Self Reporting Incident (SRI), regarding the allegation of sexual abuse on 02/25/22. Facility Representative #100 stated it was an oversight. Interview on 03/21/22 at 11:30 A.M. with the Administrator and Regional Clinical Nurse #56 revealed on 02/25/22 at 6:45 P.M. the DON #18 and ADON#19 discovered a sexual abuse incident between memory care Residents #52 and #55. The facility immediately assessed the residents and investigated the incident. Clinical Regional Nurse #56 stated the facility did not report the incident until 03/16/22 due to an oversight. The Administrator verified the (SRI) was submitted on 03/16/22 and completed on 03/17/22. The Administrator verified the discharge hearing officer had discovered the SRI had not been filed during the hearing. The Administrator verified the SRI should have been filed timely per facility policy. Review of facility policies titled, Abuse and Neglect Protocol, dated 06/13/21 and, Abuse Investigation and Reporting, dated July 2017, revealed the facility failed to implement the policy in regard to timely reporting of a self-reported incident. The facility policy stated an alleged violation of abuse, neglect, exploitation or mistreatment would be reported immediately but no later than two hours if the alleged violation involved abuse or resulted in serious bodily injury, or 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. This deficiency substantiates Complaint Number OH 104.

Based on closed medical record review, physician and staff interviews, review of radiology report and review of hospital records, the facility failed to provide timely care for a resident who had a change in condition after the resident was found on the floor. This resulted in actual harm when the resident sustained [REDACTED]. This affected one (Resident #47) of three residents reviewed for falls. The facility census was 45. Findings include: Review of Resident #47's closed medical record revealed the resident was originally admitted to the facility on [DATE]. She was discharged to the behavioral health unit of a hospital on [DATE] and was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was discharged from the facility to the emergency department of a local hospital for evaluation on 04/29/20. Review of a quarterly minimum data set ((MDS) dated [DATE] identified the resident as having severe cognitive deficits. She required physical assistance of two staff persons for bed mobility and transfers, was able to walk in her room and in the corridor with supervision, was unsteady but able to stabilize herself without staff assistance. The resident was assessed as having physical behavioral symptoms, verbal behavioral symptoms, and wandering. The resident had no falls. She received routine anti-psychotic, anti-anxiety, and anti-depressant medications. Review of the comprehensive plan of care identified the resident as having a behavior problem of sitting on the floor related to major neurocognitive disorder. This behavior placed the resident at increased risk for falls and or injury. The resident could be verbally aggressive towards others, and destructive to facility property. The behavior plan of care for the resident was initiated on 03/31/20 and revised on 04/10/20. Review of Resident #47's April 2020 physician's orders [REDACTED]. Review of Resident #47's April 2020 Medication Administration Record [REDACTED]. Review of Resident #47's nursing progress notes for 04/25/20 through 04/29/20 failed to reveal any documentation of the resident having any incidents, falls, altercations with other residents, or any assessment of any bruising or other injuries to her skin. There was no assessment including location and description of any bruising or other injuries, or a nursing assessment including an assessment of the resident's range of motion or vital signs at the time the bruising/injuries were first observed. Review of Speech Language Pathologist (SLP) #101's treatment notes dated 04/27/20 revealed Resident #47 was seen in her room for morning dysphagia therapy. The SLP note included the following observations; Postural adjustment required in bed secondary to the resident's complaints of pain when attempting to sit. Significant forehead and right shoulder bruising and the resident complained of tailbone pain. Per nursing, the resident had an unreported fall over the weekend resulting in tailbone bruising which was impacting her sitting tolerance. Review of a weekly skin assessment dated [DATE] at 6:04 P.M., Licensed Practical Nurse (LPN) #74 documented Resident #47 had no new skin abnormalities, and no bruising was documented on the skin assessment. Review of SLP #101 treatment notes dated 04/28/20 revealed the resident had removed her clothing and brief. Further bruising assessed with [REDACTED]. The nurse aide assisted the SLP in dressing the resident. Nursing and former Director of Nursing (DON) #93 were notified of the resident's condition. Review of Resident #47's radiology report dated 04/29/20 at 10:11 A.M., revealed the resident had a compression fracture at T12 with 75 percent (%) stature loss. Review of nursing progress notes dated 04/29/20 at 5:19 P.M., LPN #61 documented the resident had multi bruising in different areas. The LPN noted she was concerned about the resident's tailbone area per other nurse's report and LPN #61 contacted the