Every finding on record at Sycamorespring of Miamisburg

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure medication error rate was below five percent (%). There were three medication errors observed over 33 medication opportunities resulting in a medication error rate of 9.09%. This affected two (Residents #3 and #48) of three residents observed for medication administration. The facility census was 93 residents.Findings include:1.Review of the medical record for Resident #48 revealed an admission date of 01/11/26 with diagnoses including peripheral vascular disease (PVD), atrial fibrillation, and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #48 dated 03/23/26 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's order for Resident #48 dated 01/11/26 revealed an order for Flonase nasal spray once daily. Observation on 04/07/26 at 8:21 A.M. revealed Licensed Practical Nurse (LPN) #156 did not administer Flonase to Resident #48. The medication was not available. Interview on 04/07/26 at 8:25 A.M. with LPN #156 verified she did not administer Flonase nasal spray to Resident #48 because the medication was not available. 2.Review of the medical record for Resident #3 revealed an admission date of 04/19/19 with diagnoses including schizoaffective disorder, major depressive disorder, and convulsions. Review of the physician's orders for Resident #3 revealed orders dated 03/07/24 for fluorometholone eye drops twice a day and Refresh eye drops twice a day. Review of the MDS assessment for Resident #3 dated 02/11/26 revealed the resident was cognitively impaired and dependent with ADLs. Observation on 04/07/26 at 8:46 A.M. revealed Registered Nurse (RN) #151 did not administer Fluorometholone eye drops and Refresh eye drops to Resident #3. The medications were not available. Interview on 04/07/26 at 8:50 A.M. with RN #151 verified she did not administer Flurometholone eye drops and Refresh eye drops to Resident #3 because the drops were not available. Review of the facility policy titled Administration Oral Medications revised on March 2026 revealed the facility would ensure patients were given medications per the physician. orders. If there were any issues with physician orders, the nurse would contact the physician for clarification.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed during medication administration. This affected one (Resident #3) of three residents reviewed for medication administration. The facility census was 93 residents.Findings include: Review of the medical record for Resident #3 revealed an admission date of 04/19/19 with diagnoses including schizoaffective disorder, major depressive disorder, and convulsions. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 02/11/26 revealed the resident was cognitively impaired and dependent with activities of daily living (ADLs). Review of the care plan for Resident #3 dated 02/24/25 revealed the resident required tube feeding related to anoxic brain injury. Interventions included staff were to maintain EBP due to the presence of a gastrostomy tube (g-tube). Observation on 04/07/26 at 8:49 A.M. revealed Registered Nurse (RN) #151 administered medications to Resident #3 via g-tube and she had not donned a gown prior to administration. Interview on 04/07/26 at 8:57 A.M. with RN #151 confirmed Resident #3 was on EBP due to the g-tube. RN #151 stated she had not donned a gown prior to administering medications via g-tube to Resident #3. Review of the facility policy titled Infection Control - Transmission Based Precautions revised September 2025 revealed EBP was an infection control intervention designed to reduce transmission of specific multidrug-resistant organisms (MDRO) that employed the use of gown and gloves during high contact resident care activities. EBP were indicated for residents with indwelling medical devices including feeding tubes.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, review of a facility investigation, staff and family interviews, review of a video recording, and review of the facility policy, the facility failed to provide adequate assistance while transferring a resident resulting in an avoidable fall and failed to ensure staff timely report a fall when it occurred. This resulted in Actual Harm to Resident #78 on 08/25/25 when staff failed to provide adequate assistance when transferring the resident from a wheelchair to the bed which resulted in the resident falling to the floor, then staff assisted the resident back to bed without reporting the fall. Resident #78 was subsequently transferred to the hospital on [DATE] for treatment of a fractured femur to the left leg. This affected one (#78) of three residents reviewed for accidents. The facility census was 93. Findings include: Review of the medical record for Resident #78 revealed an admission date of 04/01/23 with diagnoses including vascular dementia, with other behavioral disturbance, unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, and major depressive disorder. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] for Resident #78 revealed the resident had severe cognitive impairment, and was dependent on staff assistance with all transfers. Review of the care plan for Resident #78 dated 09/01/25 revealed the resident is at risk for falls related to impaired mobility with interventions to assist resident with transfers, repositioning, and mobility. The care plan also revealed the physician and responsible party are to be notified of all falls. Review of the Radiology report dated 09/01/25 at 8:33 A.M. for Resident #78 revealed there Is a fracture Involving left distal femur with minimal displacement. Review of the progress note for Resident #78, with a created date of 09/02/25 at 5:45 P.M., late entry for 08/25/25 at 10:39 P.M. from Registered Nurse (RN) #301, revealed two Certified Nursing Assistants (CNA's) were transferring Resident #78 from the wheelchair to the bed. Once the resident was on the edge of the bed, she slipped off the edge of the bed onto the floor. Review of the emergency room notes dated 09/01/25 revealed Resident #78 had pain on movement of left hip because of femur fracture, brace on place. Resident #78 placed on intravenous (IV) fluids and IV blood pressure medications. Review of the hospital note dated 09/04/25 revealed surgeon spoke with Resident #78 ' s daughter and decided on nonoperative management. Review of an Incident Inter-Disciplinary Team (IDT) note for Resident #78 dated 09/04/25, completed by the Assistant Director of Nursing (ADON) #343 revealed staff were transferring Resident #78 on 08/25/25 at 10:05 P.M. when staff lost gait control and lowered her to the floor. X-rays were completed on 09/01/25 and the results showed a fracture to the left femur and resident was sent to the emergency room. Review of the witness statement dated 09/02/25 from CNA #473 revealed Resident #78 was successfully transferred then skid off the bed onto the floor. Review of the witness statement dated 09/02/25 from CNA #483 revealed while pivoting Resident #78 to bed, resident slid down and was lowered to the floor. Review of the witness statement undated from CNA #369 revealed when entering the room, Resident #78 was on the floor, sitting by the bed. CNA #369 stated he provided lifting assistance with CNA #483 to lift Resident #78 off the floor and onto the bed. Once in bed Resident #78 was maneuvered to a proper position with a draw sheet. Review of the witness statement dated 09/02/25 from Registered Nurse (RN) #301 revealed she worked with Resident #78 on 08/25/25 and she was not notified of any incidents involving the resident. Interview on 09/16/25 at 9:24 A.M. with Resident #78's family member stated Resident #78 was having increased pain the week of 08/25/25 and it kept getting worse. Resident #78's family member stated the resident's left knee was swelling up, she didn't know why because she didn't receive any reports of any incidents or accidents involving the resident. Resident #78's family stated the resident had a camera in the resident's room so she went back through and watched the videos. Resident #78's family member stated she found on 08/25/25 at around 10:05 P.M. Resident #78 was transferring herself while staff stood by and the resident was supposed to have assistance. Resident #78's family member stated the resident fell on the floor in front of the bed. Resident #78's family member revealed the facility had not reported any incidents to her. Resident #78's family member stated she called the facility and reported the fall and requested x-rays of Resident #78's left leg. When the x-rays came back with a fracture, Resident #7 was sent to the ER. Interview on 09/17/25 at 7:49 A.M. with ADON #343 revealed Resident #78 experienced a fall on 08/25/25 but the incident was not reported until 09/01/25. ADON #343 confirmed she completed the investigation of the fall involving Resident #78. ADON #343 confirmed Resident #78 was assessed on 09/01/25, the physician was notified and the resident was sent to the hospital related to a fractured left femur. Interview on 09/17/25 at 8:35 A.M. with Director of Nursing (DON) and Administrator confirmed staff did not report a fall for Resident #78 until they received a call from the resident's family member on 09/01/25 reporting Resident #78 was having increased pain and she watched the videos and seen the resident fall on 08/25/25. The DON and Administrator stated Resident #78's family member had notified the facility about the fall due to the resident's complaints of pain. The DON and Administrator reported Resident #78's family member observed a fall on the video recording device on 08/25/25 at 10:05 P.M. The DON and Administrator confirmed the facility immediately began the investigation and two CNA's (#473 and #483) were terminated due to failing to follow facility protocol of reporting a fall when it happened. The DON and Administrator confirmed the facility investigated and had witness statements competed from all the CNA's involved the night of the incident on 09/02/25. Review of the video recording dated 08/25/25 at 10:05 P.M. revealed Resident #78 was in her room with one male and one female employee. The female employee had her hands on the wheelchair handles, while the male employee is to the right of the resident approximately three feet away. Resident #78 was in a sitting position at the edge of the of the wheelchair seat, close to the bed. Resident #78 is noted with her left arm on the bed, with her elbow bent as if she is pushing, trying to transfer herself. At 10:05:26 P.M. Resident #78 asks what's that then you hear a noise and the resident slips down between the bed and the wheelchair. At no time before this did the staff in the room attempt to assist Resident #78. At 10:05:27 P.M. the male employee leaned over, reaches for the resident under her arms. Resident #78 screams, the male employee steps away from the resident and the female employee leaves the room. The video continues until 10:07:21 P.M. with the male employee standing by the back wall behind the resident observing the resident. Another male employee was observed entering Resident #78's room and assisting with transferring the resident back to bed. Review of the facility policy titled Fall and Accident Management dated 08/2019 revealed after a fall the physician and the responsible party will be notified. Nursing completes documentation related to the occurrence. The deficient practice was corrected on 09/05/25 when the facility implemented the following corrective actions: On 09/01/25, Resident #78 was assessed by RN #301, the physician was notified, and the resident was sent to the hospital for evaluation and treatment. The Administrator and DON began an investigation regarding Resident #78's fall. On 09/02/25, the DON or designee reviewed Resident #78's medical record including but not limited to medication administration records, progress notes and care plans. Resident #78's care plan was updated as needed by the DON. On 09/02/25 through 09/04/25, the DON or designee interviewed current interviewable residents to determine if there were any falls or incidents that occurred that were not documented in the medical record. No issues were noted. On 09/02/25 through 09/04/25, the DON or designee completed head to toe assessments on current non-interviewable residents to determine if there were any concerns for bruising, abrasions, swelling, complaints of pain that could be the result of an undocumented fall. No issues were noted. On 09/02/25, the DON or designee reviewed current residents' progress notes from the last 14 days to review for any possible injuries that may be related to an undocumented fall. No issues were noted. On 09/02/25, the DON or designee reviewed fall documentation from current residents experiencing a fall in the last 14 days to ensure an adequate assessment and documentation was completed, intervention implemented post fall, and notifications of responsible party and physician timely after a fall. No issues were noted. On 09/02/25, the DON, Director of Rehab and/or designee reviewed current residents' care plans to reflect accurate transfer assistance. On 09/02/25, the DON or designee provided in-service training to all nursing staff. This in-service included ensuring residents experiencing a fall and/or that have been lowered to the floor are reported to the nurse, ensuring the resident is adequately assessed by the nurse following incidents, ensuring the fall is documented in the medical record, and that the physician and responsible party are notified timely of a resident fall. Additionally, the in-service training included ensuring residents are provided with transfer assistance according to the care plan. The in-service training was completed by 09/05/25. A Quality Assurance (QA) meeting was held on 09/03/25 at 12:30 P.M. with the Administrator, Medical Director, Regional Director of Operations, DON, [NAME] President of Nursing, and Corporate QA Nurse. This deficiency represents non-compliance investigated under Complaint Number 2609393.

