Every finding on record at The Colony Healthcare Center

Based on observation, interview, record review, and facility policy review, the facility failed to maintain infection control procedures while administering medications. This affected one resident (Resident #29) out of four residents observed for medication administration. The facility census was 108.Findings include:Review of Resident #29's medical record revealed an admission date of 10/27/22 with diagnosis of type 2 diabetes mellitus.Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had intact cognition.Observation on 1/28/26 at 8:29 A.M. of Licensed Practical Nurse (LPN) #215 during medication administration revealed she did not perform hand hygiene before preparing eight medications for Resident #29. LPN #215 placed all medications in the medicine cup and administered them to Resident #29 without washing hands or using hand sanitizer.Interview on 01/28/26 at 8:47 A.M. with LPN #215 confirmed she did not perform hand hygiene before medication administration with Resident #29. LPN #215 reported I forgot and didn't have my hand sanitizer on my cart.Interview on 01/29/26 at 7:00 A.M. with Director of Nursing (DON) confirmed hand hygiene is to be performed before and after administering medications to each resident.Review of the facility policy, Medication Administration, undated, revealed to perform appropriate hand hygiene before beginning medication administration and perform hand hygiene before and after each resident's medication is administered.Review of the facility policy, Standard Precautions, undated, revealed practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infections. Proper cleaning of hands can prevent the spread of germs. Further states when to perform hand hygiene for care between residents.

Based on observation, interview, and review of the facility's policy, the facility failed to maintain the kitchen and nursing unit refrigerator and microwave on unit D in a clean and sanitary manner. This had the potential to affect all residents receiving food from the facility. The facility census was 108. Findings include:1. Observations during the initial tour of the kitchen on 07/28/25 from 9:04 A.M. through 9:22 A.M. revealed: The reach-in cooler at the end of the steamtable on the bottom inside of the door had dried, various splatters and food debris. The table next to the reach-in where the juice machine and toaster were located, the top shelf had various dried stains around the juice machine and on the wall behind it. The bottom shelf had dried red and brown stains where the boxes of juice and a black piece of machinery sat. The wall where the clean knives were hanging was dirty with various dried stains. The table across from the steam table where the steamer sat, observed on the second shelf where two wire baskets with several serving utensils and scoops with various dried splatters and stains. The bottom shelf that had oil and other food items stored had grease stains. The bottom shelf of the table with the pots and pans had various food debris. There was a large box of thickener that was wide open and had a strand of hair inside of the thickener. The shelf on the wall where the spice containers sat had various food debris/crumbs. Interview on 07/28/25 between 9:04 A.M. through 9:22 A.M., Dietary Manager (DM) #700 verified the above findings. 2. Observation on 07/30/25 at 11:57 A.M. of the lowerator (where the metal pellets are heated to keep the plates warm) was dirty with various smears/debris---the metal pellets sits in the thermal bottom, and the plate of food sits on top of the metal pellet then covered with the thermal lid --- observed three flies flying around the kitchen-landing on the pole at end of steamtable and in front of the lowerator. - Interview on 07/30/25 at 12:15 P.M. DM #700 verified the lowerator was dirty and stated they would clean it. 3. Observation on 07/31/25 at 11:04 A.M. of the nursing unit refrigerator and microwave on the D unit with Assistant Director of Nursing (ADON) #502 revealed a towel in the freezer and underneath the towel was a pink/reddish colored stained frost and a blue plastic spoon in the frost. Inside of the refrigerator were towels on each shelf observed various stains on the inside, bottom part of the refrigerator and the inside of the door. The microwave was heavily soiled with various dried stains/food splatters. Interview at this time with ADON #502 verified the above findings. Review of the diet type report dated 07/28/25 revealed all residents in the facility received meals from the kitchen. Review of the policy Equipment, dated September 2017 revealed all foodservice equipment will be clean, sanitary, and in proper working order.

