Every finding on record at Sycamore Trails Post Acute

Based on observation, medical record review, staff interviews, resident interview, and review of facility policy, the facility failed to administer medications in a timely manner. This affected four (Residents #29, #73, #10, and #44) of four residents reviewed for medication administration. The facility census was 73. Findings include: 1. Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, Chronic Obstructive Pulmonary Disease (COPD), and DM II. Review of the admission MDS assessment dated [DATE] revealed Resident #29 had intact cognition as evidenced by a BIMS score of 13. The resident was assessed to require supervision with eating, partial assistance with toileting, bathing, dressing, and transfers. Review of the Medication Administration Record (MAR) revealed medications ordered for the morning. Observation on 12/23/24 at 12:14 P.M. revealed Registered Nurse (RN) #30 administered morning medications to Resident #29. Interview on 12/23/24 at 12:20 P.M. with Registered Nurse (RN) #30 revealed she was administering Resident #29's morning medications after 12:00 P.M. 2. Review of the medical record for Resident #73 revealed an admitted [DATE] with a readmission on 10/24/24. Diagnoses included DM II, Congestive Heart Failure (CHF), and chronic kidney disease stage four. Review of the MDS assessment dated [DATE] revealed Resident #73 had intact cognition as evidenced by a BIMS score of 14. This resident was assessed to require setup with eating, partial assistance with toileting and transfers, dependent with bathing, and substantial assistance with dressing. Review of the MAR revealed medications ordered for the morning. Interview on 12/24/24 at 11:37 A.M. with Resident #73 revealed he had not received his morning medications yet. Interview on 12/24/24 at 12:03 P.M. with Assistant Director of Nursing (ADON) verified she was still administering morning medications related to staffing issues and had not administered morning medications to Resident #73. Observation on 12/24/24 at 12:07 P.M. revealed ADON administered medications to Resident #73. 3. Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), generalized anxiety disorder, major depressive disorder, and convulsions. Review of the annual MDS assessment dated [DATE] revealed Resident #10 had intact cognition as evidenced by a BIMS score of 13. The resident was assessed to require setup with eating, dependent with toileting and dressing, and substantial assistance with bathing. Review of the physician order dated 07/13/24 revealed Resident #10 was ordered Morphine Sulfate Extended-Release (ER) Oral tablet 30 milligrams (mg), give one tablet by mouth two times a day for pain. Review of the MAR dated December 2024 revealed Resident #10 was not given Morphine Sulfate 30 mg as ordered per physician orders on 12/14/24 through 12/16/24. Review of the controlled drug record dated December 2024 revealed Resident #10 was not given the following doses of Morphine ER 30 mg per physician orders: evening dose on 12/14/24, morning dose on 12/15/24, and morning and evening dose on 12/16/24. Interview on 12/24/24 with Resident #10 revealed she was not getting her medications as ordered. Resident #10 reported they are always out of one of her medications. Interview on 12/30/24 with Regional Nurse (RN) #80 verified Resident #10 was not given Morphine ER 30 mg from 12/14/24 through 12/16/24 as ordered. 4. Review of the medical record for Resident #44 revealed an admitted [DATE]. Diagnoses included bipolar disorder, Attention Deficit Hyperactivity Disorder (ADHD), and peripheral vascular disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #44 had intact cognition as evidenced by a BIMS score of 13. The resident was assessed to be independent with eating and required supervision with toileting, bathing, dressing, and transfers. Review of the physician order dated 08/22/24 revealed Resident #44 was ordered Oxycodone oral tablet 10 mg, give one tablet by mouth every six hours as needed. Review of the MAR dated November and December 2024 revealed Resident #44 did not receive Oxycodone from 11/28/24 through 12/06/24. Review of the controlled drug record dated November and December 2024 revealed Resident #44 received a dose of Oxycodone 11/28/24 at 9:30 P.M. and did not receive another dose until 12/07/24 at 9:30 P.M. Interview on 12/23/24 at 11:51 A.M. with Resident #44 reported the facility did not have her Oxycodone available for about a week about three weeks ago. Interview on 12/30/24 with RN #80 verified Resident #44 did not receive any Oxycodone from the pharmacy from 11/28/24 through 12/06/24. RN #80 verified Oxycodone was not pulled from the Pyxis (facility supply of medication) to be given to Resident #44 during that time frame. Review of the facility policy titled, Administering Medications, revised April 2019 revealed medications were administered in a safe and timely manner, and as prescribed. Medications were administered in accordance with the prescriber orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00160232.

Based on review of the medical record, observations, interviews, and policy review, the facility failed to ensure medications were administered per physician orders. There were two medication errors out of 37 opportunities resulting in a 5.4 percent medication error rate. This affected one (Resident #14) of three residents observed for medication administration. The facility census was 73. Findings include: 1. Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, type two Diabetes Mellitus (DM II), and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three. The resident was assessed to require setup with eating, toileting, bathing, dressing, and independent with transfers. Review of the physician order dated 09/13/24 revealed Resident #14 was ordered K-Phos Oral tablet 500 milligrams (mg), give 250 mg by mouth three times a day for supplement. Review of the physician order dated 09/13/24 revealed Resident #14 was ordered Potassium Chloride 20 milliequivalents (mEq) Extended-Release (ER), give 20 mEq by mouth one time a day for hypokalemia. Observation on 12/23/24 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #21 crushed Potassium Chloride ER 20 mEq and administered to Resident #14. Observation also revealed K-phosphate was not administered because the packaging did not have a dose present. Interview on 12/23/24 at 9:25 A.M. with Licensed Practical Nurse (LPN) #21 verified she crushed Potassium Chloride ER for medication administration to Resident #14. LPN #21 also verified she did not administer K-Phosphate because there was not a dose present on the packaging. Interview on 12/30/24 at 9:30 A.M. with the Regional Nurse (RN) #80 verified potassium extended release should not be crushed. Review of Medscape revealed do not crush or chew extended release capsules or tablets due to release of all the drug at once, which increases the risk of side effects. This deficiency represents non-compliance investigated under Complaint Number OH00160232.

Based on medical record review, staff interview and review of facility policy, the facility failed to administer medications per physician orders and further failed to ensure Controlled Drug Records (CDR) were maintained. This affected one resident (#10) of three residents reviewed for medication administration. The facility census was 74. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of upper-outer quadrant of right female breast, major depressive disorder and secondary malignant neoplasm of bone. Review of the annual Minimum Data Set (MDS) assessment, dated 11/8/24, revealed Resident #10 was cognitively intact. Resident #10 required set-up assistance for eating, required substantial assistance for bathing and bed mobility and was dependent on staff assistance for toileting hygiene, dressing and personal hygiene. Review of the Medication Administration Record (MAR) from 10/01/24 through 10/31/24 revealed Ativan oral tablet one milligram (mg) (Lorazepam), one mg every six hours for anxiety was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M., 10/13/24 at 6:00 P.M. and 10/22/24 at 6:00 P.M. Further review of the MAR revealed Clindamycin HCl oral capsule 150 mg, one capsule four times daily for infection was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M. and 10/22/24 at 6:00 P.M. Additionally, Methocarbamol oral tablet 1000 mg, give 1000 mg by mouth every six hours for pain was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M., 10/13/24 at 6:00 P.M. and 10/22/24 at 6:00 P.M. Lastly, Dilaudid oral tablet two mg (Hydromorphone HCl), one tablet by mouth four times a day for pain was not administered on 10/07/24 at 6:00 A.M., 10/08/24 at 6:00 P.M., 10/10/24 at 6:00 A.M., 10/13/24 at 6:00 A.M., 10/13/24 at 6:00 P.M. and 10/22/24 at 6:00 P.M. Review of the CDR revealed Lorazaepam oral tablet one mg was signed out for the 10/07/24 6:00 A.M. dose, 10/10/24 6:00 A.M. dose, 10/13/24 6:00 A.M. dose and 10/22/24 6:00 A.M dose. There was no evidence of a CDR for Dilaudid oral tablet. Interview on 11/18/24 at 4:00 P.M. with the Director of Nursing (DON) confirmed the facility had no evidence the medications identified above were adminstered as ordered, further stating the nurse who worked those shifts was no longer employed with the facility so she was unable to gather any additional information. Additionally, the DON verified the CDR for Lorazepam indicated the 10/07/24 6:00 A.M. dose, 10/10/24 6:00 A.M. dose, 10/13/24 6:00 A.M. dose and 10/22/24 6:00 A.M dose were signed out but the MAR did not reflect the medication was administered. Lastly, the DON confirmed the facility was unable to locate a CDR for Dilaudid. Review of the facility policy titled Medication Administration General Guidelines, dated November 2021, revealed the individual who administers the medication dose records the administration on the resident's MAR/electronic MAR (eMAR) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. This deficiency represents non-compliance investigated under Master Complaint Number OH00159209 and Complaint Numbers OH00159082 and OH00159031.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure appropriate hand hygiene was performed following incontinence care. This affected one resident (#20) of four residents reviewed for incontinence care. The facility census was 74. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses of idiopathic aseptic necrosis of right femur, obstructive and reflux uropathy, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 9/20/24, revealed Resident #20 had moderate cognitive impairment. Resident #20 required partial assistance with personal hygiene and was dependent on staff assistance with toileting hygiene, dressing, bed mobility and transfers. Observation on 11/18/24 at 9:55 A.M. of incontinence care for Resident #20 and completed by Certified Nursing Assistant (CNA) #190, revealed CNA #190 knocked on the door when entering the room, explained the procedure to the resident, closed the door to the room, gathered the equipment, washed her hands and applied gloves. Resident #20 was positioned by her back. CNA #190 loosened Resident #20's incontinence brief, which was soiled with urine and feces, and tucked it between the resident's legs. CNA #190 used a clean wipe for each swipe down the residents peri-area, ensuring to not cross-contaminate, and used to same process to rinse and dry the peri area. CNA #190 repositioned Resident #20 onto her right side and cleansed the resident's sacrum/coccyx area, using a clean wipe with each swipe, ensuring not to cross-contaminate, and used the same process to rinse and dry the sacrum/coccyx area. CNA #190 continued, with her gloves intact, to change out the bath blanket Resident #20 was laying on with a clean one, per the resident's request. CNA #190 then reapplied Resident #20's top sheet, causing the resident's television (TV) remote to fall into the bed. CNA #190 picked up the TV remote with her gloved hands and handed it to Resident #20. With her gloves still intact, CNA #190 proceeded to place a clean blanket on top of the sheet for the resident. CNA #190 used her gloved hands to use the bed remote to lower Resident #20's bed to the appropriate height. CNA #190 removed her gloves, washed her hands, gathered the dirty linen bag and exited the room. Interview on 11/18/24 at 10:10 A.M. with CNA #190 verified she did not remove her gloves or perform hand hygiene after providing incontinence care for Resident #20, which included a bowel movement, and proceeded to use her soiled gloves while providing the resident clean linen, touching the resident's TV remote and using the bed remote to adjust the resident's bed height. CNA #190 revealed that she feels she completed incontinence care without getting bowel movement on her gloves, so she did not feel there was cross-contamination requiring her to remove her soiled gloves. Review of the facility policy titled Incontinence Care, dated 06/08/22, revealed the purpose was to keep skin clean, dry, free of irritation and odor; identify skin problems as soon as possible so treatment can be started; prevent skin breakdown; and to prevent infection. The procedure included hand hygiene and apply gloves; lower the head and foot of the bed; hand hygiene and apply gloves; drape resident for privacy; wash all soiled skin areas and dry very well; remove gloves and wash hands; and change linen as needed. This deficiency was an incidental finding discovered during the complaint investigation.