resident's physician with her assessment. New orders were received for x-rays. The x-ray findings came back and the physician was notified. A new order was received to transfer the resident for further testing. Review of Resident #47's Emergency Department (ED) history and physical dated 04/29/20 revealed the resident was diagnosed with [REDACTED]. The hospital physician noted multiple bruises to the resident's head and hands. The resident had a recent fall, but the exact time of the fall was uncertain to the physician. The residents blood pressure was 181/71 while in the ED. Review of Resident #47's nursing progress note dated 04/30/20 at 4:19 P.M. revealed LPN #61 documented a late entry for 04/29/20 at 10:00 A.M. LPN #61 noted a physician order [REDACTED]. Further review revealed emergency medical technicians transferred the resident to a local hospital. The resident was transferred to the family's preferred hospital. During an interview with LPN #61 on 05/12/20 at 3:09 P.M. she reported when she arrived for the day shift of duty (7:00 A.M. through 7:00 P.M.) on 04/28/20, she received report from night shift LPN #59 who reported to her the resident had bruising everywhere, that it looked like the resident had been beaten up, and what looked like finger prints on the back of her shoulder. LPN #61 shared that LPN #59 communicated to her that there was no documentation regarding the bruising from the day shift nurse (LPN #74) on 04/27/20. LPN #61 reported that LPN #59 wanted to know what LPN #61 thought about the bruising so LPN #61 assessed the resident, and found the resident had multiple areas of what appeared to be fresh bruising. LPN #61 described the resident's bruising/injuries as follows: bad bruising on the left breast which went down the left side of the sternum; severe bruising on the right shoulder; a large bump on the left back side of the head; and an older bump on the head which was healing. LPN #61 shared that SLP #101 had also came to her the morning of 04/28/20 wanting to know what had happened to Resident #47 as she had also observed the resident's bruising. LPN #61 revealed on 04/28/20 she reported the issues with Resident #47 to former DON #93, and to Assistant Director of Nursing (ADON) #1 who was now the current DON. LPN #61 revealed she told both DON #93 and ADON #1 that the resident had fresh bruises everywhere, the resident was not acting herself, there was no documentation regarding the bruising or any type of incident, and that the resident might need x-rays. LPN #61 stated that ADON #1 told her that she and DON #93 were taking care of the situation and she did not need to fill out, or document, anything. LPN #61 verified she did not make any nursing entries regarding the resident's bruising/injuries until 04/29/20. LPN #61 explained that on 04/29/20 she returned to work the day shift of duty, and the resident was in her bed staring up to the ceiling, looked like she had no life left to her and the resident would not answer her. LPN #61 stated she rolled the resident over to check her and found bruising to the tailbone area. LPN #61 stated at that time she contacted the resident's physician and received new orders for x-rays. LPN #61 stated she told the x-ray technician that she thought the resident had fallen but was not certain. She communicated soon after the x-rays were taken, the radiologist office called and reported the resident had a T12 compression fracture. LPN #61 notified the resident's physician and the family, and the resident was sent out to the hospital for evaluation on 04/29/20. LPN #61 stated she held the resident's [MEDICATION NAME] and aspirin the morning of 04/29/20, however the medications were signed off as being given, and there were no notations on the MAR indicated [REDACTED]. During an interview with LPN #74 on 05/12/20 at 4:48 P.M., LPN #74 stated when she reported to work for the day shift of duty on 04/27/20 the resident was resting in bed with no concerns noted at that time. She indicated she was told the resident had been up during the night. LPN #74 communicated the night nurse, agency LPN #82, did not report the resident as having any incidents or problems during the night shift (7:00 P.M. - 7:00 A.M.) on 04/26/20 into the morning of 04/27/20. LPN #74 stated on 04/27/20 around 9:00 A.M., she was made aware by a nurse aide that the resident had bruising, and she assessed the resident. She stated the resident had what appeared to be new bruising which covered most of her left breast and left shoulder and she had an area on her right buttock. LPN #74 communicated she went to former DON #93 on 04/27/20 and reported the bruising she saw on Resident #47 and asked what was going to be done as there was no documentation regarding any incidents or injuries. She stated former DON #93 told her to do an incident report regarding the fresh bruising. LPN #74 stated she told former DON #93 that she was not going to do the incident report, and she was not going to document the bruising as something that had happened on her shift. She stated former DON #93 told her she would investigate what happened and get the documentation completed. LPN #74 affirmed she did not document the extensive bruising that was on Resident #47 nor did she initiate any neurological checks related to a potential fall, as she was told by former DON #93 that she would take care of it. LPN #74 communicated that Resident #47's routine was somewhat normal during the day shift of duty on 04/27/20 as the resident was up and walking, and then would get back in bed, and was back up for the evening meal that day. LPN #74 denied any knowledge of the resident having fallen but did document an incident on 04/21/20 in which the resident flipped over her bedside table and sustained a skin tear. During an interview with Temporary Nurse Aide (TNA) #77 on 05/12/20 at 5:42 P.M., TNA #77 reported on 04/23/20 the resident was sitting on the floor in the common area of the unit, which was normal for her, folding laundry and putting it in her basket. TNA #77 stated she went into another room on the unit and heard something loud. TNA #77 stated when she came out of the other resident's room, she observed Resident #47 laying on the floor on her back, and her laundry basket was flipped on the side. She stated she alerted LPN #74 and the other nurse aide, that the resident was lying on the floor, and she did not feel comfortable picking her up. TNA #77 stated LPN #74 and the other nurse aide verbalized that being on the floor was part of the resident's behavior, that the resident would sit on the floor and lay herself back. TNA #77 stated they assisted the resident to stand and walk, and when the resident got halfway down the hall her knees appeared to give out and she went to her knees. TNA #77 was asked to get a walker with a seat, then herself and the other nurse aide put the resident to bed. TNA #77 shared during the night shift of duty Saturday 04/25/20 into Sunday morning 04/26/20 she did a quick walk through on the unit to inform the residents she was their aide for the night. She stated when she got to Resident #47's room the resident was sitting on the floor in the middle of the room, she was not doing anything just putting her fingers on the floor. TNA #77 stated she tried to get the resident up with verbal cueing and the resident pushed her away. She stated she encouraged the resident to get up off the floor, but the resident pushed her away again and using expletive words told the aide to leave her alone as she (TNA #77) had broken the residents back. She reported the resident was bleeding from her elbow and had bruises all over, from her mid forearm to her mid right upper arm, had a bruise on her forehead which was purplish red, and a knot on the back on her head that she thought was from a previous incident. TNA #77 stated she informed the night shift nurse for the unit, agency LPN #82, who stated the resident was having a behavior, that this was normal for the resident and that the resident was fine. The nurse assisted TNA #77 with getting the resident to bed. During the night, the resident did not get out of bed but flipped herself in bed with her head towards the foot board and was hitting her head on the foot board and hitting her elbows on the wall. TNA #77 shared she reported the resident's behaviors to LPN #82 again, at which time the nurse told her that it was part of the resident's behaviors. TNA #77 stated she told the oncoming day shift nurse aide that the resident had been in bed all night, that the resident was in a lot of pain and every time TNA #77 checked on the resident she would try to hit the aide. TNA #77 denied witnessing the resident falling, and stated she only found the resident sitting on the floor. During an interview with the current DON (formerly the ADON) on 05/13/20 at 1:12 P.M., she stated on 04/27/20 around 9:00 A.M. to 10:00 A.M., LPN #74 notified her Resident #47 was bruised, and she went to observe the resident. The DON stated the resident had a hematoma to her forehead, she believed it was on the right side, a circular bruise to the right shoulder which encompassed the entire shoulder, and one of her breasts was covered in bruising. She reported she did not examine the resident's tailbone, and she did not do a full body assessment of the resident at that time. The current DON stated she went directly to former DON #93 and was under the impression that former DON #93 was completing an investigation into the situation. The current DON affirmed she was aware, after the fact, that LPN #74 did not document the resident's bruising, and affirmed the physician was not notified of the residents bruising on 04/27/20 but should have been notified. An interview was conducted with the Administrator and Corporate DON #99 on 05/13/20 at 1:38 P.M. regarding Resident #47's bruising/injuries and if there was any documentation to support the facility had thoroughly documented and assessed the resident's bruising and injuries when first discovered on 04/27/20, had notified the resident's physician when first discovered, had notified the Ohio Department of Health regarding the resident's injuries of unknown origin, or communicated with the resident's physician regarding the continued use of the anti-platelet medication in light of the resident's areas of significant bruising. The Administrator communicated she was not made aware of the extent of the resident's injuries until 05/06/20, and that was when she started her own investigation and the injuries were believed to have occurred related to an unreported fall. Corporate DON #99 stated the facility did not have any documentation regarding assessment of the