Based on observation, interviews, record review and facility policy review, the facility failed to maintain an effective pest control program to prevent flies in the facility. This had the potential to affect all 108 residents residing in the facility. Findings include:Observation on 07/28/25 at 10:25 A.M. in Resident #94 and Resident #67's room revealed six flies on Resident #94 bed. Interview on 07/28/25 at 10:32 A.M. with Housekeeping #607 confirmed observation of flies in Resident #94 and Resident #67's room and said she was not sure why there were flies. Observation and interview on 07/28/25 at 10:35 A.M. in Resident #51's room revealed flies, and he said the flies got bad last week. Observation 07/28/25 at 10:41 A.M. in Resident #102's room revealed flies in the room. Observation on 07/29/25 at 2:46 P.M. revealed flies in room B9 and C7. Observation and interview on 07/29/25 at 2:50 P.M. with Resident #79 and Resident #7 revealed flies in their room. Resident #79 said there were lots of flies, and he held up an electric fly swatter he had. Interview on 07/29/25 at 2:54 P.M. with Licensed Practical Nurse (LPN) #581 confirmed above observation of flies in resident rooms B9 and C7. Observation and interviews on 07/29/25 at 3:02 P.M. through 4:00 P.M. during resident council revealed flies in the activity room during the meeting. Resident #76 revealed flies were a daily problem at the facility, and he made his own fly swatter. Resident #99 revealed he requested his brother bring him a fly swatter. Observation on 07/29/25 at 5:08 P.M. of pest control at the facility. Observation and interview on 07/30/25 at 1:22 P.M. of Resident #115 in his room revealed a fly in the room. Resident #115's son said he had just killed a fly in the room. Observation and interview on 07/30/25 at 1:22 P.M. with Resident #102 revealed flies in her room. Resident #102 said the flies have been bad the past few days. Observation and interview on 07/31/25 at 11:31 A.M. with Resident #94 in his room revealed a fly on his bed. He said they were not better. Resident #94 said the pest control came back and got the fly traps. Observation of two sticky fly traps on wall with no flies on trap. Observation on 08/04/25 at 9:40 A.M. of resident #94 and #67's room revealed flies in the room. Observation and interview on 08/05/25 at 3:10 P.M. with Resident #44 and Resident #85 in their room revealed five flies in the room, with one fly on Resident #44's leg. Resident #85 asked if the surveyor could please help them with the fly problem. Interview on 08/05/25 at 4:00 P.M. with Director of Social Services #553 confirmed flies in Resident #44 and Resident #85's room. Interview on 08/05/25 at 3:30 P.M. with the Administrator that flies were still a problem in multiple rooms and areas. The Administrator stated pest control was coming back out. The Administrator said they have flies because residents open doors to the courtyard to go outside and smoke. Interview and observation on 08/06/2025 at 11:53 A.M. with Resident #44 and Resident #85 in their room revealed the exterminator came in last night, sprayed and put up sticky fly traps. Resident #85 said it seemed better today and they were happy. No flies were observed in the room. Review of the facilities pest control records, dated 07/10/25, revealed routine service and general pest treatment was provided. No documented concerns of house flies. Review of record from 07/29/25 at 4:36 P.M. through 5:04 P.M. revealed treatment for fruit flies and house flies. Comments and Recommendations stated Treatment for fruit flies and house flies in rooms C7 and B9. Low activity seen in both rooms. Baited walls and set two bait stickers in both rooms. Review of record from 08/05/25 at 5:45 P.M. through 6:15 P.M. revealed treatment for house flies. Comments and Recommendations stated treated room B13 for ants with no sightings. Treated perimeter, also treated room C7 for flies. No sighting in there. Also followed up with B9 for flies. Saw two flies total in the unit flying. Re-baited and sanitized drains. Review of the facility policy titled Pest Control, revision date 09/15/21, revealed B. If a problem should develop, the Environmental Services Director will contact the pest control company for an additional visit.

Based on observation, staff interview and facility policy review, the facility failed to maintain a clean and sanitary environment. This affected six (Residents #2, #38, #67, #94, #102, and #116) of 108 residents reviewed for environment. The facility census was 108. Findings include:1. Observation and interview on 07/31/25 at 11:31 A.M. in Residents #94 and #67's room revealed an unknown liquid on the bathroom floor around the toilet. The bathroom had a strong odor of urine. The flooring around toilet had a black stain around seal of toilet. The walls and ceiling of the bathroom had visible dirt and debris. The toilet was continuously running. Resident #94 stated the toilet was always running and the bathroom always smelled. Interview on 07/31/25 at 11:45 A.M. with Certified Nurse Aide (CNA) #583 confirmed unknown liquid on the floor and she stated Resident #67 urinates on the floor in the bathroom. Interview and observation on 07/31/25 at 12:10 P.M. with Maintenance Director #539 revealed Resident #67 urinates on the bathroom floor. He stated they have new tiles for the bathroom, but they have to shut down the bathroom in the room and have not done that yet. He wiped up the unknown liquid with a white washcloth which revealed a brown yellowish tint but could not confirm if this was dirt from the floor or urine. Observation on 08/04/25 at 9:40 A.M. of Residents #94 and #67's room revealed a strong smell of urine in the bathroom. Interview and observation on 08/05/25 at 9:03 A.M. with CNA #576 in Residents #94 and #67's bathroom revealed a strong smell or urine with urine of the floor in front of the toilet and an unknown brown liquid dripping down the side of the toilet. CNA #576 confirmed observation and cleaned bathroom. 2. Observation on 07/31/25 at 4:41 P.M. of Residents #2 and 102's bathroom revealed unknown liquid on the floor in front and behind the toilet and on the toilet seat with a very strong odor of urine. Interview and observation on 07/31/25 at 4:45 P.M. with Maintenance Director #539 in Residents #2 and 102's bathroom confirmed above finding. He used a white washcloth to wipe up the liquid which was yellow and confirmed it was urine. He had checked the toilets for leaks as well and did not find any. 3. Observation and interview on 08/05/25 at 3:15 P.M. with Resident #38 revealed floor trim unattached to floor and in middle of the bathroom floor. The toilet was running and Resident #38 said it constantly runs. Observation and interview on 08/04/25 at 4:33 P.M. with Licensed Practical Nurse (LPN) #545 of Resident #38 bathroom and confirmed unattached trim and running toilet. 4. Observation and interview on 08/05/25 at 4:04 P.M. of Resident #116 room revealed an extremely strong odor of garbage and stale cigarettes that could be smelled from the hallway. Resident #116 was not aware of what the smell was. Observation and interview on 08/06/25 at 4:04 P.M. with Resident #116 revealed a plastic clear garbage bag filled with clothes on the floor. Resident #116 stated he thinks someone brought them into his room yesterday and they were clean clothes. At this time LPN #581 came into room and confirmed observation of bag of clothes. LPN #581 stated they were dirty clothes and removed them from the room. Review of the facility policy titled Laundry Handling & Processing Policy, last reviewed date of 02/01/25, revealed Employees should collect soiled linens from resident/patient rooms throughout the day. This deficiency represents noncompliance investigated under Complaint Number 1358203 (OH00163378).