Based on medical record review, staff interviews, and policy review, the facility failed to ensure a resident was permitted to stay in the facility once payer source changed from Medicare Part A to private pay. This affected one (#100) out of the three residents reviewed for discharges. The facility census was 98. Finding includes: Review of the medical record for the Resident #100 revealed an admitted [DATE] with medical diagnoses of nontraumatic subarachnoid hemorrhage, cirrhosis, hepatic encephalopathy, anorexia, and congestive heart failure. Review of the medical record for Resident #100 revealed a discharge date of [DATE]. Review of the medical record for Resident #100 revealed an admission Minimum Data Set (MDS) assessment, dated 09/21/24, indicated Resident #100 had moderately impaired cognition and required partial/moderate staff assistance with eating, bed mobility, and transfers, was dependent upon staff for toilet hygiene, and required substantial/maximum staff assistance for bathing. Review of the medical resident #100 revealed a Social Service note dated 11/05/24 which stated Resident #100's daughter was notified the Medicare services would be exhausted on 11/06/24 and Resident #100 would be private pay. The note stated Resident #100's daughter asked the facility to begin the Medicaid process. The note stated Social Service notified Resident #100's daughter that Resident #100 did not have a power of attorney (POA) and because Resident #100 was severely cognitively impaired the facility would ask for a statement of expert evaluation from the physician prior to starting the Medicaid process. Review of the medical record for Resident #100 revealed no documentation to support the facility issued Resident #100 a 30-day discharge notice. Interview on 11/12/24 at 1:42 P.M. with Social Service Director (SSD) #202 stated she spoke with Resident #100's daughter on 11/06/24 about starting the Medicaid process and informed the daughter that Resident #100 did not have a POA, so the facility needed to get guardianship before the Medicaid application process started. SSD #202 stated she completed the paperwork for Resident #100's expert evaluation and placed the paperwork into the physician's mailbox to review and sign. SSD #202 stated before the physician could review the paperwork, Resident #100's family took Resident #100 with home health. SSD #202 confirmed Resident #100 would have been private pay until Medicaid application was approved but Medicaid would pay the Resident #100's balance from the date of the Medicaid application. Interview on 11/12/24 at 2:45 P.M. with Administrator stated Resident #100 had exhausted her Medicare A days and she would become private pay on 11/07/24. Administrator stated she informed Resident #100's daughter that the facility did not have a long-term care bed available, so the facility would assist with transferring Resident #100 to another facility. Administrator confirmed all facility beds were dually certified Medicare and Medicaid. Administrator stated the facility had not issued any 30- day discharge notices in the past six months. Administrator confirmed the family chose to take Resident #100 home instead of transferring to another facility. Review of the facility policy titled. Resident Transfer-Discharge Rights from the Facility, revised October 2022, stated the facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility, the transfer or discharge was appropriate because the resident's health has improved sufficiently so the resident on longer needs the services provided at the facility, the resident's urgent medical needs necessitated an immediate transfer, the safety or health of individuals in the facility was endangered due to the clinical or behavioral status of the resident, the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility or the facility ceases to operate. The policy stated transfers and discharges are permitted to take place even if a Medicaid application is pending, if the application is similar to a previous one, which was denied. This deficiency represents non-compliance investigated under Complaint Number OH00159674.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure wound care was documented in medical record. This affected one (#80) out of the three residents reviewed for wound care. The facility census was 98. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with medical diagnoses of respiratory failure, diabetes mellitus with chronic kidney disease, chronic venous hypertension, congestive heart failure, and schizoaffective disorder. Review of the medical record for Resident #80 revealed a quarterly Minimum Data Set (MDS) assessment, dated 10/30/24, which indicated Resident #80 had moderately impaired cognition and was dependent for bathing, toileting hygiene, and transfers. The MDS indicated Resident #80 was always incontinent of bladder and bowel. Review of the medical record for Resident #80 revealed a weekly wound progress note, dated 11/04/24, which stated Resident #80 had moisture associated skin damage (MASD) to right buttock and unstageable pressure ulcer to right distal buttock which was acquired 09/02/24. Review of the medical record revealed weekly skin assessments were completed and treatment orders were in place. Review of the medical record for Resident #80 revealed a physician order dated 05/01/24 to cleanse, pat dry and to apply remedy skin cream 1.5% to bilateral buttocks two times per day, an order dated 05/13/24 for low air loss mattress, and an order dated 10/31/24 to cleanse right distal buttock with normal saline, pat dry, apply calcium alginate, apply gauze, and cover with island bordered dressing daily and as needed. Review of the medical record for Resident #80 revealed the November 2024 Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) did not contain documentation to support the facility completed wound care to right distal buttock wound as ordered from 11/01/24 to 11/11/24. Interview on 11/12/24 at 1:07 P.M. with Resident #80 confirmed he received wound care to his right buttock daily but stated at times he would refuse cares. Interview on 11/12/24 at 2:16 P.M. with Director of Nursing (DON) confirmed Resident #80's medical record did not contain documentation to support wound care to right distal wound was completed as ordered 11/01/24 to 11/11/24. DON stated the order for the treatment was not entered into the electronic health record (EHR) correctly but stated the staff had completed the wound care as ordered because Resident #80 had the wound for a long time and staff was aware that the wound care needed completed daily. Interview on 11/12/24 at 3:25 P.M. with Licensed Practical Nurse (LPN) #210 confirmed she provided care for Resident #80 and performed wound care on 11/06/24 and 11/07/24. LPN #210 stated Resident #80 would require multiple dressing changes in one day due to incontinence. LPN #210 denied any concern that Resident #80's wound care to right distal buttock was not changed at least daily from 11/01/24 to 11/11/24. Interview on 11/12/24 at 3:28 P.M. with LPN #211 confirmed she worked 11/08/24 and 11/09/24 on night shifts and completed wound care to Resident #80's right distal buttock. LPN #211 stated Resident #80 had the wound for a while and she knew that treatment needed to be done. LPN #211 stated she was not aware the order was entered into the EHR incorrectly or that staff had not been documenting wound care completion. LPN #211 stated Resident #80's dressing to right distal buttock would be changed more than one time per shift because of bowel incontinence. LPN #211 denied any concern that Resident #80 wound care to right distal buttock was not changed daily from 11/01/24 to 11/11/24. Interview on 11/12/24 at 3:41 P.M. with Registered Nurse (RN) #212 stated she provided care for Resident #80 between 11/01/24 and 11/11/24. RN #212 stated she was not aware the order for treatment to the right distal buttock was not entered into the EHR correctly but stated staff knew Resident #80 had the wound to his right buttock and completed the treatment as ordered. RN #212 denied any concern that Resident #80's wound care to right distal buttock was not completed daily. Review of the facility policy titled, Skin Preventive Measures, stated staff would verify treatment orders after evaluation and documentation of wound. This deficiency represents non-compliance investigated under Complaint Number OH00159674.

Based on medical record review observation, staff interview, and review of the facility policy, the facility failed to ensure proper hand hygiene and enhanced barrier precautions were followed during incontinence care. This affected one (Resident #28) of three residents reviewed for incontinence care. The facility census was 93 residents. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including chronic bronchitis, depression, and traumatic ischemia of muscle. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 09/19/24 revealed the resident had intact cognition and required setup assistance with eating, was dependent with toileting and bathing, had a urinary catheter and was always incontinent of bowel. Review of the care plan for Resident #28 dated 09/13/24 revealed the resident had an indwelling catheter related to obstructive uropathy. Interventions included the following: perform catheter care every shift and as needed, empty catheter bag every shift and as needed, maintain enhanced barrier precautions (EBP) due to indwelling catheter, staff to check catheter tubing for kinks. Observation on 10/09/24 at 11:33 A.M. of incontinence care for Resident #28 per State tested Nurse Aide (STNA) #10 revealed the resident was in EBP related to the urinary catheter. STNA #10 did not don a gown before or during care. STNA #10 performed hand hygiene and applied gloves. Resident #28 had a large bowel movement which STNA #10 cleaned with gloved hands. STNA #10 then applied clean linens and a dry incontinence brief and adjust the resident's bed wearing the same soiled gloves. Interview on 10/09/24 at 11:55 A.M. with STNA #10 confirmed Resident #28 was in EBP due to having an indwelling urinary catheter but he did not don a gown before or during care. Further interview with STNA #10 confirmed he cleaned bowel movement from Resident #28 with his gloved hands and then applied clean linens to the bed and a dry incontinence brief to the resident and adjust the resident's bed wearing the same soiled gloves. Review of the facility policy titled Hand Hygiene dated August 2024 revealed all team members of the facility would follow hand hygiene guidelines to reduce the incidence of health care associated infections. Staff should wear gloves when contact with blood or other potentially infectious materials (body fluids, secretions, and excretions) was likely. Staff should change gloves during patient care if moving from a contaminated body site to a clean body site. Staff should remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Review of the facility policy titled Infection Control - Transmission Based Precautions dated April 2024 revealed transmission-based precautions should be used when caring for residents who were documented or suspected to have communicable diseases or infections that could be transmitted to others. EBP was an infection control intervention designed to reduce the transmission of specific multi-drug resistance organisms (MDROs) that employed the use of gowns and gloves high contact resident care activities. This deficiency represents noncompliance investigated under Complaint Number OH00157481.