Based on medical record review, observation, resident and staff interviews, and review of facility policy, the facility failed to ensure medications were observed taken by residents and not left at the beside. This affected one (#3) of three residents reviewed for medication administration. The census was 82. Findings include: Review of Resident #3's medical record reviewed an admitted [DATE]. Diagnoses listed included displaced comminuted fracture of the left tibia, injury of the popliteal artery, comminuted fracture of the left fibula, and asthma. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Observation on 09/25/24 at 1:58 P.M. revealed five pills in a medication cup sitting on a bedside table. Interview with Resident #3 during the observation revealed his nurse had left them for home to take. Interview with Registered Nurse (RN) #100 on 09/25/24 at 2:01 P.M. confirmed she had left pills at Resident #3 bedside to take. RN #100 confirmed she did not observe Resident #3 take the medications. RN #100 identified the medications as Tylenol (two tablets), gabapentin, Clindamycin (antibiotic), and Oxycodone (narcotic pain medication). Review of medication administration records (MAR) revealed Tylenol 500 milligrams (mg) two tablets, gabapentin 300 mg on tablet, Clindamycin 300 mg one tablet, and Oxycodone 10 mg one tablet were documented as being administered by RN #100 on 09/25/24. Further review of Resident #3's medical record revealed there was no physician order, care plan, or other documentation permitting the resident to self administer medications. Interview with Clinical Services Manager (CSM) #220 and CSM #200 on 09/25/24 at 2:35 P.M. confirmed that RN #100 left medications including Oxycodone. CSM #220 and CSM #200 confirmed nurse should watch residents take there medications and not leave them at the bedside. Review of the facility policy dated Medication Administration-General Guidelines dated revised December 2019 revealed medications are administered without unnecessary interruptions. The resident is always observed after administration to ensure the dose completely ingested. If a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00157578.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from unnecessary psychotropic medications by ensuring the resident was on the lowest ordered dose of an antipsychotic. This affected one (#4) of three residents reviewed for psychoactive medications. The census was 82. Findings include: Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses listed included cerebral palsy, schizoid disorder, anxiety disorder, depression, and pseudobulbar affect. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. Review of physician orders revealed an order dated 07/25/24 for Olanzapine (antipsychotic) 10 milligrams (mg) give one tablet by mouth at bedtime for Schizoaffective disorder. An order dated 09/05/24 was for Olanzapine 10 mg give one tablet by mouth at bedtime. Review of outpatient psychiatry notes revealed Olanzapine was increased to 20 mg at bedtime for auditory verbal hallucinations. Review of written physician orders revealed and order transcribed dated 09/04/24 for Olanzapine 20 mg give one tablet by mouth at bedtime. Review of medication administration records (MAR) revealed Resident #4 had received both Olanzapine 10 mg and Olanzapine 20 mg at bedtime since 09/05/24 for a total of 30 mg dose. Interview with Clinical Services Manager (CSM) #220 on 09/26/24 at 11:03 A.M. confirmed Olanzapine was ordered to be increased to 20 mg on 09/04/24 for Resident #4. CSM #220 confirmed Resident #4 had received Olanzapine 10 mg and Olanzapine 20 mg for a total of 30 mg at bedtime since 09/05/24. CSM #220 confirmed Olanzapine 10 mg should have been discontinued when Olanzapine 20 mg was ordered. Review of the facility's policy titled Chemical Restraint Use dated 11/30/23 revealed psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. This deficiency represents non-compliance investigated under Complaint Number OH00157578.

Based on medical record review and staff and pharmacist interviews, the facility failed to ensure antibiotics were provided as physician ordered resulting in a significant medication error. This affected one (#12) of three residents reviewed for medication administration. Facility census was 78 Findings include: Review of medical record for Resident #12 revealed an admitted [DATE]. Diagnoses include bipolar, anxiety, hypertension and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #12 required supervision for bed mobility, transfers, toileting and eating. Review of physician records for Resident #12 revealed an order for Imipenem-Cilastatin (antibiotic) intravenous solution reconstituted 500 milligrams (mg)-give intramuscularly four times daily with a start date of 09/02/24. Review of the September 2024 Medication Administration Record (MAR) for Resident #12 revealed Imipenem-Cilastatin (antibiotic) was scheduled four times a day at midnight, 6:00 A.M., 12:00 P.M. and 6:00 P.M. starting on 09/02/24. Further review revealed OT was documented on 09/02/24 at midnight through 6:00 A.M. (with the exception of 09/02/24 6:00 P.M. which was blank). Review of the chart code revealed OT was other. Review of the progress note dated 09/04/24 at 5:40 A.M. revealed Imipenem-Cilastatin was awaiting delivery from the pharmacy. Interview on 09/04/24 at 2:02 P.M. with Registered Nurse (RN) #104 revealed she discovered on 09/03/24 that Resident #12's Imipenem-Cilastatin had not been received from the pharmacy and called them to inquire of the status. RN #104 shared the pharmacy informed her the prescription had been profiled at the pharmacy but the order was not filled/sent out, and she was awaiting further clarification. RN #104 verified the medication had not been given as ordered and clarification had not been received at the time of the interview. Interview on 09/04/24 at 2:20 P.M. with Pharmacist #105 revealed the route Resident #12's Imipenem-Cilastatin was ordered was no longer available. The medication could be given intravenously. Pharmacist 3105 further shared Resident #12 had a previous order for the same medication ordered intravenously which had been filled prior to her recent hospitalization . The readmission orders contained the same medication, ordered intramuscularly and the system deemed the most recent prescription as a duplicate order so the prescription was profiled (kept on file). This deficiency represents non-compliance investigated under Complaint Number OH00157637.

Based on medical record review, review of hospital documentation, review of written statements, staff interviews, and policy review, the facility failed to provide adequate staff assistance during a bed bath resulting in an avoidable fall. This resulted in Actual Harm on 05/31/24 when State tested Nursing Assistant (STNA) #275 rolled Resident #70 away from her during a bed bath and the resident rolled out of bed onto the floor. Subsequently, Resident #70 was transferred to the Emergency Department (ED) for evaluation and treatment and required a suture to close a forehead laceration. This affected one (#70) of three residents reviewed for falls. The facility census was 79. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, malignant neoplasm of the brain, left hemiplegia, depression, and obesity. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 was cognitively intact. Resident #70 was dependent upon staff for bathing, toileting, hygiene, and transfers and required substantial staff assistance for bed mobility. No falls were indicated on the MDS. Review of the quarterly Fall Risk assessment completed 05/02/24 indicated Resident #70 was at high risk for falls. Review of a nurse progress note dated 05/31/24 at 9:01 A.M. documented STNA #275 notified Licensed Practical Nurse (LPN) #205 that Resident #70 had rolled out of bed during a bed bath. The note further documented LPN #205 entered Resident #70's room and he was lying prone with his head turned towards the left and a puddle of bright red drainage was pooling under his face and head. The note indicated Resident #70 had a laceration to the left eyebrow and ice was applied. Staff called nine-one-one (911) and Resident #70 was transported out of the facility. Further review of the nurses' progress notes revealed an Interdisciplinary Team (IDT) note dated 06/03/24 at 11:43 A.M. indicated the IDT met to review Resident #70's fall on 05/31/24. The IDT note indicated the STNA alerted the nurse that Resident #70 had rolled out of bed during a bed bath, nurse entered Resident #70's room to see that he was lying prone on left side of bed with face towards the window. The note documented Resident #70 had no clothing on and no undergarment. Resident #70 was noted to have a nosebleed and small laceration to his forehead. Vital signs were assessed and neurological checks were initiated. The note stated the environment was well lit, and floor clean, dry, and free from debris prior to fall. The note continued to document Resident #70 reported he reached his arm around to scratch his back and accidentally rolled himself out of bed. Resident #70 was immobilized at bedside and 911 called. Resident #70 was transported to the ED for treatment. The physician and family were notified. The IDT note stated all scans completed in ED were negative for additional fall related injury. Review of the medical record for Resident #70 revealed an ED note dated 05/31/24 which indicated Resident #70 was seen in the ED for a fall with closed head injury and facial laceration. Further review of Resident #70's medical record revealed the resident required a suture for the head laceration. Review of a written statement by STNA #275 dated 05/31/24 stated she had rolled Resident #70 onto his left side to wash his back. STNA #275's statement indicated Resident #70 attempted to scratch his back while on his left side and he started to move forward. STNA #275's statement stated she tried to roll Resident #70 on his back, but she was unable to prevent the fall from the bed. Interview on 06/25/24 at 11:10 A.M. with the Director of Nursing (DON) stated Resident #70 informed her he was scratching his back during a bed bath, and he lost his balance and rolled off the bed onto the floor. The DON confirmed one STNA (#275) had completed Resident #70's bed bath. The DON stated Resident #70 had brain cancer and the level of care he required for bathing, transfers, and toileting would vary from day to day. The DON confirmed Resident #70 was sent to the ED for a laceration to his forehead and received one suture. Interview on 06/25/24 at 2:45 P.M. with STNA #275 confirmed she was the STNA who gave Resident #70 a bed bath on 05/31/24 when he fell out of bed. STNA #275 stated Resident #70 was rolled onto his left side in the bed, and she was standing on the opposite side of the bed to wash his back. STNA #275 confirmed Resident #70 was facing away from her and that she was the only STNA who completed the bed bath. STNA #275 stated Resident #70's bed did not have grab bars. STNA #275 stated Resident #70 used his right hand to hold onto the mattress and bedframe while she washed his back. STNA #275 stated Resident #70 let go of the mattress and used his right hand to scratch an area on his back which caused Resident #70 to lose his balance and his shoulders fell off the bed. STNA #275 confirmed Resident #70 had left hemiplegia and was not able to use his left upper extremity to assist with bed mobility. STNA #275 stated she attempted to grab Resident #70's shoulders to prevent him from falling but she was not able to do so, and Resident #70 fell off the bed onto the floor. STNA #275 stated she immediately went to get nursing assistance for Resident #70 after the fall. STNA #275 stated she believed Resident #70 required two-person assistance for his bathing due to balance difficulties, confusion at times, and recent decline in health. STNA #275 stated she resigned and was no longer employed by the facility. Review of the facility policy titled, Fall-Clinical Protocol, review date of 06/08/22, revealed the facility would attempt to identify individuals with history of falls and risk factors for subsequent falls. The policy also stated based on the assessment, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and address risks of serious consequences of falling. This deficiency represents non-compliance investigated under Complaint Numbers OH00154867 and OH00154371.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure staff observed resident consume medications. This affected one (#20) out of four residents reviewed for medication administration. The facility census was 79. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with medical diagnoses of urinary tract infection, sepsis, diabetes mellitus, diabetes mellitus, hypothyroidism, and congestive heart failure. Review of the medical record for Resident #20 revealed an admission Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #20 was cognitively intact. The MDS indicated Resident #20 was dependent upon staff for toilet hygiene and bathing and required substantial staff assistance with bed mobility. Review of the medical record for Resident #20 revealed physician orders dated 06/19/24 for hydralazine 50 milligram (mg) one tablet by mouth three times per day and levothyroxine 200 microgram one tablet daily. Further review of Resident #20's medical record revealed there were no orders, assessment or further instructions allowing the resident to self-administer medications. Observation with interview on 06/25/24 at 8:16 A.M. of Resident #20 revealed a medication cup with two medication tablets inside sitting on Resident #20's bedside table. Resident #20 stated the nurse brought the medications in his room earlier that morning and he hadn't taken them yet. Resident #20 stated he did not know what medications were in the cup. Observation with interview on 06/25/24 at 8:20 A.M. with Assistant Director of Nursing (ADON) #268 confirmed there were two medication tablets sitting in a medication cup on Resident #20's bedside table. ADON #268 brought the medication cup to the medication cart and reviewed Resident #20's list of medications. ADON #268 stated the medications in the cup were levothyroxine and hydralazine which were to be administered at 6:00 A.M. Review of the facility policy titled, Preparation and Guidelines for Medication Administration, revised November 2021, stated medications are to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy also stated the resident is always observed after the administration of medication to ensure that the dose was completely ingested. This deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on personnel record review and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect all 79 residents residing in the facility. The facility census was 79. Findings include: Review of the personnel record for Activity Director (AD) #250 revealed a hire date of 06/20/23 as a housekeeper. The personnel record indicated AD #250 was promoted to Activity Director on 02/05/24. Review of AD #250's personnel record revealed no documentation to verify AD #250 had the appropriate training and/or education to hold the position of Activity Director. Interview on 06/24/24 at 4:09 P.M. with AD #250 confirmed she had been promoted from a housekeeper position to the Activity Director in February 2024. AD #250 stated worked as a nurse aide at an Assisted Living facility prior to her employment at the facility and assisted the residents at that facility with activities. AD #250 confirmed she had not received any education and/or training to be a qualified Activity Director. AD #250 stated she worked full time and completed resident assessments, care plans, attended care conferences, conducted Resident Council meetings, and completed monthly activity calendar. Interview on 06/25/24 at 2:54 P.M. with Senior Social Worker (SSW) #278 stated she was a regional employee who assisted AD #250. SSW #278 stated she had monthly calls with AD #250 to discuss the monthly activity calendar expectations, completed random audits of resident activity documentation to ensure the facility had captured activity participation, and completed random audits of resident charts to ensure admission and quarterly assessments were accurate. SSW #278 stated AD #250 would call her for guidance or suggestions for activities at the facility. SSW #278 stated she had worked as an Activity Assistant for two years in the past five years. SSW #278 stated AD #250 completed all resident activity assessments, MDS assessments, and updated the care plans. SSW #278 confirmed AD #250 was not a qualified Activity Director. This deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on record review, observations and staff and resident interviews, the facility failed to provide meals per resident choice and per the facility planned menu. This affected three (#33, #55 and #70) out of three residents reviewed for meals and had the potential to affected 78 residents residing in the facility who receive their meals from the facility, the facility identified two residents (#47, #65) who receive nothing by mouth (NPO). Facility census was 80. Findings include: Review of the May 2024 Menu revealed the posted breakfast for 05/13/24 was cold cereal, hard boiled egg, bagel, fruit cup and two percent milk. Observation on 05/13/24 from 9:06 A.M. to 9:28 A.M. of three residents (#33, #55 and #70) breakfast trays revealed their tickets did not match what was served. Observation and interview on 05/13/24 at 9:06 A.M. revealed the breakfast ticket for Resident #70 was cold cereal, two hard boiled eggs, half bagel and half cup of fruit. Observation of the breakfast meal served was bacon, toast, two hard boiled eggs and a fruit cup. Observation and interview on 05/13/24 at 9:11 A.M. revealed the breakfast ticket for Resident #33 was for two cold cereals, two hard boiled eggs, a half of a bagel and a half cup of fruit. Observation of the breakfast served was bacon, two hard boiled eggs and toast. Resident #33 voiced concern she did not receive her cereal for breakfast and voiced frustration to the staff. Interview on 05/13/24 at 9:17 A.M. with State tested Nursing Assistant (STNA) #102 revealed a concern the meals provided often did not match the menus. STNA #102 stated the facility was out of milk that morning so the menu had to be changed. Observation and interview on 05/13/24 at 9:28 A.M. revealed the breakfast ticket for Resident #55 was for cold cereal, yogurt, cottage cheese, two hard boiled eggs, 1/2 bagel and a fruit cup. Observation of the breakfast served was two hard boiled eggs, bacon, oatmeal, yogurt and a fruit cup. Resident #33 voiced concern he often did not get what was on the menu or what he ordered. Interview on 05/14/24 at 10:24 A.M. with the Dietary Manager (DM) #108 verified the facility was out of milk on the morning of 05/13/24. DM #108 stated there was a delay with the delivery which was scheduled that morning. Observation and interview on 05/14/23 at 12:34 P.M. of the lunch tray for Resident #55 revealed a cheeseburger, extra lemonade and vegetable soup on the meal ticket had not been delivered. Resident #55 also acknowledged she did not contact the dietician prior to the substitutions of the breakfast meal. Observation and interview was made with DM #108 on 05/14/34 at 12:34 P.M. of the lunch ticket and meal of Resident #55. DM #108 shared the kitchen was out of vegetable soup and acknowledged staff did not inform her that Resident #55 wanted an alternative. DM #108 also verified the cheeseburger and extra lemonade was not provided as Resident #55 requested. The facility confirmed there are 78 residents residing in the facility that receive their meals from the facility, the facility identified two residents (#47, #65) who are NPO. This deficiency represents non-compliance investigated under Complaint Number OH00153743.