Based on record review and staff interview, the facility failed to ensure intravenous antibiotics were administered according to physician orders for Resident #99. This affected one (Resident #99) of two residents reviewed for antibiotics. The facility census was 108. Findings include:Review of Resident #99's medical records revealed an admission date of 07/19/24. Diagnoses included Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) and osteomyelitis (bone infection). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #99 had intact cognition. Review of the care plan dated 07/22/25 revealed Resident #99 was receiving antibiotics for suppressive therapy related to osteomyelitis. Interventions included administering antibiotics per physician orders. Review of the physician orders for July 2025 revealed Resident #99 was ordered Piperacillin (antibiotic) intravenous (IV) 3.375 grams every eight hours for 31 doses with a start date of 07/09/25 and end date of 07/19/25. Review of Treatment Administration Record (TAR) for July 2025 revealed Piperacillin had not been administered on 07/15/25 due to course had been complete. Review of the progress note dated 07/15/25 timed 2:54 P.M. authored by Licensed Practical Nurse (LPN) #545 revealed infectious disease had been contacted and stated Resident #99 had completed his IV antibiotic, and his IV could be removed. Review of the progress note dated 07/21/25 timed 3:53 P.M. authored by LPN #545 revealed Resident #99's IV could be removed, and Resident #99 was to begin oral antibiotics. Interview on 08/05/25 at 11:44 A.M. with LPN #545 revealed she had contacted the infectious disease physician on 07/15/25 and received verbal orders to remove Resident #99's IV and begin him on oral antibiotics. LPN #545 was unable to state who had removed Resident #99's IV; however, LPN #545 stated it had been removed. LPN #545 further stated she had contacted the infectious disease physician again on 07/21/25 to clarify the oral antibiotics and again confirmed Resident #99's IV had been removed on 07/15/25. Review of physician orders with LPN #545 at time of interview confirmed orders for the IV antibiotics to be administered from 07/09/25-07/19/25. LPN #545 was unable to provide an explanation of why Resident #99's IV may have been removed on 07/15/25. Interview on 08/05/25 at 1:35 P.M. with the Director of Nursing (DON) revealed Resident #99's IV had not been removed on 07/15/25, and stated Resident #99 had removed his IV himself on 07/21/25. The DON was unable to provide an explanation for the progress note authored by LPN #545 on 07/15/25 that indicated the IV had been removed, and the resident was to begin oral antibiotics. The DON further was unable to provide an explanation regarding antibiotics not being administered on 07/15/25 due to course had been completed. The DON further confirmed no documentation related to Resident #99's IV removal.

Based on record review, observation and interview, the facility failed to ensure the correct serving sizes were served for the pureed diet. This affected 10 (Residents #14, #33, #36, #64, #71, #82, #84, #86, #91, and #105) who received a pureed diet. The facility census was 108. Findings include:Observation on 07/30/25 at 11:17 A.M. of the tray line for lunch meal service revealed that pureed chicken was served using the #10 ivory handled scoop, and the pureed rice was served using the #12 green handled scoop. Review of the menu and diet guide sheet for lunch on 07/30/25 revealed pureed chicken should be served using the #8 scoop (grey handled scoop) and the pureed rice should be served using the #10 scoop (ivory handled scoop). Review of the disher and scoop size chart revealed the #8 scoop was a grey handled scoop that provided four ounces; the #10 scoop was an ivory handled scoop that provided 3.25 ounces; and the #12 scoop was a green handled scoop that provided 2.66 ounces. Interview on 07/30/25 at 12:45 P.M. with Dietary Manager (DM) #700 verified the scoops used to serve the pureed chicken and pureed rice were not correct scoops according to the menu and diet guide. Reviewed diet type report dated 07/28/25 revealed 10 (Residents #14, #33, #36, #64, #71, #82, #84, #86, #91, and #105) received a pureed diet.