Based on medical record review, observation, staff interview, resident interview and review of the facility policy, the facility failed to ensure all medications were stored securely. This affected two (Residents #11 and #22) of seven residents reviewed for medication storage and had the potential to affect four residents (#41, #48, #68, #72) identified by the facility as being independently ambulatory and cognitively impaired. The facility census was 97. Findings include: 1.Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including displaced fracture of right lower leg and protein calorie malnutrition. Review of the admission orders for Resident #11 dated 12/14/23 revealed the resident did not want to self-administer medications. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 12/20/23 revealed the resident had intact cognition. Review of the physician orders for Resident #11 revealed an order dated 02/07/24 carboxymethylcellulose sodium one drop per eye two times a day for dry eyes. Observation of medication administration for Resident #11 on 02/15/24 at 8:24 A.M. per Licensed Practical Nurse (LPN) #176 revealed the nurse could not locate the resident's eye drops in the medication cart. LPN #176 asked Resident #11 if he knew where his eye drops were located. Resident #11 reached for his personal bag on the floor next to his bed and told LPN #176 that someone had given him the eye drops last night and he had kept them in his bag. Interview on 02/15/24 at 8:30 A.M. with LPN #176 confirmed Resident #11 did not have an order for self-administration, and the eye drops should be stored in the medication cart. 48570 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including end stage renal disease, acute osteomyelitis right foot and ankle, type two diabetes mellitus, cerebral infarction, Crohn's disease, multiple sclerosis, and peripheral vascular disease. Review of physician orders for Resident #22 revealed orders dated 10/06/23 for sevelamer carbonate 800 milligrams (mg) give four tablets by mouth with meals for end stage renal disease- may keep at bedside and PhosLo capsule give one capsule by mouth with meals-may keep at bedside. Review of the MDS assessment for Resident #22 dated 01/08/24 revealed the resident was cognitively intact. Observation on 02/13/24 11:04 A.M. revealed a bottle of sevelamer carbonate and a bottle of PhosLo were sitting on Resident #22's bed side table, and the resident was in the room. Interview on 02/13/24 at 11:04 A.M. with Resident #22 confirmed she self-administered sevelamer carbonate and PhosLo because she needed to take the medications when she ate. Review of the medication self-administration evaluation for Resident #22 dated 01/06/24 revealed the resident was able to self-administer PhosLo and sevelamer carbonate. Resident #22 was cognitively intact and was able to demonstrate secure storage of the medications in her room. The physician gave an order for the resident to self-administer PhosLo and sevelamer carbonate. Observation on 02/14/24 at 1:48 P.M. revealed Resident #22's room door was open, and resident was not in the room. There was a bottle of PhosLo and a bottle of sevelamer carbonate sitting on the resident's bedside table. Interview on 02/14/24 at 1:49 P.M. with the Director of Nursing (DON) confirmed Resident#22 was not in the room and there was a bottle of PhosLo and a bottle of sevelamer carbonate sitting on the resident's bedside table. The DON confirmed the resident was supposed to lock up her medications in her bedside dresser when she was not in the room. Interview on 02/14/24 at 1:59 P.M. with Licensed Practical Nurse (LPN) #200 confirmed Resident #22 had left her medications unattended on prior occasions and she had spoken to Resident #22 about the need to ensure her medications were locked up when she was not in the room. Review of the facility policy titled Medication Storage dated December 2012 revealed the facility would ensure medications were securely stored in a locked cabinet/cart or locked medication room. Review of the facility policy titled Self Administration of Medication dated February 2022 revealed residents had the right to self-administer medications if the Interdisciplinary Team (IDT) had determined it was clinically appropriate. If a resident requested to self-administer medications the IDT was responsible for determining if it was safe for the resident to do so.

Based on medical record review, staff interviews, review of the facility's policy, and review of the Self-Reported Incidents (SRI), the facility failed to report an allegation of verbal abuse to the State Survey Agency. This affected one (Resident #18) of three residents reviewed for abuse. The facility census was 92. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 05/07/22, revealed Resident #18 had impaired cognition and had no hallucinations, delusions, or rejection of care. Review of the plan of care revealed Resident #18 had a mood problem related to depression and feeling down. Interventions included behavioral health consults as needed and encouraging the resident to verbalize feelings in a safe and healthy manner. Review of the nursing progress notes for Resident #18 from 05/01/22 to 06/06/22 revealed there was no documentation of any incidents regarding the resident and staff members. No documentation of family concerns regarding staff members were noted. Review of the facility's Self- Reported Incidents (SRIs) from 05/01/22 to 06/16/22 revealed there was no SRI reported to the State Survey Agency regarding the allegation of verbal abuse with Resident #18 by STNA #15 that SS #120 reported. Interview on 06/17/22 at 12:05 P.M. with Social Services (SS) #210 stated there was an incident towards the end Resident #18's stay at the facility. SS #210 was unsure of the exact date of the incident but remembered she was speaking with Resident #18's granddaughter about bringing back some paperwork for Medicaid which was insufficient. The granddaughter of Resident #18 stated to SS #210 that she was unhappy with the care and services that her grandmother received at the facility. The granddaughter of Resident #18 went on to tell SS #210 she did not directly witness the incident but was in ear shot of grandma being yelled at by State tested Nursing Aide (STNA) #15. SS #210 stated she verbally notified Unit Manager (UM) #100 of the reported incident. Interview on 06/17/22 at 12:50 P.M. with Unit Manager (UM) #100 stated she doesn't remember the details of a conversation between Social Services #210 and herself. UM #100 stated if SS #210 had described the incident as a staff member was yelling at Resident #18, then she would have acted and investigated the incident further. Interview on 06/17/22 at 1:20 P.M. with the Director of Nursing (DON) confirmed there was no SRI completed regarding the incident between Resident #18 and STNA #15. Review of the facility's policy titled Abuse/Neglect/Misappropriation of Property, dated 11/2016, revealed the facility staff should immediately report all such allegations to the Administrator and the respective state survey agency in accordance with the procedures in this policy. This deficiency substantiates Complaint Number OH 466.