Based on medical record review, observations and resident and staff interviews, the facility failed to provide adequate intervention and/or supervision to ensure residents did not possess illegal drugs and/or drugs not prescribed to the resident. Additionally, the facility failed to implement a resident's care plan to ensure adequate supervision was provided during a meal. This affected three (#54, #47 and #74) of three residents reviewed for supervision related to illegal drug usage and one (#27) of three residents reviewed for supervision with meals. The facility census was 80. Findings include: 1. Review of medical record for Resident #54 revealed admitted [DATE] admitted to hospice on 11/22/23. Diagnoses include cirrhosis of the liver, chronic obstructive pulmonary disease, anemia, depression and history of cocaine abuse. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 required extensive one person assistance for toileting and supervision for bed mobility, eating and transfers. A brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of Resident #54's progress notes dated 01/01/24 revealed an unnamed State tested Nursing Assistant (STNA) alerted the nurse that Resident #54's behavior was not normal. An assessment revealed extreme lethargy, and the bed was urine soaked. A vape pen was discovered and given to the Director of Nursing (DON), hospice was contacted, and hospice was notified. A second note revealed hospice staff instructed to hold narcotic medication and obtain a urine sample for drug screen. Results of the 01/02/24 drug screen revealed a positive result for Benzodiazepine (resident had an order for Ativan). Amphetamines, Barbiturates, Cocaine, Cannabinoids, Opiates, Phencyclidine, Propoxyphene, Methadone and Methaqualone were all negative. Review of Resident #54's progress note dated 03/10/24 revealed staff found a plastic baggie with an unknown substance lying on the floor next to the bed. The DON was informed. Review of the drug screening for 03/11/24 and 04/05/24 were negative for Amphetamines, Barbiturates, Cocaine, Cannabinoids, Opiates, Benzodiazepine, Oxycodone and Methadone were all negative. Further review of the progress notes revealed on 04/05/24 revealed Resident #54 was found unresponsive with periods of apnea and agonal breathing. Narcan was given and Resident #54 became alert and oriented within 15 minutes. Resident #27 refused three times to have his room checked. Resident #27 was educated on the facility policy that no illicit substances could brought into the facility and he was educated on the importance of refraining from using illegal drugs. The physician was notified and updated. Further review of Resident #54's care plan revealed there was no care plan related to illegal drug use and/or interventions staff should implement. Interview on 05/16/24 at 12:16 P.M. with Clinical Registered Nurse (CRN) #121 revealed the police were contacted on 03/10/24 when the baggie was found in Resident #54's room. CRN #121 stated it was almost two months later on 05/04/24 the police returned to the facility and confirmed the substance found in Resident #54's room was fentanyl. CRN #121 shared Resident #54 had the right to refuse to have his room and person searched and to leave the facility. CRN #121 stated the facility was looking at alternative placement for Resident #54 but was unaware if the Ombudsman had been contacted for assistance for interventions and/or alternative placement. A joint interview on 05/16/24 at 1:54 P.M. with the Administrator and DON revealed Resident #54 had the right to refuse a room search and they were unable to restrict his right to leave the facility. It was shared referrals had been sent but all had been refused, they were unsure of the Ombudsman had been contacted for assistance. A second interview with CRN #121 at 4:42 P.M. verified there was not a care plan regarding Resident #54's possession of and/or risk of substance abuse. 2. Review of medical record for Resident #47 revealed admitted [DATE]. Diagnoses include Bipolar Disorder, anxiety and post-traumatic stress disorder. The resident remained. The quarterly MDS dated [DATE] revealed Resident #47 had a BIMS score of 13 indicating intact cognition. Resident #47 required one person assistance for toileting and supervision for eating. Review of medical record for Resident #74 revealed admitted [DATE]. Diagnoses include COPD and encephalopathy. The resident was discharged to the hospital on 05/12/24 and did not return to the facility. Review of Resident #47's progress notes dated 05/07/24 revealed the resident was placed on two hour vital checks after self-administering medication given by another resident. Interview on 05/16/24 at 9:39 A.M. with Resident #47 revealed he had been offered a breath mint by another resident (Resident #74) and he did take it. Resident #47 stated later the staff came into his room and informed him it was not breath mint, it was a pain pill. Resident #47 denied any effects or outcome from taking the medication. Resident #47 further shared staff came in and checked his vitals often for one day following the incident. A joint interview on 05/16/24 at 1:54 P.M. with the Administrator and DON revealed staff had informed the DON that Resident #74 had passed out medication to residents during a smoke break. They shared they confronted Resident #74 who consented to a search of her purse. The DON shared Percocet (pain) five milligram (mg) tablets were found along with other loose pills in the bottom of her purse. The Administrator and DON verified Percocet five mg that was found in Resident #74's purse were not prescribed by the facility. The police were contacted, and the medication was confiscated from Resident #74. The Administrator and DON confirmed Resident #47 was identified by Resident #74 as receiving the medication. The physician was notified, and orders were received to monitor him for effects and monitor his vitals every two hours for 24 hours. No outcome was noted. 3. Review of medical record for Resident #27 revealed admitted [DATE]. Diagnoses include epilepsy, dystonia, anxiety, and dementia. The resident remained in the facility. Review of Resident #27's quarterly Minimum Data Set (MDS) dated [DATE] revealed she/he required extensive two person assistance for bed mobility, transfers, and supervision for eating. A brief Interview Mental Status (BIMS) score of seven indicating severely impaired cognition. A care plan for risk of aspiration/pneumonia initiated 05/06/24 revealed interventions which included to monitor for signs and symptoms of aspiration: coughing, drooling, pocketing of food, food residual in mouth after meals, trouble chewing and or swallowing. Observation on 05/14/24 at 8:19 A.M. revealed Resident #27 was in bed with his breakfast tray in front of him. He was observed feeding himself, staff was observed passing trays at the opposite end of the hall. Observation on 05/14/24 at 12:24 P.M. revealed Resident #27 in his room, in bed with his lunch tray in front of him on the bedside table. Resident #27 was feeding himself, no spillage observed on his clothes. No staff were present in his room or in the hall. Interview on 05/14/24 at 2:26 P.M. with Therapy Director #111 revealed Resident #27 was able to feed himself but required supervision for safety due to dystonia (movement disorder causing muscles to involuntarily contract). Interview on 05/14/24 at 4:12 P.M. with State tested Nursing Assistant (STNA) #103 revealed there was miscommunication for room assignment on 05/14/24. Each of the two aids on the hall providing care for Resident #27 thought the other had been assigned to him. This deficiency represents non-compliance investigated under Complaint Numbers OH00153893, OH00153382 and OH00153743.