Based on record review and interview, the failed to ensure an as needed (PRN) psychotropic medication had a stop date for Residents #9 and #107. This affected two (Residents #9 and #107) of five residents reviewed for unnecessary medications. The facility census was 108. Findings include:1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses including Parkinson's disease, dementia, psychotic disorder with hallucinations, visual hallucinations, auditory hallucinations, delusional disorders, anxiety, major depressive disorder, chronic obstructive pulmonary disease, emphysema, asthma, hypertensive chronic kidney disease, atherosclerotic heart disease, hyperlipidemia, iron deficiency anemia, adjustment disorder, post-traumatic stress disorder, nightmare disorder, chest pain, obesity, osteoarthritis, vitamin d deficiency, and dysphagia. Review of the physician order dated 06/28/25 revealed active orders for Ativan oral tablet 0.5 milligrams (mg) (Lorazepam) (antianxiety) every six hours PRN for anxiety with no stop date. Review of the June 2025 Medication Administration Record (MAR) revealed Resident #9 received the PRN Ativan every day since 06/28/25 for a total of five times. Review of the July 2025 MAR revealed Resident #9 received the PRN Ativan every day in July except on 07/03/25, 07/18/25, and 07/28/25 for a total of 47 times. Review of the August 2025 MAR revealed Resident #9 received the PRN Ativan every day for a total of 10 times as of 08/07/25. Review of the Consultant Pharmacist Review dated 07/15/25 revealed no apparent medication irregularities noted at this time. Interview on 08/08/25 at 12:13 P.M. with the Administrator verified there was no stop date for the PRN Ativan order with a start date of 06/28/25. 2. Review of the medical record for Resident #107 revealed an admission date of 11/30/22. Diagnoses included end stage renal disease, dependence on renal dialysis, congestive heart failure, type two diabetes mellitus, Alzheimer's disease, dementia, and anxiety disorder. Review of the physician orders for August 2025 revealed active orders for Ativan oral tablet one mg. Give one tablet by mouth every eight hours PRN for anxiety with a start date of 07/02/25. Review of the July 2025 MAR revealed Resident #107 received the PRN Ativan every day since start date of 07/02/25 except on 07/14/25, 07/23/25, 07/24/25, and 07/29/25. Review of the August 2025 MAR revealed Resident #107 received the PRN Ativan on 08/01/25, 08/02/25, 08/03/25, 08/04/25, and 08/05/25. Interview on 08/05/25 at 1:38 P.M. with the Director of Nursing (DON) verified there was no stop dated to the PRN Ativan order with the start date of 07/02/25.

Based on record review, observation, interview and facility policy review, the facility failed to ensure Residents #22, who was dependent on staff for personal hygiene, was provided adequate and timely nail care. This affected one (Resident #22) of two residents reviewed for activities of daily living. The facility census was 108. Findings include:Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following nontraumatic hemorrhage affecting right dominant side, hypertensive heart and chronic kidney disease without heart failure with stage five chronic kidney disease, end-stage renal disease (ESR), heart disease, anemia, dialysis, asthma, cirrhosis of liver, ascites, dysphagia, Barrett's esophagus without dysplasia, acute respiratory failure, acquired absence of stomach, anxiety disorder, type II diabetes and hypotension. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was dependent on staff for personal hygiene. Observation and interview on 07/28/25 at 4:25 P.M. with Resident #22 revealed he had long and unclean fingernails. Resident #22 stated he would like his nails cut. Interview on 07/28/25 at 4:30 P.M. with Licensed Practical Nurse (LPN) #551 informing him that Resident #22 would like his nails cut and cleaned. Interview on 08/08/25 at 12:13 P.M. with Administrator revealed they do not document nail care, and there was no specific staff member assigned to nail care. Review of the undated facility policy titled Nail and Hair Hygiene Services revealed Routine care also includes nail hygiene services including routine trimming, cleaning and filing.