Based on medical record review, staff interviews, and facility policy review, the facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse. This affected one (Resident #18) of three residents reviewed for abuse. The facility census was 92. Findings included: Review of the medical record for Resident #18 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 05/07/22, revealed Resident #18 had impaired cognition and had no hallucinations, delusions, or rejection of care. Review of the plan of care revealed Resident #18 had a mood problem related to depression and feeling down. Interventions included behavioral health consults as needed and encouraging the resident to verbalize feelings in a safe and healthy manner. Review of the nursing progress notes for Resident #18 from 05/01/22 to 06/06/22 revealed there was no documentation of any incidents regarding the resident and staff members. No documentation of family concerns regarding staff members were noted. Interview on 06/17/22 at 12:05 P.M. with Social Services (SS) #210 stated there was an incident towards the end Resident #18's stay at the facility. SS #210 was unsure of the exact date of the incident but remembered she was speaking with Resident #18's granddaughter about bringing back some paperwork for Medicaid which was insufficient. The granddaughter of Resident #18 stated to SS #210 that she was unhappy with the care and services that her grandmother received at the facility. The granddaughter of Resident #18 went on to tell SS #210 she did not directly witness the incident but was in ear shot of grandma being yelled at by State tested Nursing Aide (STNA) #15. SS #210 stated she verbally notified Unit Manager (UM) #100 of the reported incident and verified she did not assist with any abuse investigation involving Resident #18 and STNA #15. Interview on 06/17/22 at 12:50 P.M. with Unit Manager (UM) #100 verified she did complete an investigation with a staff-resident verbal abuse allegation involving Resident #18 and STNA #15. UM #100 stated if SS #210 had described the incident as a staff member was yelling at Resident #18, then she would have acted and investigated the incident further. Interview on 06/17/22 at 1:20 P.M. with the Director of Nursing (DON) confirmed there was no abuse investigation completed regarding the allegation of verbal abuse between Resident #18 and STNA #15. Review of the facility's policy titled Abuse/Neglect/Misappropriation of Property, dated 11/2016, revealed the facility failed will investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 466.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, review of a facility investigation, observation, resident and staff interview, review of manufacturer's guidelines, and review of facility policy, the facility failed to ensure a resident was provided appropriate assistance with toileting and transfers per the plan of care. This resulted in actual harm when Resident #13 was transferred from the toilet to a wheelchair without the proper number of assistance and without use of a gait belt, the resident was lowered to the floor and the resident was subsequently admitted to the hospital for a fractured left ankle which required surgical repair. This affected one (#13) of three residents reviewed for appropriate assistance during transfers. The facility census was 74. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses include flaccid [CONDITION(S)] to the left side and cerebral infarction. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 05/17/21 revealed the resident was cognitively impaired and was totally dependent on the assistance of two staff with transfers and with toilet use. Review of the fall risk assessment for Resident #13 dated 07/06/21 revealed the resident had an increased risk for falls. Review of the care plan for Resident #13 dated 07/020/21 revealed the resident has an activities of daily living (ADL) self-care performance deficit related to history of [CONDITION(S)] ([CONDITION(S)]) with left [CONDITION(S)], depression, weakness, decreased mobility, unsteady gait, contracture, and had Meniere's Disease. Interventions included the resident required extensive assistance of two staff with toilet use and extensive use of two staff with use of pivot disc device during toileting. Review of nurse progress note for Resident #13 dated 08/08/21 at 1:10 P.M. revealed the resident was lowered to the bathroom floor by the State tested Nursing Assistant (STNA) #100 while she was being assisted. STNA #100 stated resident was standing on the pivot disc and let go of the handlebar and lost her balance. STNA #100 was unable to bear resident's weight so she lowered her to the floor and resident's left ankle was twisted as she was lowered to the floor. Resident #13's left leg was bleeding, and the notes indicate the resident's ankle was separated from her leg. The resident was transferred to the emergency room for evaluation and treatment. Review of hospital note for Resident #13 dated 08/08/21 at 2:40 P.M. revealed the resident presented at the emergency room with an open dislocated left ankle fracture which occurred at the facility while being transferred from the toilet. Resident #13's ankle fracture was surgically repaired on 08/08/21 and resident was discharged back to the facility on [DATE]. Review of the facility's follow up investigation of the incident dated 08/08/21 revealed Resident #13 was in the bathroom with STNA, using the pivot disc for transfer. Resident #13 states that while she was standing on transfer disc, she let go of the handlebar and lost her balance and she twisted her left ankle while she was being lowered to the floor. Observation on 08/27/21 at 11:45 A.M. of Resident #13 revealed resident was in her wheelchair with a fracture boot on her left lower extremity. Interview on 08/27/21 at 11:45 A.M. with Resident #13 confirmed she sustained a left ankle fracture at the facility on 08/08/21 when STNA #100 was assisting her with transfer from toilet to wheelchair. Resident #13 confirmed she was standing on the pivot disc after using the toilet and she was holding onto the grab bar with her right hand. Resident #13 confirmed she had limited use of the left side of her body since her [CONDITION(S)]. Resident #13 confirmed she just let go of the grab bar for a second and she started to fall. As she fell , Resident #13 confirmed STNA #100 grabbed onto her right upper body with her arms and tried to stop her from falling but both the resident and STNA ended up on the floor. Resident #13 confirmed STNA #100 was the only staff person in the bathroom at the time of the transfer and she was not using a gait belt. Attempted to interview STNA #100 on 08/27/21 at 12:46 P.M. and 2:29 P.M. but was unable reach her. Interview on 08/27/21 at 12:40 PM with Occupational Therapist (OT) #150 and Physical Therapist (PT) #200 confirmed they had worked with Resident #13 before her fall on 08/08/21 and resident required assistance of two staff when being transferred on and off the toilet and a gait belt should have been used when assisting resident. PT #200 further confirmed Resident #13 should have had two staff assisting with the transfer using the pivot disc. Interview on 08/27/21 at 12:51 P.M. with the Administrator confirmed STNA #100 had received written counseling for failing to follow Resident #13's care plan while transferring resident off the toilet on 08/08/21. Administrator further confirmed Resident #13 sustained a left ankle fracture when STNA #100 lowered her to the floor on 08/08/21. Administrator confirmed in addition to counseling for STNA #100, all staff received education regarding use of gait belt and following the resident's care plan (Kardex). Administrator confirmed the facility also implemented ongoing audits and held a special Quality Assurance Performance Improvement (QAPI) on 08/09/21 related to the incident. Review of the personnel file for STNA #100 revealed a form titled Team Member Counseling dated 08/08/21 for failure to perform work assignment. Further review of form revealed on 08/08/21, STNA #100 transferred Resident #13 to provide ADL care. During the transfer Resident #13's care plan was not followed. Further review of the form revealed STNA #100's comment in response to the counseling was that she was sorry this had occurred. Review of the facility policy titled Gait Belt policy dated 11/2012 revealed the gait belt was used to promote safety of the residents and employees Review of the manufacturer's guidelines for the SafetySure Pivot Disc undated revealed the pivot disc was used to for individuals with impaired mobility from paralysis and revealed a belt should be used in connection with the pivot disc to ensure maximum support and safety for the patient and the caregiver. Further review of the guidelines revealed for transfers between a wheelchair and a toilet using the pivot disc they recommended two caregivers provide assistance. Review of the facility policy titled Fall and Accident Management dated 06/2019 revealed the facility would identify the residents at risk of falls and other accidents. Interventions would be implemented and evaluated to reduce the risk of injuries, falls or other accidents. As a result of the incident, the facility took the following actions to correct the deficient practice by 08/26/21: · On 08/08/21, the staff assessed Resident #13 for injuries and arranged for transfer to the hospital for resident. · The Interdisciplinary Team (IDT) met on 08/08/21 and reviewed the incident and updated Resident #13's care plan. · All nursing staff received additional in-service education by 08/11/21 by the Administrator, Director of Nursing (DON) and designees. This education included, but was not limited to, review of residents' care plan, updates to care plans/Kardex, level of assistance, and gait belts/assistive devices. · A Performance Improvement (PI) worksheet was completed by the DON or designee twice a day for seven days, then daily for seven days, then weekly for four weeks, and then monthly thereafter with ten observations to be completed on each PI worksheet. If issues were noted, the DON or designee took appropriate action at the time the concern was noted. Results of the PI worksheet will be reported to the Quality Assurance (QA) committee for a determination of the need for further ongoing formal monitoring. · A Quality Assurance meeting was held on 08/09/21 with the Administrator, Medical Director, DON, ADON, and Corporate Nurse. · Interviews on 08/27/21 at 3:36 P.M. with STNA #250, at 3:37 P.M. with STNA #300, and at 3:38 P.M. with STNA #350 confirmed they received re-education on 08/09/21 on review of residents' care plans, updates to care plans/Kardex, level of assistance, and gait belts/assistive devices. The staff were knowledgeable regarding the content of the education. · On 08/27/21 two additional residents (#14 and #38) were sampled and reviewed for assistance with transfers. No concerns were identified. · On 08/27/21 a review of the facility's incident and accident log revealed there were no further concerns identified regarding assistance with transfers and falls. This deficiency substantiates Complaint Number OH 943.

Based on medical record review, family and staff interviews, self-reported incident review and policy review, the facility failed to report an allegation of abuse to the State Agency within 24 hours from the time the abuse allegation was reported. This affected one (#10) of three residents reviewed for potential abuse. The census was 72. Findings include: Review of medical record for Resident #10 revealed an admitted [DATE]. At the time of admission, the resident was confused and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 was admitted for rehabilitation services due to right hip pain. Review of the Hospital Encounter sheets from 05/08/21 to 06/07/21 revealed Resident #10 required 24-hour supervision for safety and required one person assist for activities of daily living. Review of Self -Reported Incident dated 06/15/21 stated allegation of sexual abuse and date of discovery was 06/15/21. The incident documented: LNHA reporting out of an abundance of caution. Facility received phone call from insurance case worker inquiring about facilities understanding of mutual patients current medial condition including dementia and past medical trauma. The facility unsubstantiated the allegation. Interview on 06/17/21 at 9:15 A.M., with the Administrator and the Director of Nursing (DON) confirmed Social Service Designee (SSD) #90 received a phone call on 06/15/21 from an Insurance Caseworker reporting a resident's family member reported to her Resident #10 was raped at the facility. On 06/15/21, the Administrator submitted a Self-Reported Incident (SRI) # 6. Review of the SRI revealed an investigation was not started. The Administrator stated, she has been waiting for the Caseworker and Resident #10's daughter to call her back with more details before investigating the allegation. Interview on 06/17/21 at 12:35 P.M., via telephone, with the Resident #10's daughter revealed her mother reported to her husband, she had been raped during a shower at the facility. Her husband reported this to SSD #100 on 06/11/21. On 06/14/21, she and her husband and Resident #10 attended the SR's care conference. At the conference she asked the SSD #90 if she was aware that her mother was raped at the facility. SSD #90 replied, yes I do, and it is being taken care of. Interview on 06/17/21 at 1:36 P.M., with Speech Therapist #105, who attended Resident #10's Care Conference on 06/14/21 confirmed Resident #10's daughter asked SSD #90 do you know my mother reported she was raped? SSD #90 said, yes we are aware, and it is being taken care of. Interview on 06/17/21 at 1:50 P.M., with the Administrator and DON revealed they have not started the abuse investigation because they have been waiting to speak to Resident #10's Caseworker and daughter. The Administrator and the DON shared they need more information because they have no knowledge of any one being abused. They have left several messages and have received no return calls. Per the interviews, it was determined that the Ohio Department of Health had not been notified of an abuse allegation. Interview on 06/17/21 at 1:55 P.M., with Speech Therapist #110 verified during Resident #10 care conference on 06/14/21, the Resident #10's daughter asked the SSD #90, do you know someone had raped my mother and if it was reported. The SSD #90 said yes. Interview on 06/17/21 at 2:30 P.M., with Resident #10's son-in-law revealed on 06/11/21, he visited Resident #10. He confirmed he was present when SSD #100 completed the Social Service Assessment with Resident #10 in her room. After the assessment was completed, he asked SSD #100 to step out of the room. She did and he reported to her that Resident #10 told him that she had been raped while getting a shower at the facility. She told him someone stuck something up there. When he came back into the room Resident #10 was upset and wanted to know why he reported what she had said. He explained to her they need to know. He further explained an hour later after reporting the incident to SSD #100, the administrator and the DON interviewed him and Resident #10 where he repeated to them Resident #10 told him she had been raped during her shower. Review of the undated policy titled Abuse/Neglect/Misappropriation of Property revealed the facility will investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . If abuse or serious bodily injury is alleged it should be reported to State Survey Agency immediately, but no later than (2) hours after the allegation is made. All other alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Once the Administrator and the SSD are notified, an investigation of the allegation violation will be conducted. This deficiency is an incidental finding discovered during the complaint investigation.