Based on record review, staff, physician and pharmacy staff interviews, the facility failed to ensure medications were administered as physician ordered. This affected two (#134 and #55) of three residents reviewed for medication administration. The facility census was 80. Findings include: 1. Review of medical record for Resident #134 revealed admitted [DATE]. Diagnoses include paraplegia and schizophrenia, depression and anxiety. Resident #134 remains in the facility. Review of Resident #134's annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #134 required extensive two-person assistance for bed mobility, transfers and supervision for eating. Review of the physician orders revealed an order for Estrogens Conjugated Vaginal Cream 0.625 Milligrams/Gram. Insert 0.5 Grams vaginally one time a day for vaginal dryness. Review of medication administration record (MAR) and the progress note dated 04/14/24, 04/23/24, 04/25/24 and 05/13/24 documented Estrogens Conjugated Vaginal Cream was not given/administered to Resident #134 because it was unavailable. Interview on 05/16/24 at 12:42 P.M. with Pharmacy Staff #120 revealed a 30 day supply of Estrogens Conjugated Vaginal Cream was delivered to the facility on [DATE], 04/16/24 and 05/13/24. Interview on 05/16/24 at 1:54 P.M. with the Director of Nursing (DON) revealed Resident #134's Estrogen Conjugated Vaginal Cream was on the treatment cart and acknowledged agency staff may be unaware of its location so it was not administered as ordered. 2. Review of medical record for Resident #55 revealed admitted [DATE]. The resident was admitted with diagnoses including congestive heart failure, type two diabetes mellitus, and depression. Additional diagnosis added on 04/25/24 of aftercare following surgical amputation, left below the knee amputation and history of Methicillin Resistant Staphylococcus Aureus. Resident #55 remains in the facility. Review of Resident #55's admission MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating intact cognition. Resident #55 required extensive two-person assistance for bed mobility, transfers, toileting and supervision for eating. Review of the progress note dated 02/26/24 at 1:02 P.M. revealed the visiting Nurse Practitioner was in during the morning and prescribed a new order for Doxycycline (antibiotic) 100 milligrams (mg) one capsule by mouth two times a day for left heel wound with foul odor, necrotic tissue for ten days. Record review of Resident #55's February Medication Administration Record (MAR) revealed the Doxycycline was not given on 02/26/24 until the evening shift. Review of Resident #55's physician orders revealed an order for Doxycycline (antibiotic) 100 milligrams (mg) one capsule by mouth two times a day for left heel wound with foul odor, necrotic tissue for ten days. The documentation revealed the medication was listed as on hand. Interview on 05/15/24 at 9:51 A.M. Physician #117 acknowledged an antibiotic (Doxycycline 100 mg) had been ordered on 02/26/24. Physician #117 stated it would be his expectation the medication would be given if it was readily available at the facility or as soon as it came from the pharmacy. Interview on 05/15/24 at 12:38 P.M. with Pharmacist #118 revealed Doxycycline was readily available in the pyxis on 02/26/24 when it was ordered for Resident #55. Interview on 05/14/24 at approximately 3:12 P.M. with Clinical Registered Nurse (CRN) #121 revealed the evening time slot on the MAR for Resident #55 on 02/26/24 encompassed a 7:00 P.M. to 11:00 P.M. time block. CRN #121 further shared when reviewing Resident #55's MAR, the Doxycycline was given at 12:08 A.M. on 02/27/24. CRN #121 confirmed the Doxycycline was available in the facilities pyxis and could have been administered to Resident #55 sooner. This deficiency represents non-compliance investigated under Complaint Numbers OH00153893 and OH00153743. This deficiency represents ongoing noncompliance from the survey dated 04/25/24.

Based on record review, observation, staff and resident interviews, the facility failed to ensure treatments orders were completed as ordered. This affected one (#55) of three residents reviewed for implementation of treatments. The facility census was 80. Findings include: Review of medical record for Resident #55 revealed admitted [DATE]. Diagnoses include congestive heart failure, type two diabetes mellitus, and depression. Additional diagnosis added on 04/25/24 of aftercare following surgical amputation, left below the knee amputation and history of Methicillin Resistant Staphylococcus Aureus. The resident remained in the facility. Review of Resident #55's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #55 required extensive two-person assistance for bed mobility, transfers, toileting and supervision for eating. A care plan for an alteration in skin integrity to the left below knee surgical site documented interventions which included to provide treatments as ordered. Review of the physician orders revealed an order to cleanse left below knee amputation site with wound cleanser, pat dry, apply hydrogel moistened collagen to wound bed, cover with abdominal pad (ABD), secure with kerlix and compress with wrap. Treatment was ordered daily with a start date of 05/01/24. Interview on 05/13/24 at 9:28 A.M. with Resident #55 revealed a concern his dressing was not changed the day prior. Observation on 05/13/24 at 10:19 A.M. of the dressing change for Resident #55 by Assistant Director of Nursing (ADON) #100 revealed when she removed the kerlix and exposed the Abdominal (ABD) Pad, it was dated 05/11/24. ADON #100 confirmed Resident #55's dressing was not changed daily as ordered. This deficiency represents non-compliance investigated under Complaint Numbers OH00153893 and OH00153743.

Based on record review and staff interviews, the facility failed to update resident care plan to include a resident's possession and suspected use of illegal substances. This affected one (#54) of three residents reviewed for care planning. The facility census was 80. Findings include: Review of medical record for Resident #54 revealed admitted [DATE] admitted to hospice on 11/22/23. Diagnoses including cirrhosis of the liver, chronic obstructive pulmonary disease, anemia, depression and history of cocaine abuse. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 required extensive one person assistance for toileting and supervision for bed mobility, eating and transfers. A brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of the progress note dated 03/10/24 revealed staff had found a plastic baggie with an unknown substance lying on the floor next to the bed. The Director of Nursing (DON) was informed. Review of the progress notes revealed on 04/05/24, Resident #54 was found unresponsive with periods of apnea and agonal breathing. Narcan was given and Resident #54 became alert and oriented within 15 minutes. Further review of Resident #54's care plan revealed there was no care plan related to illegal drug use and/or interventions staff should implement. Interview on 05/16/24 at 12:16 P.M. with Clinical Registered Nurse (CRN) #121 revealed the police were called after the substance was found in Resident #54's room on 03/10/24. CRN #121 stated the facility was not informed until 05/05/24 the substance found in Resident #54's room tested positive for fentanyl. A second interview with CRN #121 at 4:42 P.M. verified there was not a care plan regarding possession of and/or risk of substance abuse. This deficiency represents non-compliance investigated under Complaint Number OH00153893.