resident, or notification of the resident's physician, until the day she was sent out to the hospital. Corporate DON #99 also affirmed that no facility Self-Reported Incident (SRI) was submitted, and in hindsight an SRI should have been completed due to the nature of the resident's bruising and injuries. During an interview with agency LPN #82 on 05/13/20 at 3:38 P.M., LPN #82 affirmed she worked at the facility often, typically worked the night shift of duty, and was familiar with Resident #47. She reported she believed she did work the weekend of 04/25/20 and 04/26/20 during the night shift of duty, and was assigned to the secured unit, where Resident #47 resided. LPN #82 shared the resident walked on her own, that she had never seen her fall, but had observed her get down on the floor on her own. She denied that she had been made aware of the resident having any falls or injuries, or complaints of pain during the night shift of duty on 04/25/20 or 04/26/20. LPN #82 did share there was one time, could not recall the date, the resident was sitting on the floor in her room and she helped TNA #77 get her into bed. She explained the resident did have a bruise on her forehead, that she had gotten beforehand from a fall a few weeks before. LPN #82 stated she had charted on the bruising to the resident's head prior and documented that the bruising continued. She stated she did not notice any bruising to the resident other than the bruise to her forehead on 04/25/20 or 04/26/20 but admitted she did not observe the resident undressed. During an interview with contracted SLP #101 on 05/13/20 at 5:13 P.M., SLP #101 reported she had worked at the facility a limited amount of time on contract and had been working with Resident #47 for several weeks to advance her diet. She reported on 04/27/20 she provided treatment to the resident about 11:45 A.M. to 12:00 P.M. The resident was in bed with her door closed, and she tried to have the resident sit up. The resident kept trying to lay down and would slouch to one side and she complained of pain. SLP #101 communicated she got the resident repositioned so she could sit up and eat. The nurse aide working the unit that day (could not recall her name) told SLP #101 that when she dressed the resident she complained of pain. The nurse aide also reported bruising to the resident's tailbone. The nurse aide also told her that LPN #74 had assisted her with dressing the resident and was aware of the tail bone bruising. SLP #101 stated she talked to LPN #74 who voiced she (LPN #74) had looked at the resident's skin and tailbone and affirmed there was bruising present, and that there was nothing in the resident's medical record about it. SLP #101 described bruising to the right side of the resident's forehead that looked established, not developing, but SLP #101 denied the bruising was there on Friday, 04/24/20, when she treated her. SLP #101 reported on 04/28/20 the residents door was closed and as she entered the room the resident had stripped naked and SLP #101 observed the resident with bruising on her right shoulder to bicep half way down her shoulder blade, her left breast was entirely bruised, and she had bruising on her lower spine. SLP #101 stated she assisted the nurse aide with dressing the resident and the resident was very stiff and seemed uncomfortable. She stated the resident did not want to walk. She reported the resident was not talking to her as normal, and SLP #101 went to speak to the nurse, LPN #61, on duty about the resident's condition. SLP #101 stated LPN #61 shared that SLP #101 was the first person to say anything about the resident's bruising, and that there was no documentation in the resident's medical record. LPN #61 told her she was not given anything in report regarding the resident's bruising/injuries. SLP #101 communicated that both herself and LPN #61 went to talk with former DON #93. SLP #101 stated when she told former DON #93 how she found the resident on 04/27/20 and on 04/28/20, that former DON #93 stated x-rays were going to be ordered. She stated she checked at the end of the day, at approximately 4:00 P.M., and there was no evidence of x-rays being done. SLP #101 shared she was made aware that Resident #47 had a fracture of her T12 vertebra the morning of 04/29/20 when she returned to the facility for work. An interview was conducted with Resident #47's attending physician, Physician #200, on 05/14/20 at 4:52 P.M. regarding the resident and her discharge from the facility to the hospital. Physician #200 reported he did not recall being notified of the resident having extensive bruising to her shoulder, breast, and tailbone prior to the day she was sent out to the hospital. He stated the on-call physician might have been notified. He also indicated if the bruising was as extensive as described he would have evaluated the use of the anti-platelet medication and probably would have stopped the [MEDICATION NAME]. Physician #200 stated he would have also sent the resident to the hospital for an evaluation and blood work. Physician #200 reported when he was made aware of the resident's back pain on 04/29/20, x-rays were ordered, and the resident was sent out to the hospital the same day for further evaluation. This is an incidental deficiency found during investigation of Master Complaint Numbers OH 506 and OH 417.