Based on medical record review, family and staff interviews, self-reported incident review and policy review, the facility failed to initiate an investigation upon receiving an allegation of sexual abuse. This affected one (#10) of three residents reviewed for potential abuse. The census was 72. Findings include: Review of medical record for Resident #10 revealed an admitted [DATE]. At the time of admission, the resident was confused and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 was admitted for rehabilitation services due to right hip pain. Review of the Hospital Encounter sheets from 05/08/21 to 06/07/21 revealed Resident #10 required 24-hour supervision for safety and required one person assist for activities of daily living. Review of Self -Reported Incident dated 06/15/21 stated allegation of sexual abuse and date of discovery was 06/15/21. The incident documented: LNHA reporting out of an abundance of caution. Facility received phone call from insurance case worker inquiring about facilities understanding of mutual patients current medial condition including dementia and past medical trauma. The facility unsubstantiated the allegation. Interview on 06/17/21 at 9:15 A.M., with the Administrator and the Director of Nursing (DON) confirmed Social Service Designee (SSD) #90 received a phone call on 06/15/21 from an Insurance Caseworker reporting a resident's family member reported to her Resident #10 was raped at the facility. On 06/15/21, the Administrator submitted a Self-Reported Incident (SRI) # 6. Review of the SRI revealed an investigation was not started. The Administrator stated, she has been waiting for the Caseworker and Resident #10's daughter to call her back with more details before investigating the allegation. Interview on 06/17/21 at 12:35 P.M., via telephone, with the Resident #10's daughter revealed her mother reported to her husband, she had been raped during a shower at the facility. Her husband reported this to SSD #100 on 06/11/21. On 06/14/21, she and her husband and Resident #10 attended the SR's care conference. At the conference she asked the SSD #90 if she was aware that her mother was raped at the facility. SSD #90 replied, yes I do, and it is being taken care of. Interview on 06/17/21 at 1:36 P.M., with Speech Therapist #105, who attended Resident #10's Care Conference on 06/14/21 confirmed Resident #10's daughter asked SSD #90 do you know my mother reported she was raped? SSD #90 said, yes we are aware, and it is being taken care of. Interview on 06/17/21 at 1:50 P.M., with the Administrator and DON revealed they have not started the abuse investigation because they have been waiting to speak to Resident #10's Caseworker and daughter. The Administrator and the DON shared they need more information because they have no knowledge of any one being abused. They have left several messages and have received no return calls. Per the interviews, it was determined that the Ohio Department of Health had not been notified of an abuse allegation. Interview on 06/17/21 at 1:55 P.M., with Speech Therapist #110 verified during Resident #10 care conference on 06/14/21, the Resident #10's daughter asked the SSD #90, do you know someone had raped my mother and if it was reported. The SSD #90 said yes. Interview on 06/17/21 at 2:30 P.M., with Resident #10's son-in-law revealed on 06/11/21, he visited Resident #10. He confirmed he was present when SSD #100 completed the Social Service Assessment with Resident #10 in her room. After the assessment was completed, he asked SSD #100 to step out of the room. She did and he reported to her that Resident #10 told him that she had been raped while getting a shower at the facility. She told him someone stuck something up there. When he came back into the room Resident #10 was upset and wanted to know why he reported what she had said. He explained to her they need to know. He further explained an hour later after reporting the incident to SSD #100, the administrator and the DON interviewed him and Resident #10 where he repeated to them Resident #10 told him she had been raped during her shower. Review of the undated policy titled Abuse/Neglect/Misappropriation of Property revealed the facility will investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . If abuse or serious bodily injury is alleged it should be reported to State Survey Agency immediately, but no later than (2) hours after the allegation is made. All other alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Once the Administrator and the SSD are notified, an investigation of the allegation violation will be conducted. This defciceincy is an incidental finding discovered during the complaint investigation.

Based on staff interview, observation, policy review and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in designated quarantined area to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected one (#13) out of five residents residing in the quarantine unit. Facility census was 80. Findings include: Observation on 05/13/21 at 9:11 A.M. in the quarantined unit revealed Housekeeper #20 was cleaning in Resident #13's room without a gown. Further observations revealed a sign posted on Resident #13's doorframe that instructed anyone entering to room to wear an N95 face masks, face shield, gloves and gown. Interview on 05/13/21 at 9:13 A.M., Housekeeper #20 verified Resident #13 was in quarantine. Housekeeper #20 further verified that a gown was required when cleaning Resident #13's room and that gowns were available. Review of the facilities Infection Control policy revised 10/20 revealed appropriate PPE include a gown are to be used for residents residing in transmission based precaution. Review of the CDC website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#new-admissions, updated 03/29/21, revealed healthcare professionals (HCP) should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for residents who are in quarantine for observations related to COVID-19. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on closed record review, room change/roommate change notice review, staff interview, and review of facility policy, the facility failed to notify each resident's representative when there was a facility initiated room change/roommate change for the resident. This affected one (#90) of four residents reviewed for notification of changes. The facility census was 86. Findings include: Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired at the facility on [DATE]. Review of an admission minimum data set assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of a Room Change/Roommate Change notice signed by former Licensed Social Worker (LSW) #98 on [DATE] revealed the resident was notified on [DATE] that he would be moving from 245 (Covid-19 unit) to room [ROOM NUMBER] (recovery unit) on [DATE]. The room change notice completed by former LSW #98 revealed that the resident was made aware of the room change, but there was no documentation the family/representative of the resident was notified of the room change. Review of a Room Change/Roommate Change notice signed by Social Service Designee (SSD) #99 on [DATE] revealed the resident was notified on [DATE] that he would be receiving a new roommate in room [ROOM NUMBER] on [DATE]. The roommate change notice completed by SSD #99 revealed that the resident was made aware of the roommate change, but there was no documentation the family/representative of the resident was notified of the roommate change. Interview with the Administrator on [DATE] at 12:45 P.M., and follow-up interview on [DATE] at 4:31 P.M., affirmed there was no documentation to support that Resident #90's family/representative was made aware of the room change on [DATE], or the roommate change on [DATE]. The Administrator affirmed the facility's policy/procedure for room/roommate changes did not specify that the resident and their family/representative were both to be notified with such changes. Interview with SSD #99 on [DATE] at 4:41 P.M. revealed that it was her understating that when a resident's room/roommate was changed the resident as well as the family/representative was to be notified. She stated the family/representative it notified and the new room number and new telephone number the resident can be reached at is given. SSD #99 stated that a room/roommate change assessment in the electronic health record is completed where you document that the resident and family/representative was made aware of the change. She explained that both the resident and their family/representative soul be notified of the changes regardless of the resident's cognitive status unless a resident requests that the information regarding the change is not communicated. Review of the facility policy titled Roommate Change/Room Change Notice revealed the facility specified that only the resident would receive notification regarding roommate changes, and for room changes the resident and/or responsible party would be notified. The policy did not specify that both the resident and their designated representative could be notified of such changes. This deficiency substantiates Complaint Numbers OH 273 and OH 766.

Based on medical record review and resident representative and staff interview, the facility failed to notify the resident's representative when medications were not available for administration. This affected one (#17) of five residents review for unnecessary medication. The census was 88. Findings include: Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] at 5:07 P.M. [DIAGNOSES REDACTED]. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #17 required extensive assist of one person for bed mobility, locomotion, and walking. The resident required extensive assistance of two for transfers and was dependent upon staff for dressing and eating. A brief interview of mental status was not completed because the resident was rarely/never understood. The assessment revealed the resident had long term memory problems and was not able to recall the current season, location of own room, staff names/faces, or the he/she was in a nursing home. Review of a Medication Administration Record [REDACTED].M. were unavailable. The medication identified as unavailable for administration included lacosamide tablet (anticonvulsant) 200 milligram (mg); [MEDICATION NAME] (anticonvulsant/antianxiety) one mg, [MEDICATION NAME] tablet (anticonvulsant) 64.8 mg; [MEDICATION NAME] sodium (anticonvulsant) 100 mg with 30 mg give two capsules (total of 160 mg); Eliquis (anticoagulant) five mg; Losartan potassium (antihypertensive) 25 mg; and [MEDICATION NAME] ([MEDICATION NAME]) 600 mg. Continued review of the MAR indicated [REDACTED].M. Review of the medical record for Resident #17 revealed there was no evidence of the representative for Resident #17 being notified of medications that were not administered on 02/19/20 or 02/20/20. Interview on 03/03/20 at 11:37 A.M. with two of Resident #17's representatives revealed the facility did not notify the representatives of the medications which were unavailable for administration on 02/19/20 and 02/20/20. Interview on 03/05/20 at 2:42 P.M. with the Director of Nursing (DON) verified the medical record for Resident #17 contained no evidence the resident's representatives were notified of the medication not administered to the resident on 02/19/20 and 02/20/20.

Based on medical record review, staff interview, policy review and review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary medications when the staff failed to follow physician ordered parameters regarding the administration of a cardiac medication. This affected one (#29) of five residents reviewed for unnecessary medications. The facility census was 88. Findings included: Medical record review for Resident #29 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set ((MDS) dated [DATE] revealed she cognitively intact. Functional status was total dependence for bed mobility and transfers with two-person assistance. She was total dependence for toilet use with one-person assistance and supervision for eating with set-up help. Review of physician orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Those dates were 12/10/19, 12/11/19, 12/14/19, 12/15/19, 12/16/19, 12/24/19, 12/27/19, 12/28/19 and 12/29/19. Further review of the MAR from 01/01/20 through 01/31/20 revealed there were ten dates the medication was administered with a pulse documented less than 70 bpm. Those dates were 01/01/20, 01/02/20, 01/04/20 ,01/06/20, 01/07/20, 01/10/20, 01/11/20, 01/12/20, 01/14/20, and 01/31/20. Review of the MAR from 02/01/20 through 02/29/20 revealed there was ten times the medication was given with a pulse less than 70. Those dates were 02/02/20, 02/06/20, 02/08/20, 02/12/20, 02/15/20, 02/19/20, 02/20/20, 02/22/20, 02/26/20 and 02/27/20. Interview with the Director of Nursing (DON) on 03/05/20 at 10:28 A.M. verified the above mentioned dates the [MEDICATION NAME] was given during the time frame to the resident with a pulse of less than 70. Review of policy entitled Change of Condition revised 06/01/15 revealed the facility staff will reported identified significant changes in resident's status. Documentation of the condition will be noted in the nursing notes or interdisciplinary charting. The resident's physician will be notified of significant changes in the resident's condition. Review of medication information from Medscape revealed [MEDICATION NAME] is a cardiac medication used to treat [MEDICAL CONDITION] (chest pain), hypertension, [DIAGNOSES REDACTED] (fast heart beat) and [MEDICAL CONDITION]/flutter