Based on medical record review, staff interview, medication administration time review, and policy review, the facility failed to administer physician ordered medications and ensure medications were timely order to have available for administration. This affected four #21, #41, #58 and #63 of eight residents reviewed for medication administration. The facility census was 79. Findings include: 1. Review of medical record for Resident #21 revealed an admitted [DATE], with diagnoses of other seizures, epilepsy, intractable, without status epilepticus, and hemiplegia, chronic obstructive pulmonary disease and unspecified affecting left nondominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 was cognitively intact. Review of physician orders dated 11/14/23, to administer Oxcarbazepine tablet, 300 milligrams (mg), give 2 tablets by mouth at bedtime for epilepsy and give 1 tablet by mouth, one time a day for epilepsy; Pepcid tablet (famotidine) 20 mg, give 1 tablet, by mouth two times a day for gastroesophageal reflux disorder; and ferrous sulfate tablet (65 Fe) 325 mg, give 325 mg by mouth two times a day for low hemoglobin and hematocrit. Review of physician orders dated 11/15/23, to administer umeclidinium bromide aerosol powder breath activated 62.5 microgram/inhalation, one puff, inhale orally one time a day for chronic obstructive pulmonary disease (COPD); aspirin low dose tablet chewable, 81 mg, give 1 tablet by mouth one time a day for heart health; Colace capsule, (docusate sodium)100 mg, give 1 capsule by mouth one time a day for constipation; Claritin oral tablet (Loratadine), 10 mg, give 10 mg by mouth one time a day for nasal drainage; doxycycline monohydrate capsule, 100 mg, give 1 capsule by mouth one time a day for recurrent urinary tract infection (UTI); potassium chloride Extended Release (ER) tablet, 10 milliequivalent (mEq), give 10 mEq, by mouth one time a day for hypokalemia; and Multivitamin/Zinc Stress tablet (multiple vitamins-minerals), give 1 tablet by mouth one time a day for supplement. Review of a physician order dated 11/17/23, to administer calcium carbonate-vitamin D tablet, 500-200 mg/unit give 1 tablet by mouth two times a day for supplement. Review of a physician order dated 02/02/24, to administer guaifenesin ER tablet-12 Hour, 600 mg, give 1 tablet by mouth two times a day for cough. Review of the Medication Administration Record (MAR) dated March 2024 revealed on 03/17/24, morning medication administration the following medications were not signed off as administered: aspirin 81 mg, Claritin 10 mg, Colace 100 mg, doxycycline monohydrate 100 mg, Multivitamin with Zinc tablet, oxcarbazepine 300 mg, potassium chloride ER 90 mg, umeclidinium bromide 62.5 mg, calcium carbonate - vitamin D tablet, ferrous sulfate 325 mg, guaifenesin ER 600 mg and Pepcid 20 mg. On 03/31/24, doxycycline monohydrate 100 mg was not administered due to not available. Review of the MAR dated April 2024 revealed on 04/06/24 at 9:16 A.M., the oxcarbazepine 300 mg was not administered due to on order; on 04/07/24 at 10:53 A.M., Pepcid 20 mg was not administered due to awaiting delivery; on 04/24/24 at 10:49 A.M., meclizine MCI 12.5 mg was not administered. 2. Review of medical record for Resident #41 revealed an admitted [DATE], with diagnoses of paraplegia, unspecified, urinary tract infection, absence epileptic syndrome, intractable, and without status epilepticus. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 was cognitively intact. Review of physician orders dated 03/14/24, to administer buspirone HCl oral tablet 15 mg, give 1 tablet by mouth three times a day; Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) inject as per sliding scale: if 150 - 200 = 4unit (u); 201 - 250 = 6u; 251 - 300 = 8u; 301 - 350 = 10u; 351 - 400 = 12u; 401 - 500 = 14u, Notify physician (MD) if <70 or >500, subcutaneously before meals and at bedtime; Nucynta oral tablet (tapentadol HCl), 50 mg, give 1 tablet by mouth three times a day for pain management; Pregabalin oral capsule 75 mg, give 75 mg by mouth three times a day for pain - take 1 capsule (75 mg total) by mouth in the morning and 1 capsule (75 mg total) at noon and 1 capsule (75 mg total) in the evening; methocarbamol oral tablet, 500 mg, give 1 tablet by mouth three times a day for muscle spasms; levothyroxine sodium oral tablet 50 mcg, give 50 mcg by mouth in the morning for hypothyroidism, polyethylene glycol powder, give 17 gram orally two times a day for constipation, Theragran-M oral tablet (multiple vitamins w/ minerals) give 1 tablet by mouth one time a day for vitamin supplement, Desitin External Paste 40 % (zinc oxide) apply to bilateral buttocks topically, one time a day for skin condition; and Estrogens Conjugated Vaginal Cream, 0.625 mg/gram, insert 0.5 gram vaginally one time a day for vaginal dryness. Review of physician orders dated 03/15/24, to administer midodrine HCl oral tablet 10 mg, give 1 tablet by mouth three times a day for low blood pressure hold for systolic blood pressure (SBP) >120 and chlorhexidine gluconate external liquid 4 %, apply to rash topically one time a day every Tuesday, Friday for Skin condition. Review of a physician order dated 03/19/24, to administer Pyridium oral tablet (phenazopyridine HCl) 100 mg, give 1 tablet by mouth three times a day for dysuria. Review of a physician order dated 03/24/24, to administer Pentosan Polysulfate Sodium oral capsule 100 mg, give 1 capsule by mouth three times a day for behavior problems. Review of a physician order dated 04/01/24, to administer Cephalexin capsule 500 mg, give 1 capsule by mouth three times a day for infection/urinary tract infection (UTI) for 7 days. Review of the MAR for March 2024 revealed on 03/14/24, Pentosan Polysulfate Sodium 100 mg was not documented as not given and documented as OT, and buspirone 15 mg afternoon dose not documented as given. On 03/15/24, Pentosan Polysulfate Sodium 100 mg, afternoon dose was documented as OT and not given; Insulin Lispro 100 unit / ml was not documented as given; and Nucynta 50 mg documented as 2:00 P.M., dose OT and not given. On 03/16/24, Pentosan Polysulfate Sodium 100 mg, evening dose was documented as OT and not given. On 03/19/24, Pregabalin Oral Capsule 75 mg was not documented as given; Nucynta 50 mg was not documented as given; Methocarbamol 500 mg was not documented as given; and Levothyroxine Sodium 50 mcg not documented as given. On 03/24/24, Pentsan Polysulfate Sodium 100 mg morning and afternoon dose documented as drug not available and not given; and on 03/27/24, Pentsan Polysulfate Sodium 100 mg morning and afternoon dose documented as OT and drug not given. Review of the MAR for April 2024 revealed on 04/04/24, Levothyroxine Sodium 50 mcg not documented as given; and Cephalexin 500 mg, 8:00 A.M. dose not documented as given. On 04/12/24, Midodrine HCI 10 mg afternoon dose not documented as given. On 04/20/24, Insulin Lispro 100 units / 1 ml , 7:30 A.M. and 5:30 P.M. dose not documented as given; Pyridium 100 mg, morning dose not documented as given; Midodrine HCI 10 mg, morning and afternoon dose not documented as given; Buspirone 15 mg not documented as given; Polyethylene Glycol 17 gram documented as drug not available and not given; Theragram-M not documented as given; Desitin External Paste 40% not documented as given; and Extrogens Conjugated Vaginal Cream 0.625 mg / gm Insert 0.5 gram not documented as given; and on 04/23/24, Chlorhexidine Gluconate External Liquid 4% was documented as drug not available and not given. 3. Review of medical record for Resident #62 revealed an admitted [DATE], with diagnoses of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, and epilepsy, not intractable, without status epilepticus. Review of the quarterly MDS assessment dated [DATE], revealed Resident #63 with moderate cognitive impairment. Review of physician orders dated 03/23/24, to administer Depakote oral tablet delayed release (divalproex sodium) 250 mg, 3 times daily for seizures and levetiracetams oral tablet 1000 mg, 2 times daily for seizures. Review of the Electronic Medical Record (EMAR) Resident Detail report for April 2024, revealed Resident #58 received the Depakote Oral Tablet Delayed Release 250 mg (Divalprox Sodium) on 04/22/24 at 1:34 A.M., 9:58 A.M. and 11:30 P.M.; on 04/11/24 at 1:18 A.M.; on 04/10/24 at 12:38 A.M.; on 04/08/24 at 4:23 P.M. and 12:54 A.M.; on 04/05/24 at 5:44 A.M.; on 04/04/24 at 1:47 A.M.; on 04/02/24 at 3:24 A.M.; and on 04/01/24 at 1:20 P.M. The times were not consistent, or the medication was not administered 3 times a day or at all. Review of the EMAR Resident Detail report for March and April 2024, revealed Resident #58 received the levetiracetam oral tablet 1000 mg on 03/29/24 at 12:33 P.M.; on 03/30/24 at 2:22 A.M.; on 04/01/24 at 1:20 A.M.; on 04/02/24 at 3:24 A.M. and 1:18 P.M., on 04/04/24 at 1:48 A.M., on 04/05/24 at 5:44 A.M., on 04/08/24 at 12:54 A.M. and 1:48 P.M.; on 04/10/24 at 12:39 A.M. and 12:46 A.M.; on 04/11/24 at 1:19 A.M.; on 04/15/24 at 11:42 A.M.; on 04/21/22 at 11:22 A.M.; and 04/22/24 at 1:34 A.M. and 11:30 P.M. The times were not consistent, or the medication was not administered 2 times a day or at all. 4. Review of medical record for Resident #63 revealed an admitted [DATE], with diagnoses unspecified convulsions, Crohn's disease, irritable bowel syndrome without diarrhea, and constipation. Review of the physician orders dated 03/15/24, to administer MiraLax Oral Packet (polyethylene glycol 3350) give 17 grams by mouth two times a day for constipation; Nifedipine Extended Release (ER) 90 mg oral tablet 24 hour, give 1 tablet one time a day for hypertension; and Lunesta oral tablet 2mg (eszopiclone) give 1 tablet one time a day for sleep. Review of the physician order dated 03/16/24, to administer Lidocaine External Patch 4 %, apply to lower back topically one time a day for pain. Review of the physician order dated 03/20/24, to administer Hydrocortisone external cream 2.5%, apply to inner thighs and groin for chaffing. Review of the physician order dated 03/23/24, to administer Zofran 4 mg, give 1 tablet by mouth before meals for nausea. Review of the MAR for March 2024 for Resident #63 revealed on 03/23/24, Hydrocortisone external cream 2.5%, apply to inner thighs and groin documented as OT (other and not administered in the morning). On 03/28/24, Zofran 4 mg, documented as OT (other) and not administered for 7:30 A.M. dose. Review of the MAR for April 2024, for Resident #63 revealed on 04/10/24, Lidocaine 4% Patch documented as OT (other) and not administered in the morning. On 04/12/24, Miralax 17 grams documented as OT (other) and not administered in the morning. On 04/14/24, Miralax 17 grams documented as not available and not administered in the morning. On 04/19/24, Nifedipine ER 90 mg documented as not available and not given in the morning. On 04/20/24, Nifedipine ER 90 mg documented as OT (other) and not given in the morning. On 04/21/24 and 04/22/24, Lunesta 2 mg documented as OT (other) and not administered in the evening. Interview on 04/24/24 at 10:35 A.M., with Licensed Practical Nurse (LPN) #325 revealed medications are administered if available, and the facility runs out of stock medications frequently. LPN #325 stated when medications are not available nurses will chart DN for drug not available or OT for other and sometimes the nurses will document in the nurses notes about this. Interview on 04/24/24 at 11:29 A.M., with Registered Nurse (RN) #336 revealed if it is documented on the MAR as DN, it means drug is not available and not given; if OT is documented on the MAR, it also means the drug was not given. RN #336 stated it is just for another reason other than drug not available and should be documented in the notes as to why, but that never happens. RN #336 stated it is the nurses responsibility to reorder drugs and supplies timely, but that does not always happen. RN #336 stated it is a weekly problem that medications are not available and there is not a backup supply of over-the-counter medications available when the supply runs out. Interview on 04/24/24 at 4:25 P.M., with Director of Nursing (DON) revealed there were no concerns reported related to medications not available. DON reported if it is an over-the-counter medication, the facility will go to Walmart or the local pharmacy and pick it up. DON verified the medications were not documented as being administered per physician orders for Resident #21, #41, #58 and #63. Review of the facility provided Medication Pass Times scheduled revealed pass times for 2 times daily are 7:00 A.M. - 11:00 A.M. and 7:00 A.M. - 11:00 P.M. Review of the facility provided Medication Pass Times schedule revealed the pass times for 3 times daily are 7:00 A.M. - 11:00 A.M. and 1:00 P.M. - 2:30 P.M. and 7:00 P.M. - 11:00 P.M. Review of the policy titled, Specific Medication Administration Procedures, dated November 2021, revealed it is the policy to administer medications in a safe and effective manner. Review 5 rights 3 times, check Medication Administration Record (MAR) / Treatment Administration Record (TAR) for order. This deficiency represents non-compliance investigated under Master Complaint Number OH00153130 and Complaint Number OH00152823

Based on record review, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to ensure there was sufficient staffing to provide timely assistance with Activities of Daily Living (ADL's). This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82. Findings include: Review of medical record for Resident #11 revealed admitted [DATE] with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition on The resident was admitted with diagnoses including anxiety, depression, sleep apnea and stage three kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility and supervision for eating. Review of the progress note dated 03/07/24 by Assistant Director of Nursing (ADON) #106 revealed documentation that Resident #11 had requested to take the sit to stand transfer device to her room. Resident #11 was educated she was not able to use the standby herself and the device required two staff members to operate. Interview on 03/28/24 with ADON #106 revealed Resident #11 was upset on 03/07/24 because she needed to use the bathroom and unfortunately each aid was occupied in a room. ADON #106 stated she was unable to assist Resident #11 by herself as the sit to stand device required two staff. ADON #106 stated it took an additional thirty minutes for Resident #11 to be assisted to the bathroom. Interview on 03/28/24 at 1:48 P.M. with Resident #11 revealed she had waited two hours to be provided care on the evening of 03/27/24. Resident #11 stated her State tested Nursing Assistant (STNA) #111 came into her room around 9:00 P.M. Resident #11 stated she was upset because no one acknowledged her call light was on and at least told her they would be back in to assist her when they were free. Resident #11 stated she also voiced her concern to Human Resource #110. Interview on 03/28/24 at 1:59 P.M. with Human Resource #110 acknowledged he had been informed by Resident #11 that she had her call light on for two hours before STNA #111 entered the room to provide care. Human Resource #110 did not refute her statement, and stated education would be provided to STNA #111. Interview on 03/28/24 at 2:29 P.M. with STNA #111 revealed she did not arrive for her 7:00 P.M. shift until 8:00 P.M., and stated she had previously informed the facility she would be late. STNA #111 stated there was no STNA to receive report from upon her arrival. STNA #111 also revealed she was upset her assignment had the top of the 100-hall added to her 300-hall assignment. STNA #111 verified Resident #11 was on her added assignment. STNA #111 acknowledged Resident #11's call light had been on when she arrived and once she figured out her assignment, she answered it. STNA #111 said Resident #11 had informed her the call light had been on for two hours. STNA #111 stated Resident #11 was incontinent and needed to be taken to the bathroom to be cleaned. Interview on 03/28/24 at 3:24 P.M. with Licensed Practical Nurse (LPN) #112 revealed she worked the evening of 03/27/24. LPN #112 stated Resident #11 was being assisted by staff in the bathroom in getting cleaned up. LPN #112 stated Resident #11 informed her she had her call light on for two hours. LPN #112 shared she did not doubt Resident #11's call light was on for an extended amount of time. LPN #112 shared STNA #111 was late for her shift and upset with her assignment when she did come in, and there was a nurse who was a no call no show and adjustments in the schedule had to be made. The facility confirmed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Interview on 03/28/24 at 5:18 P.M. with LPN #114 revealed she worked day shift on 03/27/24 and stayed until about 8:30 P.M. because her replacement nurse was late. LPN #114 shared STNA #111 came into work late and was upset with her assignment, called management and walked off the unit. LPN #114 stated she did not see her return, and she left at 8:30 P.M. LPN #114 acknowledged Resident #11's call light was going off during that time period, but she could not say for how long. Review of the nursing clock in times provided by the facility revealed STNA #111 punched in for her on 03/27/24 at 8:00 P.M. Review of the staffing sheet for STNA #111 revealed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Review of the facility policy, Call Light, Use of, last reviewed 11/30/23 documented to answer call lights whether or not you are assigned to the area. This deficiency represents non-compliance investigated under Complaint Numbers OH00152381, OH00152091 and OH00151819