Based on medical record review, review of a fall investigation, observations and resident and staff interview, the facility failed to ensure Resident #5 was provided with adequate supervision resulting in an avoidable fall. This resulted in actual harm when Resident #5 experienced an avoidable fall and suffered a nasal fracture. This affected one (#5) out of four residents reviewed for falls. The facility identified 14 residents with falls from June 2017 to present. The facility census was 45. Findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. cardiac arrhythmia, atherosclerosis, [DIAGNOSES REDACTED], general anxiety disorder, major depressive disorder, age-related osteoporosis, osteoarthritis and muscle weakness. Review of Resident #5's physician orders [REDACTED]. Review of Resident #5's annual comprehensive minimum data set ((MDS) dated [DATE] revealed the resident scored a four out of 15 on the brief interview for mental status (BIMS) indicating the resident was severely cognitively impaired. The resident had no falls since the last assessment dated [DATE]. The resident is an extensive assistance of one staff for transfers, bed mobility, walking in the room. locomotion on/off the unit, dressing, toilet use and personal hygiene. According to the MDS, the resident is not steady, only able to stabilize self with human assistance with balance during transition and walking, the resident uses a wheelchair and is at high risk for falling. Resident #5's fall risk care plan with a recent revision date of 02/16/17 was reviewed. According to the care plan Resident #5 has a personal history of falls and is high risk for future falls related to activity intolerance, impaired respiratory/cardiac status, use of high risk medications, dementia and occasional incontinence as evidence by results of fall risk assessment. The fall risk care plan identified interventions which included: staff to anticipate and meet the residents needs as possible; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: exercise group, ball games, restorative programs as ordered; ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; follow facility fall protocol if one should occur; physical therapy evaluation and treat if ordered and as needed; the resident needs a safe environment with: even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in lowest position for the resident, handrails on walls in corridor, personal items within reach as possible; the resident uses electronic alarm and ensure the device is in place and functioning as ordered per facility policy and procedure. Further review of Resident #5's activities of daily living (ADL) care plan with a revised date of 02/16/17 revealed the resident requires supervision, encouragement, and physical assistance for balance with transferring and the resident utilizes a walker to transfer. Review of an acute care plan dated 08/08/17 revealed Resident #5 had a nasal fracture. No other specific details were available and/or located during the chart review specifically related to Resident #5's fall on 08/07/17. Review of the Hospital emergency room Instructions dated 08/08/17 revealed Resident #5 was treated and released back to the nursing facility. Resident #5 was treated a closed nasal fracture, epistaxis (nose bleed), chronic anticoagulation, fall, and facial bruising. Interview on 08/11/17 at 9:47 A.M. with Licensed Practical Nurse (LPN) #9 revealed the LPN was familiar with fall prevention protocols. LPN #9 further stated Resident #5 recently fall and get sent to the emergency room where it was determined the resident broke their nose. Observation on 08/11/17 at 12:02 P.M. revealed Resident #5 in wheelchair in room with dark bruising under the left eye and dark bruising under the right eye. Resident #5 stated she was told by staff that she fell . Resident #5 was observed to have a chair alarm and was wearing non-slip socks. Interview on 08/11/17 at 3:45 P.M. with LPN #29 revealed on 08/07/17 during second shift (3:00 P.M. to 11:00 P.M.) LPN #29 was working with one other nurse (LPN #7). LPN #29 further revealed that there were no State tested Nursing Assistants (STNA's) on the unit in which LPN #29 and LPN #7 were working. LPN #29 verified both LPN's were working as nurses as well as STNA's. LPN #29 verified there was one STNA on the locked dementia unit who was not able to leave that unit as it is a locked unit. Further interview with LPN #29 revealed as both LPN's were putting another resident (Resident #28) to bed since there were no STNA to assist them, Resident #5 who was in her wheelchair sitting at the nurses' station in view of the LPN had wheeled herself to her room to attempt to toilet herself. LPN #29 verified that upon leaving Resident #28's room on 08/07/17 at approximately 10:15 P.M. it was discovered Resident #5 was not in visual sight of the nurses' station. LPN #29 