Based on medical record review, cubex (emergency medication box) supply list review, staff, Nurse Practitioner and physician interviews, policy review and review of medication information from Medscape, the facility failed administer medications as ordered by the physician resulting in significant medication errors. This affected one (#17) of five residents review for unnecessary medication. The census was 88. Findings include: Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] at 5:07 P.M. [DIAGNOSES REDACTED]. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #17 required extensive assist of one person for bed mobility, locomotion, and walking. The resident required extensive assistance of two for transfers and was dependent upon staff for dressing and eating. A brief interview of mental status was not completed because the resident was rarely/never understood. The assessment revealed the resident had long term memory problems and was not able to recall the current season, location of own room, staff names/faces, or the he/she was in a nursing home. Review of a Medication Administration Record [REDACTED].M. were unavailable. The medication identified as unavailable for administration included lacosamide tablet (anticonvulsant) 200 milligram (mg); [MEDICATION NAME] (anticonvulsant/antianxiety) one mg, [MEDICATION NAME] tablet (anticonvulsant) 64.8 mg; [MEDICATION NAME] sodium (anticonvulsant) 100 mg with 30 mg give two capsules (total of 160 mg); Eliquis (anticoagulant) five mg; Losartan potassium (antihypertensive) 25 mg; and [MEDICATION NAME] ([MEDICATION NAME]) 600 mg. Continued review of the MAR indicated [REDACTED].M. Review of a document titled, Cubex Formulary undated revealed the medications Eliquis 2.5 mg (supply of eight), [MEDICATION NAME] 600 mg (supply of 10), [MEDICATION NAME] 32.4 mg (supply of 10), [MEDICATION NAME] 100 mg (supply of six), [MEDICATION NAME] 50 mg chew tablet (supply of five), [MEDICATION NAME] one mg (supply of two), Losartan 25 mg (supply of 10) where listed as available for resident use in the facilities emergency medication supply. The only medication not listed as available in the emergency medication supply was lacosamide. Interview on 03/04/20 at 8:33 A.M. with the Director of Nursing (DON) revealed when a resident was admitted to the facility and had physician ordered medication due for administration, the medications could be obtained from the facilities emergency medication supply. The DON further revealed if a medication was not available in the emergency box supply then the physician would be notified for further direction. Continued interview with the DON revealed the code 16, when documented on a residents MAR, indicated the medication was not available from pharmacy. The DON verified documentation on the MAR indicated [REDACTED].M. on 02/19/20, which included [MEDICATION NAME] one mg; [MEDICATION NAME] 64.8 mg; [MEDICATION NAME] sodium 160 mg; lacosamide 200 mg; Eliquis 5 mg; Losartan potassium 25 mg; and [MEDICATION NAME] 600 mg was not not available from pharmacy. The DON further verified the [MEDICATION NAME] scheduled on 02/20/20 at 9:00 P.M. was documented as unavailable. The DON confirmed the medications that were documented as unavailable on 02/19/20 and 02/20/20 were not administered to Resident #17. Continued interview with the DON verified six of the seven medications that were documented on the resident MAR indicated [REDACTED]. Interview on 03/04/20 at 8:58 A.M. with Physician #239 (Resident #17 primary care physician) revealed when medication were available in the facilities emergency supply and there was a valid prescription, it would be expect that the medications would be administered. Interview with the physician revealed the only medication that should have been held for Resident #17 on 02/19/20 at 9:00 P.M. was the lacosamide, because it was not available in the emergency box. Continued interview with Physician #239 revealed on this day, 03/04/20, the facility spoke with this physician in regards to the medications that were placed on hold on 02/19/20 by the on call nurse practitioner. The interview revealed it was this physician's professional opinion that the available medications should have been administered as ordered. Interview with the physician revealed the physician was made aware of the 02/19/20 medications being placed on hold on 03/04/20 and the physician was asked to sign the telephone ordered for the held medication on 03/04/20, even though the telephone order indicated the order was signed by this physician on 02/19/20. The physician did not know who documented the sign date as 02/19/20. Interview 03/04/20 at 10:37 A.M. with Nurse Practitioner (NP) #238 (on call for Physician #239 on 02/19/20) revealed facility staff called the NP on 02/19/20, and a verbal order was given to hold unavailable medications until they were available the next morning. Interview with NP #238 revealed the NP was not aware of the facility having an emergency medication supply. Further interview with the NP revealed it was the NP's expectation that any medications which had a valid order and was available in the emergency supply would be administered to Resident #17 and not be held until the next morning. Review of a policy titles, Emergency Boxes and On-Site Stores, dated 06/21/17, revealed the pharmacy supplies an emergency box and other on-site stores of medications to be utilized by he facility in the case of new admissions, urgent new orders received after hours, or when immediate medication administration was required. When receiving a new medication order that needs to be administered prior to the next pharmacy delivery, the nurse obtaining the order should check the on-site store list prior to accepting the order from the physician to see if that medication is available in the facility. If not, the physician should be informed of the available medications to determine if an alternative can be ordered. Review of medication information from Medscape revealed the following: [MEDICATION NAME] is used as an antianxiety; [MEDICATION NAME] is an anticonvulsant (anti-[MEDICAL CONDITION]); [MEDICATION NAME] sodium is an anticonvulsant; Eliquis is an anticoagulant; Losartan is used to treat hypertension and [MEDICATION NAME] is used to treat a cough.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, fall statement review, hospital radiographic imaging review, observation, staff interviews and review of facility policy the facility failed to ensure two staff provided personal care with bed mobility to a resident as care planned. This resulted in actual harm when a state tested nursing assistant (STNA) provided care to a resident by herself. The resident was assessed and care planned for the assistance of two staff for bed mobility. The resident sustained [REDACTED]. This affected one (Resident #80) of three residents reviewed for falls. The resident census was 83. Findings include: Review of the medical record revealed Resident #80 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the five day scheduled Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident was able to make herself understood and understood others. The resident had moderate cognitive impairment. The resident was dependent on the physical assistance of two staff with bed mobility. Bed mobility was defined as how the resident moved to and from the lying position, turned side to side and positioned the body while in bed or alternate furniture. Review of the care plan dated 06/04/19 for activity of daily living (ADL) self-care performance deficit revealed an intervention for the extensive assistance of two staff with bed mobility. Review of the a progress note dated 12/30/19 at 11:00 [NAME]M. revealed STNA #81 alerted Licensed Practical Nurse (LPN) #105 that while she was assisting the resident with perineal care and brief change, the resident rolled off the bed and was laying on the floor. Upon entering the room, the resident was observed on the floor in a supine position. The resident stated she did not hit her head hard. The resident had pain in her lower extremities. A head to toe assessment was completed and a skin tear and hematoma was noted on the residents right lower extremity and an abrasion on her lower left extremity. First aid was provided and a new order was received to send the resident to the emergency room (ER) via nine-one-one (911) for further evaluation. The resident was assisted back into her bed by five staff. Her blood pressure was 177/97, respiratory rate was 18, pulse was 87 beats per minute, temperature was 98.4 degrees Fahrenheit (F) and oxygen saturation of 98 percent (%) on room air. Physician #102 was in the building and assessed the resident. The resident's Power of Attorney (POA) was notified. Review of Physician #102 progress notes dated 12/30/19 revealed the physician was urgently called to the room to see the resident who suffered a fall out of bed. The staff reported the resident was receiving care when she rolled out of bed. Upon his entrance to the room, the resident was on the floor surrounded by the nurses. The resident denied pain in her neck or back. The staff reported she had contractures of the lower extremities. The assessment was left hip pain and a right lower extremity skin laceration. The plan was to send her to the hospital for imaging studies of the left hip and pelvis to rule out a fracture. A suture or two might be needed for the skin laceration. The resident was sent urgently to the ER for further evaluation and treatment. Review of the fall statement form dated 12/30/19 at 11:00 [NAME]M. revealed STNA #81 was providing care to the resident, she rolled the resident to the side and reached back to get the brief and a couple of seconds later the resident fell . STNA #81 made sure the resident was okay and responsive and she flagged the nurses into the room. Review of a second fall statement form dated 12/30/19 at 11:00 [NAME]M. revealed Registered Nurse (RN)/Assistant Director of Nursing (ADON) #53 documented STNA #81 was attempting to change the residents brief when the resident rolled off the bed onto the floor. RN/ADON #53 went into the room, and assisted LPN #105 with assessing the resident. RN/ADON #53 noted a skin tear on the residents right lower leg. She assisted the five staff and transferred the resident back into bed. Review of the fall statement form dated 12/30/19 at 4:30 P.M. revealed LPN #105 documented STNA #81 alerted her when the resident rolled onto the floor from her bed. LPN #105 immediately entered the room to assess the resident. RN/ADON #53 notified Physician #102 who gave new orders to send the resident to the ER for further evaluation. Review of the hospital's radiographic imaging dated 12/30/19 revealed the resident sustained [REDACTED]. There was an acute, comminuted and markedly displaced fracture involving the distal region of the left femur. There was an acute, comminuted and marginally displaced fracture involving the distal region of the left femur. There was an acute and comminuted displaced and angulated fracture involving the distal region of the right femur. On 02/12/20 at 11:15 [NAME]M. an observation was made as STNA's #80 and #90 provided incontinence care to Resident #80. The resident was laying on her back on a low air loss, scoop mattress. She had bilateral lower leg contractures which were bent up towards her chest. On 02/12/20 at 12:15 [NAME]M. a telephone interview with STNA #81, revealed she cared for Resident #80 when she rolled out of bed. STNA #81 said the resident was holding onto the grab bar and she was going to wash the resident up. When she turned the resident on her right side and reached for the incontinence brief at the foot of the bed, the resident rolled out of bed. STNA #81 said the resident always complained of pain. STNA #81 said she would have liked to have two staff with she provided care to the resident but staff were busy so she provided care by herself. On 02/12/20 at 2:20 P.M. an interview with STNA #90, revealed prior to Resident #80's fall she always utilized two staff assistance when turning the resident in bed. STNA #90 said one staff could provide perineal care when the resident was on her back but she needed two staff when turning her on her side with care. On 02/12/20 at 2:28 P.M. an interview with STNA #95, revealed prior to Resident #80's fall one staff could provide incontinence care but she always utilized two staff when turning the resident on her side. She said the resident was not able to assist with turning. On 02/12/20 at 2:40 P.M. an interview with STNA #79, revealed prior to Resident #80's fall she always utilized two staff when turning the resident on her side during care. On 02/12/20 at 3:00 P.M. a telephone interview with LPN #105. LPN #105 revealed prior to Resident #80's fall there should have been two staff when turning or lifting the resident up in bed. On 02/12/20 at 4:00 P.M. an interview with the Director of Nursing (DON) verified the MDS dated [DATE] documented the resident was dependent on the physical assistance of two staff with bed mobility. The DON further verified the residents care plan for ADL indicated the resident required the extensive assistance of two staff with bed mobility. The DON verified STNA #81 provided care to Resident #80 by herself. STNA #81 turned the resident onto her side during perineal care and the resident fell out of bed and onto the floor. The DON verified per the radiographic imaging the resident sustained [REDACTED]. Review of the facility's policy for Fall and Management revised 05/2016 revealed the facility would identify residents at risk for falls and other accidents. Interventions would be implemented and evaluated to reduce the risk of injuries, falls or other accidents. The facility would implement interventions to reduce the hazard(s) and risk(s). As a result of the incident, the facility took the following actions to correct the deficient practice by 01/03/20. * On 12/30/19 the DON and/or designee reviewed all current resident's care plans were reviewed to ensure their care plans accurately reflected bed mobility assistance. * On 12/30/19 RN/ADON #53 reviewed all residents progress notes for the last 30 days. * On 12/30/19 education was provided to all nursing staff. The education was provided by the Administrator, DON, RN/ADON #53, Unit Manager #01, Regional Health Consultant (RHH) #02 and/or Corporate Nurse trainer #03. This education included but was not limited to a review of resident's care plans, updates to care plan/Kardex, level of assistance, fall assistance and fall investigations. Education was completed by 01/03/20. * On 12/30/19 a Quality Assurance (QA) meeting was held with the Administrator, Medical Director #1, DON, RN/ADON #53, and Corporate Nurse #03. * On 12/31/19 the Administrator initiated Performance Improvement (PI) worksheets for monitoring. This PI worksheet is being completed by the DON or designee daily for seven days, then weekly for four weeks, then monthly. If issues are noted by the DON or designee, appropriate action will be taken at the time the concern is noted. Results of the PI worksheets will be reported to the QA committee for a determination of the need for further ongoing formal monitoring. This certification deficiency substantiated Complaint Number OH 894.