Based on record review, observation and interview, the facility failed to identify maggots in Resident #5's wound. This affected one (Resident #5) of two residents reviewed for wound care. The facility failed to ensure blood pressure medication was administered according to physician orders for Resident #5. This affected one (Resident #5) of three residents observed for medication administration. The facility failed to ensure Resident #54's chole drain dressing was performed according to physician orders. This affected one (Resident #54) of one resident observed for chole drain dressings. The facility census was 108. Findings include:1. Review of Resident #5's medical records revealed an admission date of 09/04/24. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, dementia and diabetes. Review of the physician orders dated 05/06/25 through 05/16/25 revealed to cleanse Resident #5's toes on the right foot, apply betadine (antiseptic) in between toes daily and as needed. Review of the current physician orders for July 2025 revealed Resident #5 was ordered metoprolol (blood pressure medication) 50 milligrams (mg) one time a day. Orders included to hold medication if systolic blood pressure reading was below 110 or if heart rate was below 60. Review of the progress note dated 05/19/25 timed 6:19 A.M. authored by Director of Nursing (DON) revealed Resident #5 had increased drainage, redness and swelling along with increased pain to legs. The physician was contacted, and orders were received to send Resident #5 to the hospital. Review of the podiatry progress note dated 05/20/25 revealed Resident #5 had stated they do not take good care of her wounds at the facility. The progress note further stated Resident #5 was unaware she had maggots in her wounds. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was dependent on staff with toileting, bathing and personal hygiene. Review of the care plan dated 07/12/25 revealed Resident #5 was at risk for altered skin integrity. Interventions included administer treatments as ordered, complete weekly skin checks, encourage resident to elevate feet at intervals during the day, and evaluate existing wound daily for changes. Telephone interview on 07/28/25 at 11:24 A.M. with Resident #5's daughter revealed she was informed by the hospital during her admission in May 2025 that Resident #5 had maggots in her wounds. Resident #5's daughter stated she felt the facility had not been caring for her wounds daily as required and stated the maggots had developed due to neglect from the facility. Observation of medication administration on 07/29/25 at 7:30 A.M. with Licensed Practical Nurse (LPN) #503 revealed she had popped Resident #5's metoprolol from a medication card. The medication card had instructions on the top that stated to hold medication if systolic blood pressure was below 110 or heart rate below 60. LPN #503 did not obtain a blood pressure or heart rate prior to administering metoprolol. Interview with LPN #503 at the time of the observation confirmed she had not obtained blood pressure reading or heart rate prior to administering the medication. Interview on 08/06/25 at 1:05 P.M. with the DON revealed she had not been aware Resident #5 had maggots in her wound. Review of Resident #5's Treatment Administration Record (TAR) for May 2025 with DON at the time of the interview confirmed treatments had been documented as having been completed, with no documented refusals of treatments. Review of the podiatry note dated 05/20/25 with the DON at the time of interview confirmed documentation of maggots in Resident #5's wound. 2. Review of Resident #54's medical records revealed an admission date of 01/06/25. Diagnoses included malnutrition and Alzheimer's. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #54 had impaired cognition. Review of the current physician orders for July 2025 revealed to cleanse Resident #54's chole site with normal saline and cover with a drain sponge daily and as needed. Review of the TAR for July 2025 revealed Resident #54's chole dressing changes had been documented daily as ordered. Observation on 07/28/25 at 1:05 P.M. with LPN #503 revealed Resident #54 had a silicone dressing to her chole site. Interview with LPN #503 at time of observation revealed she was unaware of what dressing had been ordered. Interview on 08/05/24 at 1:35 P.M. with the DON confirmed Resident #54's physician orders were for a gauze dressing; however, the silicone dressing was in place at time of observation. Review of Resident #54's TAR for July 2025 with the DON at the time of the interview revealed the documentation on the TAR indicated a gauze dressing had been completed.

Based on record review and staff interview, the facility failed to ensure intravenous antibiotics were administered according to physician orders for Resident #99. This affected one (Resident #99) of two residents reviewed for antibiotics. The facility census was 108. Findings include:Review of Resident #99's medical records revealed an admission date of 07/19/24. Diagnoses included Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) and osteomyelitis (bone infection). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #99 had intact cognition. Review of the care plan dated 07/22/25 revealed Resident #99 was receiving antibiotics for suppressive therapy related to osteomyelitis. Interventions included administering antibiotics per physician orders. Review of the physician orders for July 2025 revealed Resident #99 was ordered Piperacillin (antibiotic) intravenous (IV) 3.375 grams every eight hours for 31 doses with a start date of 07/09/25 and end date of 07/19/25. Review of Treatment Administration Record (TAR) for July 2025 revealed Piperacillin had not been administered on 07/15/25 due to course had been complete. Review of the progress note dated 07/15/25 timed 2:54 P.M. authored by Licensed Practical Nurse (LPN) #545 revealed infectious disease had been contacted and stated Resident #99 had completed his IV antibiotic, and his IV could be removed. Review of the progress note dated 07/21/25 timed 3:53 P.M. authored by LPN #545 revealed Resident #99's IV could be removed, and Resident #99 was to begin oral antibiotics. Interview on 08/05/25 at 11:44 A.M. with LPN #545 revealed she had contacted the infectious disease physician on 07/15/25 and received verbal orders to remove Resident #99's IV and begin him on oral antibiotics. LPN #545 was unable to state who had removed Resident #99's IV; however, LPN #545 stated it had been removed. LPN #545 further stated she had contacted the infectious disease physician again on 07/21/25 to clarify the oral antibiotics and again confirmed Resident #99's IV had been removed on 07/15/25. Review of physician orders with LPN #545 at time of interview confirmed orders for the IV antibiotics to be administered from 07/09/25-07/19/25. LPN #545 was unable to provide an explanation of why Resident #99's IV may have been removed on 07/15/25. Interview on 08/05/25 at 1:35 P.M. with the Director of Nursing (DON) revealed Resident #99's IV had not been removed on 07/15/25, and stated Resident #99 had removed his IV himself on 07/21/25. The DON was unable to provide an explanation for the progress note authored by LPN #545 on 07/15/25 that indicated the IV had been removed, and the resident was to begin oral antibiotics. The DON further was unable to provide an explanation regarding antibiotics not being administered on 07/15/25 due to course had been completed. The DON further confirmed no documentation related to Resident #99's IV removal.