Based on record review, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to provide timely Activities of Daily Living (ADL's) assistance. This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82. Findings include: Review of medical record for Resident #11 revealed admitted [DATE] with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition on The resident was admitted with diagnoses including anxiety, depression, sleep apnea and stage three kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility and supervision for eating. Review of the progress note dated 03/07/24 by Assistant Director of Nursing (ADON) #106 revealed documentation that Resident #11 had requested to take the sit to stand transfer device to her room. Resident #11 was educated she was not able to use the standby herself and the device required two staff members to operate. Interview on 03/28/24 with ADON #106 revealed Resident #11 was upset on 03/07/24 because she needed to use the bathroom and unfortunately each aid was occupied in a room. ADON #106 stated she was unable to assist Resident #11 by herself as the sit to stand device required two staff. ADON #106 stated it took an additional thirty minutes for Resident #11 to be assisted to the bathroom. Interview on 03/28/24 at 1:48 P.M. with Resident #11 revealed she had waited two hours to be provided care on the evening of 03/27/24. Resident #11 stated her State tested Nursing Assistant (STNA) #111 came into her room around 9:00 P.M. Resident #11 stated she was upset because no one acknowledged her call light was on and at least told her they would be back in to assist her when they were free. Resident #11 stated she also voiced her concern to Human Resource #110. Interview on 03/28/24 at 1:59 P.M. with Human Resource #110 acknowledged he had been informed by Resident #11 that she had her call light on for two hours before STNA #111 entered the room to provide care. Human Resource #110 did not refute her statement, and stated education would be provided to STNA #111. Interview on 03/28/24 at 2:29 P.M. with STNA #111 revealed she did not arrive for her 7:00 P.M. shift until 8:00 P.M., and stated she had previously informed the facility she would be late. STNA #111 stated there was no STNA to receive report from upon her arrival. STNA #111 also revealed she was upset her assignment had the top of the 100-hall added to her 300-hall assignment. STNA #111 verified Resident #11 was on her added assignment. STNA #111 acknowledged Resident #11's call light had been on when she arrived and once she figured out her assignment, she answered it. STNA #111 said Resident #11 had informed her the call light had been on for two hours. STNA #111 stated Resident #11 was incontinent and needed to be taken to the bathroom to be cleaned. Interview on 03/28/24 at 3:24 P.M. with Licensed Practical Nurse (LPN) #112 revealed she worked the evening of 03/27/24. LPN #112 stated Resident #11 was being assisted by staff in the bathroom in getting cleaned up. LPN #112 stated Resident #11 informed her she had her call light on for two hours. LPN #112 shared she did not doubt Resident #11's call light was on for an extended amount of time. LPN #112 shared STNA #111 was late for her shift and upset with her assignment when she did come in, and there was a nurse who was a no call no show and adjustments in the schedule had to be made. The facility confirmed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Interview on 03/28/24 at 5:18 P.M. with LPN #114 revealed she worked day shift on 03/27/24 and stayed until about 8:30 P.M. because her replacement nurse was late. LPN #114 shared STNA #111 came into work late and was upset with her assignment, called management and walked off the unit. LPN #114 stated she did not see her return, and she left at 8:30 P.M. LPN #114 acknowledged Resident #11's call light was going off during that time period, but she could not say for how long. Review of the nursing clock in times provided by the facility revealed STNA #111 punched in for her on 03/27/24 at 8:00 P.M. Review of the staffing sheet for STNA #111 revealed STNA #111 was assigned to 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 hall and top of the 100 hallway assignment. Review of the facility policy, Call Light, Use of, last reviewed 11/30/23 documented to answer call lights whether or not you are assigned to the area. This deficiency represents non-compliance investigated under Complaint Numbers OH00152381, OH00152091 and OH00151819

Based on record review, observations, staff interviews and policy review, the facility failed to ensure infection control procedures were followed during wound care. This affected one (#14) of three residents reviewed for wound care. Facility census was 82. Findings include: Review of medical record for Resident #14 revealed admitted [DATE]. Diagnoses include diabetes mellitus type two, necrotizing fasciitis, acute osteomyelitis left ankle and foot. The resident remains at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #14 required extensive one person assistance for toileting and supervision for eating, bed mobility and transfers. Review of Resident #14's physician orders revealed an order to cleanse wound with normal saline, pat dry with non-sterile gauze and reapply wound vacuum negative pressure on Mondays, Wednesdays and Fridays with a start date of 03/25/24. A second order to cleanse external fixator pins with normal saline, pat dry and apply split sponge every sift with a start date of 03/16/24. Observation on 03/17/24 at 3:35 P.M. of wound care by Registered Nurse (RN) #105 for Resident #14 revealed RN #105 removed the old sponge and dressing from the left lateral ankle of Resident #14 and disposed of it in the trash can. Without removing her gloves, she applied normal saline to the wound and patted it dry. RN #105 then opened a new dressing kit, removed and cut the sponge to fit the wound and secured it with tape. A small hole was cut into the tape and the wound vacuum was reapplied and restarted. RN #105 then removed her gloves and grabbed another pair of gloves and applied them without performing hand hygiene. RN #105 then proceeded to clean the external fixator pins. RN #105 cleansed the top two pins with normal saline on a four by four, and patted the area dry. RN #105 then repeated the same procedure to the bottom pins, using the same pair of gloves. After care was completed, RN #105 removed her gloves and washed her hands using soap and water. Interview on 03/17/24 at 4:11 P.M. with RN #105 verified she did not change her gloves after removing the old dressing, or in between the care of two separate wound sites. Review of the facility policy titled, Dressing Change dated 11/30/23 documented after removing and disposing of soiled dressing, dispose of gloves. Also documented was to cleanse wound as prescribed, remove gloves and wash hands or use hand sanitizer. This deficiency represents non-compliance investigated under Complaint Numbers OH00152243 and OH00152091.

Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected #81 of three residents reviewed. The census was 78. Findings include: Review of Resident #59's medical record revealed an admitted [DATE]. Diagnoses included end stage renal disease, hypertensive heart failure, hemiplegia, type two diabetes mellitus, and chronic leg ulcer. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #59 was severely cognitively impaired. Review of physician orders revealed an order dated 11/02/23 for Percocet (narcotic pain medication oxycodone and acetaminophen) five and 325 milligrams (5-325 mg) give 5-325 every four hour as needed (PRN) for pain. Give every four hours PRN for general discomfort repositioning, relaxation, distraction and comfort measures provided and ineffective. Review of the facility's Controlled Drug Record revealed one tablet of Percocet 5-325 mg was documented as being withdrawn on 12/14/23 at 10:00 A.M. and on 12/14/23 at 4:00 P.M. Review of medication administration records (MAR's) revealed no documentation of Percocet 5-325 mg being administered on 12/14/23 at 10:00 A.M. and on 12/14/23 at 4:00 P.M. During a phone interview on 12/18/23 at 10:00 Registered Nurse (RN) #200 stated she administered Percocet 5-325 mg to Resident #59 on 12/14/23 at 10:00 A.M. and on 12/14/23 at 4:00 P.M. RN #200 was unable to explain why the Percocet administrations were not documented in Resident #59's MAR. During an interview on 12/18/23 at 11:07 A.M. A.M. the Director of Nursing (DON) confirmed the missing and inaccurate documentation in Resident #59's MAR for Percocet 5-325 mg. Review of the facility's policy titled Medication Administration-General Guidelines dated November 2021 revealed the individual who administers the medication dose records the administration on the resident's medication administration record (MAR) and or electronic medication administration record (eMar) directly after the medication is given. At the end of each medication pass the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administers the medications report off-duty without first recording the administration of medications. This deficiency represents non-compliance investigated under Complaint Number OH00148990.

Based on medical record review, resident interview, and staff interview, the facility failed to schedule a blood transfusion as ordered for Resident #273 after critical laboratory (lab) results were received. This resulted in actual harm when Resident #273 was hospitalized due to symptoms of chest pain and shortness of breath and required blood [CONDITION(S)]. This affected one (Resident #273) of three residents reviewed for hospitalization . Additionally, the facility failed to ensure Resident #24's wound dressing was applied as ordered. This affected one (Resident #24) of one resident reviewed for wound care. The facility failed to ensure Resident #34 received timely antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (Resident #34) of three residents reviewed for UTIs. The facility failed to ensure a resident received timely treatment following a fall. This affected one (Resident #62) four residents reviewed for falls. The facility census was 72. Findings include: 1. Medical record review for Resident #273 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #237's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of two staff members for Activities of Daily Living (ADLs). Review of Resident #273's lab results dated 08/01/22 revealed a hemoglobin level at 6.2, critically low. Lab results dated 08/08/22 revealed a hemoglobin level at 6.4, critically low. Both lab results indicated the labs were verified by repeat analysis. Review of Resident #273's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Once scheduled, arrange for transportation, and add to the calendar. Review of the progress note dated 08/08/22 at 8:27 A.M. revealed Resident #273 had a hemoglobin level of 6.4. The resident reported he was not feeling well and was very cold and requested to be transferred to the hospital. Review of the progress note dated 08/08/22 at 8:08 P.M. revealed Resident #273 had critical lab results of a 6.4 hemoglobin level and was ordered to be sent to the emergency room (ER) for blood [CONDITION(S)]. Continued review of progress notes revealed no documented regarding the lab results on 08/01/22, including subsequent treatment plans. Review of the acute care transfer report dated 08/08/22 revealed Resident #273 was transferred to the hospital due to hemoglobin concerns. Review of the hospital ER documentation dated 08/08/22 revealed Resident #273 was admitted to the hospital on 08/08/22 with a hemoglobin of 5.8 and was diagnosed with symptomatic [CONDITION(S)] and chest pain, with a plan for blood [CONDITION(S)] and orthopedic surgery consult. Review of the history and physical revealed the physician reported Resident #273 admitted with symptomatic low hemoglobin with recent blood loss and shortness of breath. The resident reported his wound vac was removed due to low output, but since removal, output had increased with blood loss. It was reported the resident's hemoglobin was low and Resident #273 was supposed to receive blood [CONDITION(S)], but never did. Blood pressure in the emergency department was in the 145 to 150's (high). Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician note dated 08/12/22 revealed Resident #273 was having shortness of breath with increasing oxygen needs in the ER with a hemoglobin level of 5.8. The resident was admitted to the intensive care unit (ICU). Interview on 08/15/22 at 1:37 P.M. with Resident #273 revealed the resident had labs completed weekly. The resident reported he was told by nursing staff he was supposed to get a blood transfusion from an outpatient clinic, due to having a low hemoglobin level, but the appointment was never scheduled. Resident #273 stated his family wrote a message on a dry erase board to remind staff to schedule the blood transfusion by 08/05/22. Observation revealed the note was still present. Interview on 08/17/22 at 9:39 A.M. with the Director of Nursing (DON) revealed she had been working on getting Resident #273 an appointment for the blood [CONDITION(S)] and reported the physician was also assisting in getting the appointment and communicating with the transfusion clinic. The DON stated they had a tentative appointment for 08/05/22 but was unable to secure transportation services. The DON verified there was no evidence of these appointments being scheduled and no referral information, fax results, etc. The DON reported she was off work on 08/08/22 and 08/09/22 and when she returned, she planned to continue to set up the resident's appointment, but he had already been transferred to the hospital. The DON further verified the discrepancy in dates for the resident's blood transfusion order. The order was dated 08/03/22 for the resident to have a blood transfusion on 08/02/22. The DON was thinking the order could have been obtained verbally and documented late however, she was not sure. Interview on 08/17/22 at 2:36 P.M. with Physician #226 revealed she was informed of Resident #273's critical lab results via text on 08/01/22. Physician #226 reported she wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician #226 verified she did not assist the DON in coordinating the appointment and thought the facility would have scheduled the appointment in a timely manner. On 08/05/22 Physician #226 was notified the resident had not received the transfusion, and she was planning to follow up on 08/08/22, when the infusion clinic was open, but the resident had gone out to the hospital. Physician #226 reported she did not have time to schedule follow-up appointments for residents and thought the facility would have followed her order. 2. Review of the medical record for the Resident #24 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #24 was cognitively intact and required supervision and limited assistance of one staff for mobility. Resident #24 had a [CONDITION(S)] with infection in the foot Review of Resident #24's care plan dated 06/10/22 revealed no mention of wound treatments. Review of Resident #24's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 08/16/22 at 9:35 A.M. with Resident #24 revealed he had a wound on his ankle. Resident #24 revealed staff completed treatments and he should have a bandage on his wound. Resident #24 reported the dressing must have come off when he was sleeping and stated he wanted the nurse to apply a new dressing because the wound was draining on the bed sheets. Observation revealed there was no dressing applied to the resident's ankle wound. Observation on 08/16/22 at 4:45 P.M. revealed Resident #24 still did not have any bandage or dressing applied to his ankle wound. Interview on 08/16/22 at 4:48 P.M. with Registered Nurse (RN) #225 verified Resident #24 did not have a wound dressing applied to his right ankle. RN #225 looked at her paperwork and reported the resident did not have any dressing changes ordered/scheduled. RN #225 reviewed the resident's medical record and found Resident #24 had a wound treatment ordered for his right ankle and she was not aware of the order. 3. Review of the medical record for the Resident #34 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #34 had significant cognitive impairment and required extensive assistance of two staff members for transfers and mobility. Review of the lab results collected on 08/11/22 and resulted on 08/13/22 revealed Resident #34 had a urinary tract infection ([CONDITION(S)]) positive for E. coli in the urine. Review of the progress note dated 08/15/22 revealed the physician was contacted regarding Resident #34's urinalysis result and ordered an antibiotic for a seven-day course. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 08/17/22 at 9:39 A.M. with the DON revealed staff should check for lab results each shift and should inform the physician and family after review. The DON reported the physician and nurse practitioner (NP) were available to call on evenings and weekends to discuss irregular lab results and treatments. The DON reported the expectation was for staff to have called the physician or NP on 08/13/22 when they received Resident #34's urinalysis results. Interview on 08/17/22 at 2:36 P.M. with Physician #226 revealed staff could get in touch with her by an electronic chat system or by text messaging. Physician #226 reported she expected staff to get in touch with her the same day of receiving lab results. Physician #226 indicated she would have started antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Antibiotic treatment was started on 08/15/22. Review of facility policy titled Lab, dated 03/2022 revealed lab results would be forwarded to or communicated with the ordering physician before the end of the shift during which the lab resulted. Review of facility policy titled, Change in Status, Identifying and Communicating, Long Term Care, dated 08/20/21 revealed the facility was responsible for communicating a change in condition to the appropriate practitioner. 4. Record review revealed Resident #62 was admitted to the facility in 2013. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 01/11/22 revealed Resident #62 had urinary incontinence related to impaired mobility, urinary retention, [CONDITION(S)] brain injury, and [CONDITION(S)]. Interventions included to provide assistance with toileting at routine intervals. Review of the care plan dated 01/11/22 revealed Resident #62 was at risk for falls due to sensory deficit related to a brain injury and safety awareness loss due to brain injury, recent falls, and difficulty walking. Interventions were to assist and instruct resident to move himself back in wheelchair, assist resident to position in center of the bed while sleeping, leave door open when resident was alone, provide a dump wheelchair to assist with maintaining sitting balance, education to staff for toileting, encourage to be in common area while in chair for increased supervision, have commonly used items within easy reach, non-skid material to seat of wheelchair, offer toileting before and after each meal and at bedtime, reinforce use of call light for transfer to the toilet, remind and reinforce use of call light assistance, remind resident to keep seatbelt in place, and to remind him to lift his feet when being transferred into the wheelchair. Provide a scoop mattress to the bed. The resident required assistance for transferring from one position to another as evidenced by impaired mobility. Make sure to use a gait belt with one-person assistance to facilitate safe transfers. Review of annual Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was moderately cognitively impaired. He required extensive assistance for bed mobility and transfers. He required the assistance of one person for toilet use. Review of the most recent fall assessment, date 07/29/22, documented Resident #62 had difficulty maintaining balance and impaired balance during transitions. The internal risk factors were loss of arm or leg movement and cognitive impairment. The resident triggered for fall deficit related to recurring falls without injury. Resident had falls in the past, but has had no falls since the prior assessment or during the look back period. The resident was educated and care planned for fall risk and interventions. There were no referrals needed at the time of the assessment and precautions were in place. Review of the progress notes dated 08/08/22 at 4:04 P.M. revealed the resident was found on the floor in his bathroom, attempting to transfer himself from the toilet to the wheelchair. Vital signs were within normal limits, but he complained of pain to his right elbow. The physician was texted and awaiting reply. Neurological checks were initiated. Review of the facility's fall investigation, dated 08/08/22, revealed Resident #62 was assisted to the toilet by staff and reminded to use the call light when finished. The resident did not use the call light and attempted to transfer back into the wheelchair by himself. He was found on the bathroom floor. Vital signs were taken, skin was assessed and the resident was placed back into the wheelchair. The resident denied hitting his head but complained of elbow pain. Review of a witness statement written by LPN #120 on 08/08/22 revealed after the resident's fall, his range of motion was within normal limits. He was ambulating in his wheelchair. He complained of pain here and there. The physician was notified and an X-ray was ordered. Review of Radiology Report, dated 08/09/22 at 11:08 A.M. revealed the right hand had radiolucency (transparency) within the distal radius and was suspicious for a non-displaced fracture. The right elbow did not have any fracture or dislocation. Review of the progress note dated 08/10/22 at 10:50 A.M. revealed Registered Nurse (RN) #174 notified the physician of the x-ray results for the right hand fracture, 24 hours after the results were received by the facility. The resident was having pain and swelling to the right hand. The physician gave the order to send to the emergency room for arm to be set. Review of the pain evaluation on 08/09/22 and 08/10/22 revealed no concerns for pain. Review of the progress note dated 08/10/22 at 4:30 P.M. revealed the resident returned to the facility with a splint to the right arm. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/17/22 at 11:15 A.M., Registered Nurse (RN) RN #174 stated she sent Resident #62 to the hospital on 08/10/22. RN #174 verified the X-ray results were received on 08/09/22 but the physician wasn't notified until the next day, 08/10/22. During an interview on 08/17/22 at 3:14 P.M., LPN #109 stated he lab faxed x-ray results to the facility and it was the nurses' responsibility to review incoming faxes and follow-up with the physician. This deficiency substantiates Complaint Number OH 967.