Based on medical record review, personnel record review, review of the facility's self-reported incidents, resident interview, staff interview and policy review, the facility failed to implement their abuse policy by not reporting and completing a thorough investigation related to an allegation of verbal abuse. This affected one (#1) of three residents reviewed for abuse. In addition, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This had the potential to affect all 98 residents residing in the facility. Findings include: 1. Review of Resident #1's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 07/12/19, revealed the resident's cognition was intact. Review of the mood section revealed Resident #1 had little interest or pleasure in doing things in two to six days of the seven day look back period of the MDS assessment. Resident #1 was noted as feeling tired or having little energy during two to six days of the seven day look back period of the MDS assessment. No behaviors were noted during the MDS assessment. Resident #1 was noted as independent for bed mobility, dressing, eating, toileting and personal hygiene. Resident #1 was noted as having required extensive assistance with transfers and walking in her room and in the corridor. Resident #1 was noted as always continent with bladder and bowel continence. Review of the facility's self-reported incidents (SRIs) revealed there was no SRI involving Resident #1. Interview on 09/17/19 with Resident #1 at 10:14 [NAME]M. revealed she thought it was an agency nurse who had threatened her, but she was not sure and the staff gossiped and they knew she had gone out to a local psychiatric hospital and she was scared of that (going back), and it was embarrassing for her. Resident #1 stated on the day of the incident there was another resident who was waiting on her medication and that resident had stated go ahead and give Resident #1 her medication first and the nurse stated you better shut up or I'll do the paperwork and send you to the local psych hospital. She stated she told the supervisor and the facility did nothing about it. Resident #1 stated she told her daughter about this incident. Resident #1 stated she recalled the nurse having a cute name and she provided the name and description of the alleged perpetrator. Resident #1 stated her main issues were that she felt the staff gossiped about her and she didn't like being threatened about going back to a local psych hospital. Interview on 09/18/19 at 8:43 [NAME]M. with Licensed Practical Nurse (LPN) #55 who stated she was not familiar with Resident #1 as her normal assignment was the rehabilitation unit. LPN #55 stated on that particular day, 09/04/19, the resident propelled in her wheelchair down to the common area on the rehabilitation side and specifically asked for this nurse by name. Resident #1 stated someone had threatened her. Resident #1 gave no name, but stated she was told she was going to be sent back to the local psych hospital. LPN #55 stated it was chaotic at the time Resident #1 came to tell her this information, there were many nurses around the common area, and she informed the Assistant Director of Nursing (ADON) who stated she was already aware of the situation. LPN #55 stated the resident stayed in the common area for a little while and left. LPN #55 had stated to Resident #1 she would inform the ADON and she had done so. LPN #55 stated when she went to inform the ADON of the incident she described the resident and gave her first name to the ADON and explained the resident had come to see her and what the situation was. Interview on 09/18/19 at 11:02 [NAME]M. with ADON #200 stated she accidentally overheard Resident #1 screaming at the social services assistant out in the hallway on 09/04/19. The ADON stated the social services person was trying to assure the resident that the facility was trying to get her a plane ticket, and no one was going to a local psych hospital. The ADON continued she thought she was on call and it was later in the day when LPN #55 mentioned to her that Resident #1 had approached her about the incident, and she let LPN #55 know the facility was aware of the situation and handling it and working on calming the resident down and reassuring her. At that point, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were aware of the situation. The ADON stated that when LPN #55 had informed her, she was already aware of the situation and the resident had stated earlier in the day if she was bad, she would be going back to the local psych hospital. LPN #55 stated she did not recall exactly what LPN #55 had said but she recalled LPN #55 contacting her and stating the resident had specifically reached out to her by name and it had to do with her going back to a local psych hospital and the ADON stated the facility was working on the situation and about her going back to her family. Interview on 09/18/19 at 2:06 P.M. with the LNHA verified the facility did not file a SRI or complete an investigation related to the allegation of threatening and retaliatory behavior reported by Resident #1. He explained he did not know about the incident. The LNHA stated he had talked to Resident #1 regularly and he told her they were working on helping her go back home to be with her family. She didn't report to him specifically about the incident. Review of the facility's abuse policy, dated 01/01/18, revealed under the section reporting bullet number one and two which revealed the facility staff would report immediately the incident to the administrator and notify the appropriate state agency immediately after the identification of suspected incident. Under the section investigation bullet one revealed the facility will investigate any alleged resident/patient neglect, mistreatment, misappropriation of property/funds, and/or physical, verbal, sexual, mental (emotional/psychological) abuse. 2. Review of the personnel records for the following employees revealed: Licensed Practical Nurse (LPN) #44 had a hire date of 08/12/19, Culinary #3 had a hire date of 06/10/19, Physical Therapy #5 had a hire date of 07/29/19, Culinary #13 had a hire date of 04/15/19, Occupational Therapy #17 had a hire date of 07/22/19, Registered Nurse (RN) #100 had a hire date of 07/29/19, RN #200 had a hire date of 09/09/19 and RN #300 had a hire date of 06/10/19. There was no evidence these employees were checked against the State Nurse Aide Registry prior to employment. Interview on 09/19/19 at 10:00 [NAME]M. with Human Resources #500 who stated he was not aware the facility needed to check the State Nurse Aide Registry. HR #500 stated the facility did check the Nurse Aide Registry to see if an State tested Nurse Aide (STNA) was in good standing but was not aware the other employees required to be checked against the Nurse Aide Registry. HR #500 verified of the 14 newly hired employees six of those employees were STNA and had their STNA standing verified. HR #500 verified the facility did not check the remaining employees on the Nurse Aide Registry to see if they were in good standing or had been reported to the Nurse Aide Registry. Review of the facility's policy titled Resident Abuse Prohibition, dated 01/01/18, revealed the facility would screen all potential employees for a history of abuse, neglect or mistreating residents/patients during the hire process. Screening will consist of but not limited to: abuse registry check.

Based on record review, observation, staff interview and facility policy, the facility failed to ensure hot water was maintained at a safe temperature. The facility identified eight residents who were cognitively impaired and independently mobile. The facility also failed to ensure a fall investigation was completed for one resident. This affected one (Resident #10) of one residents reviewed during the complaint investigation. The facility census was 98. Findings include: 1. Observation on 09/17/19 at 10:40 [NAME]M. revealed the water in room [ROOM NUMBER] was hot to the touch and steaming. The water temperature observed was 128 degrees Fahrenheit (F). Observation on 09/17/19 at 10:51 [NAME]M. revealed the water in room [ROOM NUMBER] was hot to the touch and steaming. The water temperature observed was 125 degrees F. Observation on 09/17/19 at 10:54 [NAME]M. revealed the water in room [ROOM NUMBER] was hot to the touch and steaming. The water temperature was 126 degrees F. Observation on 09/17/19 at 10:57 [NAME]M. revealed the water in room [ROOM NUMBER] was hot to the touch and steaming. The water temperature was 124 degrees F. Observation on 09/17/19 at 11:16 [NAME]M. revealed the water in room [ROOM NUMBER] was hot to the touch and steaming. The water temperature was 126 degrees F. Observation and interview on 09/17/19 at 12:50 P.M. with Plant Engineering #250 verified the water temperature in room [ROOM NUMBER] was observed as 128 degrees F. The water temperature in room [ROOM NUMBER] was observed as 130 degrees F. The water temperature in room [ROOM NUMBER] was observed as 132 degrees F and the water temperature in room [ROOM NUMBER] was observed as 127 degrees F. Plant Engineering #250 stated he did not know what the required temperatures were supposed to be. Plant Engineering #250 stated the rooms that were checked were definitely above 120 degrees. Interview on 09/17/19 at 1:10 P.M. with the Licensed Nursing Home Administrator stated the facility tried to keep the water temperatures below 110 degrees Fahrenheit but he was not certain what the regulations were for the water temperatures he would have to go look to be certain. Review of the facility's policy titled Clinical Water Temperature Monitoring revealed clinical water temperatures were to be maintained with state requirements. 2. Review of the medical record for Resident #10 revealed a re-entry date of 06/19/19. [DIAGNOSES REDACTED]. Review of the thirty day Minimum Data Set (MDS) assessment, dated 07/15/19, revealed the resident had intact cognition. The resident was noted as having required extensive assistance for bed mobility, transfers, dressing and toileting. Resident #10 was noted as independent for location on and off the unit. Review of the plan of care revealed the resident was at risk for fall related to injury due to impaired mobility, hepatic [MEDICAL CONDITIONS], diabetes, pain, anxiety and [MEDICAL CONDITION]. Interventions included to assess the need for new interventions as needed, if fall occurs, assess/reassess fall risk upon admission, quarterly and with any significant change, call light within reach when in room, defined perimeter mattress, ensure proper footwear, clutter free environment and frequent checks on the resident. Review of the resident's fall risk score, dated 05/10/19, revealed a fall score of 15, which indicated the resident was at moderate risk with no history of falls. Review of the progress notes, dated 07/07/19, revealed the resident had an unwitnessed fall and was found on the floor with her head hurting and bleeding. Emergency nine-one-one (911) was called and the resident was sent to the local emergency room with three attendants. As a new intervention it was listed education on call light use and keeping the bed in lowest position was provided. There was no evidence the facility completed a fall investigation to investigate the if the resident's fall plan of care was in place prior to the resident's fall and the circumstances surrounding the time of the resident's fall. Interview on 09/18/19 at 12:37 P.M. with the Director of Nursing verified the nurse who was working and charted the progress note did not do an incident report. The DON further stated a fall investigation would be completed based on what the facility knew now. Review of the facility policy titled Fall and Accident Management dated 03/2019 revealed an investigation would be completed post fall.