Based on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure staff treated Resident #109 with dignity and respect. This affected one resident (#109) out of three residents reviewed for abusive treatment in the facility. The facility census was 108. Findings include: Review of the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, restlessness, depression, insomnia, malnutrition, asthma, anorexia, high blood pressure, kidney failure, spondylosis, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 had severe cognitive impairment, had behaviors including wandering and refusing care, and was independent with transfers and ambulation. Resident #109's plan of care initiated on 05/03/24 indicated a risk for falls related to impaired cognition related to diagnosis of Alzheimer's disease, behavioral symptoms, incontinence, restlessness/agitation, hearing loss, history of left pubis fracture and recent admission to the facility. Review of the nursing progress note dated 05/26/24 stated Resident #109's family alerted the staff that while Resident #109 was seated in the dining room, State tested Nursing Assistant (STNA) #115 was telling her to sit down in her chair and assisted Resident #109 to sit down. STNA #115 was removed from the situation. Resident #109 was assessed and found no injuries and denied complaints of pain or discomfort. A review of SRI tracking number 247958 indicated Resident #109's family approached Assistant Director of Nursing (ADON) #119 on 05/26/24 and reported when the family entered the dining room, they saw STNA #115 speaking loudly and sternly to Resident #109. STNA #115 was telling Resident #109 to sit down in her wheelchair and attempted to reposition Resident #109. Resident #109's family intervened and then left the dining room to report the incident to ADON #119. STNA #115 was asked to leave the dining room and sent home pending an investigation of the incident. Resident #109 was interviewed but was unable to recount what happened. Resident #109 was assessed and found no injuries and was not exhibiting signs of anxiety or distress. STNA #115 was interviewed and stated Resident #109 was constantly attempting to stand up out of her wheelchair, and STNA #115 asked her multiple times to sit down in a stern tone. STNA #115 stated she attempted to reposition Resident #109 in her wheelchair and was worried Resident #109 might fall. Resident #109's family confronted STNA #115 about the way she was interacting with Resident #115 and words were exchanged between STNA #115 and Resident #109's family. An interview with Licensed Practical Nurse (LPN) #116 indicated STNA #115 was involved in an altercation with Resident #109 in which STNA #115 grabbed the back of Resident #115's pants to force her to sit down and prevent her from falling. An interview on 05/30/24 at 8:24 A.M. with ADON #119 revealed she was present in the facility on 05/26/24 when the incident between Resident #109 and STNA #115 occurred. ADON #119 stated Resident #109's family walked in the dining room and heard STNA #115 yelling at Resident #109 asking her to sit down and grabbing the back of Resident #109's pants to forcefully make her sit down. ADON #119 stated when the family intervened, STNA #115 became defensive and told the family to not tell her how to do her job. ADON #119 stated she removed STNA #115 from dining room and conducted an interview with STNA #115. ADON #119 indicated STNA #115 was frustrated because Resident #109 kept trying to stand and walk out of the dining room during the meal service. STNA #115 reported the family was aggressive towards her, and she felt defensive. ADON #119 stated she had STNA #115 write a statement regarding the incident before sending her home pending the outcome of the investigation. ADON #119 stated she conducted an interview with STNA #117 who was in the dining room at the time of the incident between Resident #109, STNA #115, and Resident #109's family. STNA #117 reported STNA #115 aggressively pulled Resident #109 down in her chair and was yelling at Resident #109 in a loud voice. An interview with STNA #117 on 05/30/24 at 11:14 A.M. indicated she witnessed the interaction between Resident #109 and STNA #115. STNA #115 was yelling at Resident #109 to sit down and forcefully pulled Resident #109 down by the back of her pants to make her sit down. When the family intervened, STNA #115 started to argue with them and told them to not tell her how to do her job. STNA #117 stated she thought STNA #115 could have handled the situation differently without becoming angry. An interview with STNA #115 on 05/30/21 at 11:21 A.M. indicated Resident #109 was constantly attempting to get up and walk away from her wheelchair. She was worried Resident #109 would fall and held the back of Resident #109's waistband on her pants and assisted her to sit down in the wheelchair. She did not use a gait belt and tugged on Resident #109's belt loop to pull her down to a seated position. She was yelling at Resident #109 to sit down because Resident #109 was very hard of hearing. Resident #109 was resisting her efforts to guide her back to a seated position and may have appeared aggressive, but this was not her intention. An interview with Resident #36 on 06/03/24 at 8:30 A.M. revealed she was present in the dining room during the incident between Resident #109 and STNA #115. Resident #36 stated Resident #109 was trying to stand up and walk away from her wheelchair and STNA #115 had to keep directing her to sit down so she wouldn't fall. Resident #36 stated STNA #115 was trying to assist Resident #109 her own way and could have interacted with Resident #109 in a different manner while helping Resident #109. An interview with the Director of Nursing (DON) on 06/03/24 at 11:30 A.M. verified the above findings. A review of the undated facility policy titled Resident Rights indicated it was the facility's policy to provide resident centered care that meets the psychological, physical, and emotional needs/concerns of residents. Safety of residents, visitors and employees was the top priority of care. Care for residents would be performed in a safe and respectful manner. Residents have the right to voice how they want to be treated. Employees would notify their immediate supervisor when care or treatment was refused. The procedure included when providing care to speak respectfully to residents. This deficiency is an incidental finding identified during the complaint investigation.