Based on medical record review, fall investigation review, policy review, staff and resident interviews, the facility failed to ensure a safe transfer was provided by two staff to prevent a fall with injury. This resulted in actual harm when a State tested Nursing Assistant (STNA) #102 transferred Resident #28 alone allowing the resident to sustained a fall and subsequently sustained a fractured rib. This affected one (#28) of five residents reviewed for falls. The facility identified 29 residents that required assistance with ambulation or use of assistive devices. The facility census was 98. Findings include: Review of resident record revealed Resident #28 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of the undated facility Kardex Report revealed safety intervention for Resident #28 included intervention of two-person extensive assist for transfers, toileting, and bed mobility due to fall risk. Review of Resident #28's Care Plan dated 11/16/18 revealed the resident was at risk for falls due to left sided weakness related to a stroke, abnormal gait, muscle weakness, and [MEDICAL CONDITION]. Interventions including have commonly used articles within reach, provide assistance with transfer and ambulate as needed to go to the restroom. Interventions initiated on 01/22/19, (after a fall) revealed resident was educated to call out for assistance with getting dressed. Intervention initiated on 02/11/18 (after a fall) revealed two-person extensive assistance for transfers, toileting and bed mobility. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was moderately cognitively impaired with no noted behaviors. Review of Section G-Functional assessment revealed the resident required extensive two-person assistance with bed mobility, transfers, dressing, toileting, personal hygiene, walking did not occur, extensive one-person assistance with locomotion, and supervision with setup for eating. The resident was noted as not steady with moving from seated to standing position and/or surface-to-surface transfers. Review of Section DJ-Health condition revealed the resident had two or more falls since admission/entry/reentry or prior assessment with one fall with major injury noted. Review of Nursing Progress Notes dated 01/21/19, revealed Resident #28 was found in the room on the floor near the closet with a noted laceration and hematoma to the right lower back of the head. The physician was notified, and the resident was sent to the local hospital and returned with [DIAGNOSES REDACTED]. On 02/01/19, Resident #28 was found face down in the room next to the bed, with a goose egg forming over the left brow. The resident was assessed, and physician was notified with no new order. On 02/03/19, the resident had complaints to the left hip and wrist with x-rays ordered, and no acute fracture noted. On 02/06/19, the resident had complaints of worsening left hip pain, with new orders obtained for another x-ray. On 02/07/19, x-ray results received and reviewed with indication to get a computed topography (CT) scan to check for possible fracture. Resident #28 was sent to the local hospital, admitted , and diagnosed with [REDACTED].#28 returned to the facility with incision line to left hip. On 03/27/19 approximately 4:30 P.M., the aid was in the room with the residents when the resident lost her balance and slid to the floor. The resident was alert and complained of right hip and rib pain. The physician and family were notified, and orders for x-rays were obtained and revealed the resident sustained [REDACTED]. Review of the fall investigation on 03/27/19, revealed State tested Nurse Aide (STNA) #102 was transferring Resident #28 from the wheelchair to the toilet, when the resident fell backwards striking the wheelchair. The resident was assessed by the nurse, and the resident had complaints of hip and chest pain. The nurse notified the physician who ordered x-rays. Review of Radiology Results dated 03/27/19 revealed Resident #28 was noted with a fracture involving the right 10th rib with no displacement. Interview on 04/16/19 at 11:27 A.M., with Resident #28 revealed she recently fell in the bathroom and broke her rib when an aid couldn't hold her up as she was assisting her to the bathroom and the resident fell hitting the wheelchair. Resident #28 stated there was only one aid assisting her to the restroom at the time of the incident. Resident #28 stated after she broke her rib she had pain, and received Tylenol, but it didn't really help so she would send it back most the time. Interview with the Director of Nursing on 04/17/19 at 1:08 P.M., revealed on 02/01/18, Resident #28 sustained a fall resulting in a [MEDICAL CONDITION]. DON stated the updated interventions was Resident #28 was made a two-person assist for activities of daily living (ADL's). On 03/27/19, STNA #102 transferred the resident by herself and the resident fell . Interview on 04/17/19 at 3:00 P.M., with STNA #102 revealed she was the aid working with Resident #28 the day of her fall on 03/27/19. STNA #102 stated she went in the room to assist Resident #28 to the bathroom independently. When Resident #28 was assisted to a standing position at the sink, and had a good grip on the sink, STNA #102 went to move the wheelchair to assist her to the toilet, and Resident #28 lost her grip and fell back hitting the seat of the wheelchair. STNA #102 stated aids are notified in report and on Kardex of what assistance resident's required with ADL's. STNA #102 stated no one ever informed her that Resident #28 was a two-person assist. STNA #102 then reviewed Kardex and verified Kardex noted Resident #28 was a two-person physical assist for safety. Review of the facility policy titled Falls Practice Guide Flowchart, dated 2011, revealed when resident sustains a fall the facility will complete fall evaluations, revise the resident care plan, and update the resident's information in Kardex. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on closed medical record review, review of hospital records, review of facility policy, and staff interviews, the facility failed to appropriately monitor, accurately assess, provide interventions, coordinate care between providers, manage pain, and seek timely medical attention for avoidable facility acquired wounds and pressure ulcer for one resident (Resident #102) of five reviewed for skin breakdown. This resulted in Immediate Jeopardy when Resident #102 was sent to the hospital for a critical potassium laboratory value of 8.0 millimoles per liter (mmol/L) which was unrelated to the resident ' s leg wounds. Resident #102 experienced actual harm as the hospital staff identified necrotic right lower leg wounds with gangrene (dead tissue) and osteo[DIAGNOSES REDACTED] (painful bone infection) which required a right Above Knee Amputation (AKA) due to the seriousness of the resident ' s lower leg wounds. The facility census was 97. On 04/12/16 at 3:56 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Quality Assurance Consultant (QAC) #30 and Regional Director of Operations (RDO) #50 were notified Immediate Jeopardy began on 03/16/16, when Resident #102 suffered harm when she developed uncontrolled pain, even with narcotic pain medication, worsening wounds and pressure ulcers without appropriate interventions to promote healing and had multiple missed treatments. Resident #102 was sent to the hospital on [DATE] due to a critical laboratory value. While at the hospital, the medical staff identified the resident ' s right lower leg wounds with gangrene and necrotic tissue resulting in a right AKA. The Immediate Jeopardy was removed on 04/12/16 when skin sweeps were completed by licensed nurses on all residents residing in the facility and the facility implemented the following corrective actions: · On 03/27/16 Resident #102 was sent to the hospital emergency room (ER). · On 04/12/16, a skin sweep was completed on all residents residing in the facility by the wound team including the DON, Registered Nurse (RN) #13 and Licensed Practical Nurse (LPN) #14. Three new areas were identified for Residents #6, #8 and #22. No unknown etiologies were identified. · On 04/12/16, the facility nursing managers began retraining licensed staff and direct care staff on the Skin and Pain Practice Guidelines that were already in place. · On 04/12/16, a Quality Assurance (QA) meeting was held with the medical director via teleconference on the prevention plan and accepted by the medical director. · On 04/13/16, all newly identified skin alterations were assessed further by the wound team and notification was made to the Certified Nurse Practitioner (CNP) #15. · Effective immediately, the LNHA and DON will monitor the Skin and Pain program to include notification to the attending physician of changes in condition through the morning Interdisciplinary Team (IDT) meeting daily for the next 14 days, then Monday through Friday. Quality Assurance Consultant #30 will attend weekly wound rounds for four weeks along with weekly skin sweeps for four weeks. Areas of deficiency will be submitted to the QA committee and corrected immediately. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] documented the resident had no skin alterations upon admission. On 01/30/15, Resident #102 had an order to apply a splint to the right lower leg at night due to her [DIAGNOSES REDACTED].#102 had cognitive impairment and required extensive assistance of two staff for bed mobility and transfer. She had one Stage IV pressure area, one venous ulcer, and a newly developed Stage II pressure area not present on the last assessment dated [DATE]. Review of the Braden Scale for Predicting Pressure Ulcer risk dated 11/18/15 documented Resident #102 was at moderate risk for skin breakdown. The quarterly due in February 2016 was not completed. Review of skin notes dated 12/10/15 documented a new friction/skin breakdown area to the right lateral calf area which measured 1.0 centimeter (cm) by 0.5 cm by 0.1 cm. The wound bed was red with attached edges and 100 % granulation tissue. The resident denied any pain prior to, during and after treatment. Skin notes from 12/17/15 through 02/12/16 revealed the area had shown some improvement. The next skin note (two weeks later) completed by the DON was dated 02/26/16 and revealed the wound now measured 6.4 cm by 2.0 cm by 1.0 cm, and there was no description of the wound. Nurses ' notes dated 02/29/16 and 03/01/16 revealed the resident cried out when her leg was touched or moved. The skin note dated 03/02/16 revealed the wound worsened and measured 13.5 cm by 5.0 cm by 1.5 cm with eschar 35% and 15% non-viable tissue. The Physician Assistant (PA) performed bedside debridement and noted a large amount of exudate. The skin note dated 03/04/16 documented the wound with unstageable eschar present, and a large amount of exudate with foul odor was noted. On 03/11/16 the nurse ' s note revealed the wound was unstageable with eschar present. The PA performed a second debridement of area. A large amount of exudate was noted. Nurse's note dated 03/11/16 documented leg pain upon movement. Nurse's note dated 