Based on medical record review, review of hospital records, interview with facility staff, the attending physician and a nurse practitioner, review of laboratory (lab) testing results, review of the facility policy titled Laboratory Services and Reporting, and review of the Medscape Guidelines 2019, the facility failed to ensure adequate monitoring was completed for one resident (Resident #43) who received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME]. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and serious-life threatening harm to Resident #43 when the resident required transportation to the local emergency room (ER) with a critically elevated International Normalized Ratio (INR) level (used to monitor therapeutic levels of blood clotting) of 16.3 with urethral bleeding noted. This affected one (#43) of four residents who received anticoagulant medication. The facility identified three residents currently receiving anticoagulant medication at the time of the survey. The facility census was 81. On 02/07/19 at 1:30 P.M., the Administrator, Regional Consultant #142, and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/16/18 when the facility failed to obtain a physician ordered lab (INR) test to monitor Resident #43's [MEDICATION NAME] level. The resident continued to receive [MEDICATION NAME] five milligrams (mg) without any INR monitoring until 11/27/18 when Licensed Practical Nurse (LPN) #64 discovered no lab monitoring had been done. LPN #64 obtained orders for the labs for the INR to be done the morning of 11/27/18. The lab results on 11/27/18 at 7:31 A.M. revealed Resident #43 had a critically elevated INR level of 16.3 (normal therapeutic range 2.0 to 3.0). The resident was sent to the localER on [DATE] with a repeat INR level of 18.6 and received three doses of 2.5 mg of Vitamin K in an attempt to reverse the effects of the [MEDICATION NAME] medication. The ER nursing staff member also found signs and symptoms of [MEDICATION NAME] toxicity with blood in the resident's ureter. The Immediate Jeopardy was removed on 11/27/18 when the medical records of the remaining two residents receiving anticoagulant medications (#189 and #192) revealed the residents had INR levels within acceptable therapeutic ranges, were receiving appropriate laboratory monitoring, and no signs and symptoms of bleeding were noted. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/20/19, when the facility implemented the following corrective actions: · On 11/27/18, Resident #43 was sent to the hospital ER for evaluation and treatment. · On 11/27/18, the DON reviewed the medical records of the two other residents (#189 and #192), who were currently receiving anticoagulant medications, in the facility to ensure their INR levels were within acceptable therapeutic ranges and laboratory monitoring was being completed as ordered by the physician. There were no further issues identified. · On 11/28/18, Resident #43 returned from the hospital with a physician order to discontinue the anticoagulant medication, [MEDICATION NAME]. · On 02/07/19, Residents #58, #68 and #346 were identified by the facility as receiving [MEDICATION NAME]. The DON audited all three resident's medical records and verified physician ordered INR lab tests were being completed as ordered. · On 02/07/19 at 1:15 P.M., in-service education was initiated by the DON, Registered Nurse (RN) Unit Managers #04, #69, #188 and RN Minimum Data Set (MDS) #04 for licensed facility nurses to reinforce the facility's lab policy and ensure physician ordered lab tests including [MEDICATION NAME] monitoring labs were completed as ordered. All education was completed for all licensed nurses working in the facility on this date at 2:18 P.M. Starting on 02/07/19 at 1:15 P.M., any licensed nurse or agency nurse who was not working or on leave will complete the in-service education prior to starting their next shift. · On 02/07/19 at 2:00 P.M., a Quality/Continuity of Care Worksheet was completed for all three residents on [MEDICATION NAME] in the facility (Residents #58, #68, and #346). All residents in the facility have current monitoring per physician orders. The worksheet will be completed by the DON or designee daily for four weeks, then twice a week for four weeks then weekly for four weeks. If issues are noted, the DON or designee will take appropriate action at the time the concern is noted. Results of the worksheet will be reported to the Quality Assurance (QA) committee for a determination of the need for further on-going formal monitoring. · On 02/07/19 at 2:15 P.M., a QA meeting was held with Medical Director #450, the DON, Administrator, Licensed Nurses, Activity Director, Dietary Manager, and Dietician to review the facility's [MEDICATION NAME] policy, [MEDICATION NAME] Monitoring, and to discuss the plan of correction. Action plans to address the deficiency as well as review the policy and overall system were reviewed and approved by the QA committee. On 02/08/19, a second full QA meeting will be held to review the plan of correction and to review initial audit findings. At that time, the committee will determine if the plan implemented is effective. The QA committee will continue to monitor through the usual committee process and make recommendations if indicated. · On 02/07/19 from 3:00 P.M. to 4:00 P.M., nursing staff interviews were conducted with LPN #01, LPN #03, LPN #19 and RN #04, RN #26, and RN #69 who were employed by the facility. All LPN's and RN's interviewed verified recent education on anticoagulants including [MEDICATION NAME], using the monitoring tool to track [MEDICATION NAME] (PT)/INR levels, [MEDICATION NAME] orders and lab orders. · On 02/07/19, review of current medical records of the three residents (#58, #68 and #346) currently receiving anticoagulant medications, and five closed medical records [REDACTED]. There were no other issues identified with these eight records. · On 02/20/19, review of medical records for two residents (#58 and #68) revealed there was evidence the residents were receiving the accurate dosage of the medication and the INR was completed as ordered by the physician. · On 02/20/19, the facility had completed all [MEDICATION NAME] administration and INR level audits on a daily basis and there were no issues identified. Findings include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment and was totally dependent on staff for bed mobility and transfers. Review of the anticoagulant plan of care, dated 11/01/18, revealed interventions to give medications as ordered and to monitor and document for side effects and effectiveness. Additional interventions included to monitor laboratory values to monitor and document the effect of anticoagulant therapy, and report values outside desired range. Review of the medical progress notes revealed on 11/14/18 at 1:00 P.M., LPN #12 documented the resident was seen by the wound nurse and ordered a venous Doppler (an ultrasound examination of the veins) for his right lower extremity due to increased swelling. Review of the results of the Venous Doppler dated 11/14/18 revealed the resident had an acute nonocclusive [MEDICAL CONDITIONS] in the right lower extremity. Review of the physician orders revealed an order dated 11/15/18 for the anticoagulant [MEDICATION NAME] five mg once a day for [MEDICAL CONDITION] to right lower extremity. A PT/INR value to be drawn on Friday, 11/16/18. There was no evidence the PT/INR lab value was completed as ordered by the physician from 11/16/18 through 11/26/18. Review of the physician orders, dated 11/27/18, revealed Nurse Practitioner (NP) #800 ordered a PT/INR lab value to be completed. Review of laboratory results dated [DATE] at 7:30 A.M. revealed the resident's INR level was critically high at 16.3. NP #800 was notified and ordered Resident #43 to be sent to the hospital for evaluation and treatment. Review of the nursing progress notes from 11/15/18 to 11/27/18 revealed no negative findings of the effects of the anticoagulant medication. Review of the Medication Administration Record [REDACTED].M. daily from 11/15/18 to 11/26/18 until the resident was sent to the hospital for evaluation and treatment on 11/27/18. Review of the hospital discharge summary revealed Resident #43 was admitted on [DATE] due to significant, elevated INR level of 16.3., repeat blood work was done in the hospital ER and revealed an elevated INR level of 18.6. The assessment and plan revealed the resident had severe coagulopathy secondary to [MEDICATION NAME] with an INR level of 18.6 status [REDACTED]. Hemoglobin and Hematocrit were stable at 12.1 and a repeat INR level of 4.7. Resident #43 was given three doses of Vitamin K 2.5 mg orally to reverse the effects of [MEDICATION NAME] and the INR improved to the level of 4.7. There were no active signs of bleeding noted except for mild urethral bleeding. The hospital discharged the resident back to the facility on [DATE]. The physician ordered to discontinue [MEDICATION NAME] and continue [MEDICATION NAME] (blood thinner) 40 mg injection daily for [MEDICAL CONDITION]. Interview on 02/07/19 at 9:59 A.M., with the DON and RN Unit Manager #69 verified the physician ordered PT/INR level for 11/16/18 was not completed. The order was put into the electronic system, but the lab order was missed. RN #69 stated she was notified by LPN #64 the morning of 11/27/18 when she discovered it and obtained orders for the PT/INR to be drawn that morning. Telephone interview on 02/07/19 at 2:00 P.M. with the attending Physician #680 revealed he recalled being notified by NP #800 that Resident #43 had critically elevated PT/INR lab results and was sent to the hospital for evaluation and treatment. Telephone interview on 02/07/19 at 3:00 P.M. with NP #800 revealed the facility notified her of the critical lab results on 11/27/18, and she ordered the facility to send the resident to the hospital for evaluation and treatment. An attempt to interview LPN #64 during the survey was unsuccessful. Review of the facility policy titled, Laboratory Services and Reporting, dated (MONTH) (YEAR), revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with the state law. Review of the medication information titled Medscape Guidelines 2019 revealed [MEDICATION NAME] was an anticoagulant and used as treatment of [REDACTED]. Under black box warning it indicated [MEDICATION NAME] can cause major or fatal bleeding; bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR greater that 4), and age sixty-five years or older. Regular INR monitoring of INR should be performed on all treated patients; those at high risk for bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR and a shorter duration of therapy is recommended.