Based on record review, interview, and facility policy review the facility failed to ensure Resident #83's sponsor was notified of significant changes in Resident #83's condition. This affected one resident (#83) out of three residents reviewed for changes in condition. The facility census was 108. Findings include: Review of the medical record revealed Resident #83 was admitted on [DATE] with diagnoses including cerebral vascular disease, vascular dementia pulmonary disease, high blood pressure, atherosclerotic heart disease, hyperlipidemia, iron deficiency anemia major depressive disorder, insomnia, osteoporosis, diaphragmatic hernia, gastroesophageal reflux disease with esophageal obstruction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had a significant change in her ability to sit up from a lying down position and from sitting to standing. The MDS assessment dated [DATE] indicated she was independent in the ability to sit up from a lying down position and from sitting to standing. The MDS assessment dated [DATE] indicated Resident #83 needed maximum assistance of one staff member to assist her to sit up from a lying down position and from sitting to standing. Resident #83's MDS assessment dated [DATE] indicated she was severely cognitively impaired. A review of Resident #83's physician order dated 04/16/24 revealed an order to administer cephalexin (antibiotic) 500 milligrams three times a day orally for the treatment of a wound infection. There was no documented evidence in the medical record that Resident #83's family/responsible party were notified of the significant change in condition or the wound infection. An interview with Minimum Data Set Registered Nurse (MDS RN) #118 on 06/03/24 at 11:30 A.M. revealed she was responsible for attending the interdisciplinary plan meetings to discuss significant changes in a resident's condition. MDS RN #118 stated the licensed nurses were responsible for notification of a resident's representative and/or power of attorney. An interview with Director of Nursing (DON) on 06/03/24 at 12:00 P.M. verified the above findings. A review of the facility's undated policy titled Notification of Change in Condition indicated circumstances requiring notification included but was not limited to: Accidents Significant change in resident's physical, mental, or psychological condition such as deterioration in health, mental or psychological status. New treatment Transfer or discharge of resident from center. Change in roommate assignment. When a change in condition was noted, the nursing staff would contact the resident's representative, notify the physician, and the resident if they were their own responsible party. This deficiency represents non-compliance investigated under Complaint Number OH00154257.

Based on observation, interview, and policy review, the facility failed to ensure all medications were stored and labeled as required. This affected five (Residents #47, #48, #49, #50, #51) of 10 residents reviewed. Findings include: Observation on 03/14/24 at 7:37 A.M. revealed Licensed Practical Nurse (LPN) #216 had pre-poured medications for Residents #47, #48, #49, #50, #51. A drawer within the medication cart contained five medication cups each containing medications with the resident's name. There was no information regarding the names or strength of the medications in the cups. Interview with LPN #216, at the time of the observation, revealed the medications were pre-poured because he was required to be in the dining room from 7:30 A.M. to 9:00 A.M. to observe residents during breakfast and he had more than 30 residents to administer medications to after breakfast service was finished. Review of the facility's undated policy titled Medication Administration revealed medications were to be poured just prior to administrating to the resident.