03/15/16 revealed treatments were performed and a moderate amount of bloody foul smelling drainage was noted to the back of the left calf dressing. The nurse's note dated 03/16/16 revealed treatments were performed and green drainage was noted on the dressing with foul odor, and the resident had facial grimacing during the treatment. There was no notification to the physician of the worsening wound and pain during treatments. The skin note dated 03/18/16 revealed the wound measured 12.4 cm by 4.7 cm with unstageable eschar present. The PA performed a third debridement of the area and there was a large amount of exudate. Nurse ' s note dated 03/19/16 revealed treatment was completed to the wound, and a foul odor was noted and was tender to touch. The medical record had no other documentation regarding the wound until 03/25/16. The Hospice nurse ' s note dated 03/22/16 revealed wounds on the right calf were draining a brownish drainage with a foul odor. Certified Nurse Practitioner (CNP) #15 ordered [MEDICATION NAME] (anti-biotic) for [MEDICAL CONDITION]. Review of the Hospice STNA note dated 03/23/16 documented the resident was in a lot of pain during care and the Hospice nurse was made aware. Nurse's note dated 03/23/16 revealed an order for [REDACTED]. Nurse ' s note dated 03/24/16 documented to discontinue the Keflex medication as the resident had an allergy to the medication. There was no follow up with the physician regarding to discontinue the Keflex. The wound now measured 13.5 cm by 5.0 cm by 1.5 cm with unstageable eschar present. Treatments were changed to twice daily and as needed. Nurse's note dated 03/26/16 at 2:52 P.M. revealed the resident was very lethargic and clammy. The resident had a blood pressure reading of 88/44 millimeters of mercury (mm Hg). New orders were obtained for [MEDICATION NAME] (anti-biotic) for wound infection and [MEDICATION NAME] (anti-biotic) for wound infection. At 8:36 P.M., a Short Turn Around Time (STAT) Complete Blood Count (CBC) and Metabolic Profile (BMP) were drawn. STAT laboratory results were faxed to the facility at 3:07 A.M., and called to Licensed Practical Nurse (LPN) #100. Review of the laboratory results revealed a critical elevated potassium level of 8.0 mmol/L (normal range 3.4 - 5.3) and white blood count (WBC) 11.7 per cubic millimeter of blood (normal range 3.8 to 10.8 ) (increased due to fighting infection). However, the doctor was not immediately notified of these critical laboratory values until 5:02 A.M. and an order was received to send the resident to theER on [DATE]. Review of Resident #102's Treatment Administration Record (TAR) dated March 2016 revealed the splint to the right leg (ordered over a year prior) continued to be put in place after it had been identified as the cause of the right calf wound. The treatment to the wound was documented as not being completed twice daily as ordered on the following dates: 03/19/16, 03/20/16, 03/23/16, 03/25/16 and 03/26/16, all for the evening shift. Review of the Medication Administration Record [REDACTED]. The resident received the break through pain medication of [MEDICATION NAME] on the following dates: 03/04/16, 03/06/16, 03/14/16, 03/20/16 and 03/23/16. Despite all of the pain medications the resident still had pain when the leg was touched or moved and the physician was not notified. Antibiotics ordered on [DATE] were not followed due to allergies [REDACTED]. Review of hospital records dated 03/27/16 documented extensive multiple right lower extremity decubitus Stage IV wounds with black eschar on admission and a request for a vascular surgery consult immediately. New areas were identified on the right lateral ankle (which was not followed in the facility). On 03/29/16, vascular studies showed severe [MEDICAL CONDITION] however, there was still blood flow. The surgeon recommended an AKA and was waiting for Resident #102's daughter's approval. On 03/31/16 the surgeon note revealed Resident #102 was an unfortunate [AGE] year old female who had developed non-healing gangrenous sores on her right leg and was in severe pain. A right AKA was performed to promote wound healing. Review of the surgical pathology report dated 04/04/16 revealed the right leg was amputated above the knee, with lateral ulcerated [MEDICAL CONDITION], with underlying acute osteo[DIAGNOSES REDACTED] (rare bone infection). Sections of the bone underlying the ulcerated region with acute osteo[DIAGNOSES REDACTED]. Pathology received a right amputated foot and on the lateral aspect of the leg which measured 14.5 cm by 5.0 cm with red, black ulcerated necrotic lesion. On the lateral aspect of the heel the area was measured at 8.0 cm by 6.0 cm black necrotic to red ulcerated [MEDICAL CONDITION]. Telephone interview on 04/11/16 at 10:06 A.M. with Resident #102's daughter revealed the facility told her they sent her mother to the hospital on [DATE] for increased potassium levels. The facility had further told the daughter her mother ' s leg wounds were getting better. However, when the daughter arrived at the hospital, the hospital staff discovered the nastiness under the dressings. The hospital staff began talking immediately about cutting off her mother's leg. Interview on 04/11/16 11:17 A.M., State tested Nursing Assistant (STNA) #4 stated she had taken care of Resident #102. She stated when she would help scoot her up in bed she would be in a lot of pain. Interview on 04/11/16 at 11:28 A.M., STNA #7 stated the resident always had boots on and she smelled foul odors from the wound dressings. The STNA stated she told the nurses the resident was in so much pain any time they would move her, or touch her right leg. Interview on 04/11/16 at 12:16 P.M., LPN #12 stated she took care of her almost every day she worked. The LPN further stated the resident had boots on all the time and during the last month the wounds had gotten worse. Interview on 04/11/16 at 1:48 P.M., Unit Manager (UM) #13, UM #14, the DON and LNHA stated they had changes in wound care providers in January 2016, and they felt the antibiotic medication not being followed through was a miscommunication between nursing, Hospice and the practitioner. Interview on 04/11/16 at 3:25 P.M., Certified Nurse Practitioner (CNP) #15 stated Hospice Registered Nurse (RN) #16 informed her about an odor from the resident's wounds. She placed her on an antibiotic she thought around 03/23/16 however, the antibiotics ordered were not started due to an allergy. She did not know what happened to the orders after this. Interview on 04/11/16 at 3:33 P.M., Medical Doctor (MD) wound consultant #17, stated the resident ' s wounds were not healing and were getting worse. When he saw her on 03/23/16 the leg was warm and they were calling her daughter to see how aggressive she wanted her treated due her being a Hospice patient. There was no evidence the daughter was contacted. Interview on 04/12/16 at 10:08 A.M., Director of Rehabilitation (DOR) #18 stated the therapy department did not order the splint. She further stated the foot splint had been ordered on [DATE], however she did not know by whom. Interview on 04/12/16 at 10:24 A.M., STNA #25 stated the resident would have pain whenever her leg was touched. Telephone interview on 04/12/16 at 11:14 A.M., Hospice RN #16 stated she began care for Resident #102 in October 2015 and stated the resident had wounds to her right lower extremity. She stated the wounds had an odor and she had increased pain in the leg. Interview on 04/12/16 at 11:26 A.M., the Administrator, DON and QAC #30 stated the right calf wound was a result of the splint device which was ordered 01/30/15, over a year ago. Interview on 04/12/16 at 11:49 A.M. with Medical Director (MD) #40 revealed CNP #15 handled the long term care residents and she would update him as needed. He stated he did not follow the wounds closely because the wound team did. He further stated he was aware the resident had wounds, however not to the extent of the wounds or the pain. He further stated osteo[DIAGNOSES REDACTED] could develop in as little as 24 hours and an acute onset meant it was from the wound. He also stated Hospice care is not a reason not to treat the wounds. Interview on 04/13/16 at 9:06 A.M., RDO #50, and Divisional Consultant (DC) #60 confirmed the facility did not follow their policy regarding skin and pain. They did not complete an investigation when the center identified the splint caused a wound to the resident and why it was still in place. Interview on 04/13/16 at 2:12 P.M., PA #70 stated Resident #102 had necrotic tissue and he had consulted MD #17 about the wounds because they were not getting any better. He stated he did complete three debridements. They were trying to get her in for surgical debridement, however had not talked to the daughter. He further stated he was not made aware the resident had a splint and it was what caused the wound. He further stated he was unaware the splint was still being applied up until she was admitted to the hospital. He was also unaware the treatments he ordered twice daily were not being followed. Telephone interview on 04/15/16 at 9:27 A.M., LPN #1 stated Resident #102 had a bad wound on her leg. LPN #1 stated the wound had a lot of drainage and always had an odor. The LPN further stated the resident always had pain when the area was touched. LPN #1 stated the resident had a hard plastic splint which was applied in the evening, with the blue boots over the splint. He stated the surgeon came in and looked at her leg, he was rough with her, looked at it quickly, gave the same treatment order and stated she needed surgery and left. No order was written for the surgery consult. Review of the policy titled Requirements and Guidelines for Clinical Record Content dated 2015 documented progress notes are electronically documented in the electronic health record to reflect the patient's condition, significant care issues, response to treatment and changes in condition and treatment. In instances of change in condition or significant care issues, progress note entries are made until the point the condition stabilizes or the situation is otherwise resolved. Physician notification of the patient change in condition is documented in the progress notes including the physician's response, and if orders were given, information on the orders received, implementation of such orders, and the patient's response. Dictated practitioners notes need to be in the medical record within seven days. Review of the policy titled Skin Practice Guide dated 01/2013 documented The Braden Scale is completed for four weeks total (at the time of admission and then weekly for the next three weeks), quarterly, with a significant change and as clinically indicated. The Braden Scale allows the selective targeting of preventive interventions and assists in resource identification so that resources can be targeted to match the risk. Remember, even a score that indicated no risk does not guarantee a person will not develop a pressure ulcer, especially if their condition changes. This deficiency substantiates complaint number OH 547.