stated she ran to Resident #5's room where she saw the top of Resident #5's head sticking out of the bathroom door, the resident had an alarm but it was not sounding and there was a substantial amount of blood. LPN #29 stated the alarm sounded once the LPN sat down next to Resident #5 to assess the injuries. Interview on 08/11/17 at 4:47 P.M. with Corporate Administrator revealed the facility tries to have two nurses and three STNA's on second shift. Interview on 08/11/17 at 5:02 P.M. with Corporate Administrator and review of an Incident Investigation Report revealed Resident #5 experienced a fall on 08/07/17 at 10:15 P.M. The form was reviewed and indicates that a gait belt was not applicable, the incident was unwitnessed and the resident had gait disturbances. Further interview with Corporate Director of Nursing (DON) verified that the signature of the nurse on the form was of LPN #9 and the DON, neither of whom was working on the night of the incident. Corporate Administrator verified the incident report was filled out as an Interdisciplinary Team report and was dated 08/08/17 which is one day after the incident. Interview on 08/11/17 at 5:21 P.M. with Corporate Administrator verified that on second shift (3:00 P.M. to 11:00 P.M.) LPN #29 was working with LPN #7. STNA #3 was the only STNA scheduled to work so the facility borrowed another STNA (#1) from a sister facility. STNA #1 clocked out at 9:30 P.M. Corporate Administrator verified after 9:30 P.M. there was one STNA working in the facility and two LPN's. This deficiency substantiates Complaint Number OH 691.

Based on medical record review, observations, interviews and review of all investigation the facility failed to implement fall interventions for residents. This affected two Residents (#27 and #24) of three reviewed for falls. This resulted in actual harm to Resident #24 who sustained a fall during an improper transfer. The resident sustained [REDACTED]. The facility identified 12 residents who required mechanical transfers. The census was 37. Findings Include: 1. Review of Resident #24's closed medical record revealed [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated on 01/04/16 revealed the resident was severely cognitively impaired and required total assistance of two with all transfers. Review of the care plan for falls updated on 01/04/16 revealed Resident #24 required assistance of two for safe transfers. Review of the facility fall investigation dated on 03/11/16 at 6:10 P.M. revealed State tested Nursing Assistant (STNA) #66 was putting the resident to bed by herself. STNA #66 stood Resident #24 up and both of them fell to the floor. The report noted no obvious injury. The nurse on duty called the doctor and obtained an order for [REDACTED]. Review of the X-ray report dated 03/11/16 revealed Resident #24's distal femur and left tibia were fractured. The resident was then transported to the hospital and required surgery for [REDACTED]. Review of the nurses notes dated 03/12/16 indicated the aide and the resident fell to the floor. an order for [REDACTED]. The resident was sent to the hospital. A review of Resident #24's Medication Administrator Records (MAR) was conducted. Prior to the incident on 03/11/16 the resident rarely required pain medications. Upon her return to the facility after her hospitalization and surgery the resident required the use of a narcotic analgesic to control her pain. The medical record revealed the resident had a further decline in her appetite also. Interview with the Director of Nursing (DON) on 01/11/16 at 2:00 P.M. revealed Resident #24 required two persons for safety during transfers and at times a mechanical lift depending on her cognitive status. The DON verified on 03/11/16, STNA #66 attempted to transfer Resident #24 by herself and this resulted in a fall with injury to the resident. 2. Review of the medical record for Resident #27 revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 10/11/16 noted Resident #27 was cognitively intact and required extensive assistance (one person physical assist) for bed mobility and transfers. Review of the care plan for fall risk, revised on 11/23/16, included intervention of an electronic alarm. On 01/11/17 at 10:30 A.M., Resident #27 was observed sitting in her wheelchair. Resident #27 did not have an electric alarm on her wheelchair. There were no alarm pads next to her bed. During an interview with State tested Nursing Assistant (STNA) #18 on 01/11/17 at 10:35 A.M. indicated she was not aware the resident had an electric alarm on her wheelchair or near her bed. STNA #18 verified there was no electronic alarm device located near Resident #27. During an interview with the DON on 01/11/17 at 11:00 A.M., the DON verified there was no electronic alarm device in place for Resident #27. The DON further verified this was an intervention listed on the fall care plan.