Based on observation, interview, and policy and procedure review, the facility failed to ensure staff maintained infection control standards when administering medications. This affected one (Resident #47) of five residents observed for medication administration. Findings include: Observation on 03/14/24 at 8:13 A.M. revealed Licensed Practical Nurse (LPN) #216 preparing medications to administer to Resident #47. LPN #216 popped medications from blister packs into his bare hand and then picked up medications that were dropped and put them into a medication cup to administer to Resident #47. An interview with LPN #216 at the time of the observation confirmed the observations. Review of the facility's undated policy titled Medication Administration revealed medications were not to be touched, either when opening a liquid or dose pack. Dropped medications were to be discarded.

Based on record review and interview the facility did not ensure the activity director was qualified to establish and provide a therapeutic activity program to meet the needs and interests of the resident population in the facility. This affected all 110 residents living in the facility. Findings include: Review of the employee file for Activity Director (AD) #805 revealed a hire date of 03/28/23 with a signed job description dated for 03/28/23. As stated in the Purpose/Belief statement the position of the AD establishes an activity program of wide variety for the residents, enhancing the resident's wellness, in harmony with the overall plan of care set forth by the health care team, and in accordance with state and federal regulations. This position plans, implements, supervises and supports all operations of the activities department. While focusing on delivery of quality care, the position must also manage the assigned resources. As listed in the Qualifications/Knowledge/Skills and Abilities section, the AD role requires either a bachelor's degree in therapeutic recreation or related field or 90 hour course for activity professionals and continuing education, prior management, supervisory, leadership experience preferably in a health care environment, prior work/life experiences, preferably in a healthcare setting, they must be knowledgeable of activity practices, standards of practice, state practice acts and procedures, as well as laws, regulations, and guidelines that pertain to long-term care. They must be able to plan, organize, and conduct a variety of activities and must be willing to seek out new methods and principles and be willing to incorporate them into existing activity practices. There was no evidence found in the employee file for AD #805 to indicate she met requirements in the job description. Interview on 10/17/23 at 4:15 P.M. with AD #805 revealed she did not have a bachelor's degree in therapeutic recreation or related field, she did not complete the 90-hour course for activity professionals and had no continuing education. She stated Social Service Director (SSD) # 802 had her activity qualification so the facility had her working under that certification but SSD #802 did not over see any of the activity department functions or programs. AD #805 stated she developed all the activity calendars herself and did all the scheduling of the activity aides working in the activity department. Interview on 10/19/23 at 11:35 A.M. with the Administrator revealed she sent AD #805 to activities boot camp which was a 13.5 hour training. She stated AD #805 did not have any of the requirements described in the job description for the Activities Director. She stated SSD #802 had her qualifications which the Administrator felt was sufficient to meet the requirement. This deficiency respresents non-compliance identified during the investigation of Complaint Number OH00147820.

Based on observation and interview, the facility failed to ensure dietary staff were competent to complete their duties. This had the potential to affect all 109 residents who received meals from the kitchen except one resident (Resident #98) who the facility identified as eating nothing by mouth. The census was 110. Findings include: Review of the staff on-boarding packets for all dietary staff hired within the last six months revealed three staff (Cook #818, Dietary Aide #819, and State tested Nurse Aide [STNA] #869) answered the on-boarding quiz questions incorrectly despite the correct answers being listed immediately following the questions. On 10/16/23 at 8:42 A.M., observation of the kitchen revealed food was stored on the floor in the walk-in refrigerator, walk-in freezer, and dry storage. On 10/16/23 at 8:58 A.M., interview with Dietary Aide #824 stated new staff did not get the appropriate training to know how to put away food items after they were delivered to the facility. On 10/18/23 at 11:20 A.M., observation of the lunch meal tray line revealed four residents (#6, #14, #73, and #105) did not have an entree listed on their meal tickets. Cook #820 put one serving of potatoes and one serving of peas on each of those four plates. Dietary Aide #824 checked the meal tickets, confirmed what was on the plate matched the meal ticket, and covered each of those four plates for service. At the time of the observation, interview with Cook #820 and Dietary Aide #824 both verified there was no main entree on the meal tickets for Residents #6, #14, #73, and #105, and confirmed that the trays would be served with just one serving of potatoes, one serving of peas, and no entree or protein. Cook #820 stated he only provided what was listed on the meal tickets and if there was no entree listed, then no entree was served on that tray. On 10/18/23 at 6:30 P.M., interview with Registered Dietitian (RD) #909 stated there was a lot of turnover with staff in the kitchen and there was no permanent dietary manager to ensure new staff received adequate training. She stated kitchen staff probably needed training on problem solving due to not recognizing an issue when some lunch tickets only included the potatoes and peas with no protein. She said staff were trained to read the tickets to ensure accuracy, but they should have recognized that something was wrong when there was no protein (main entree) on those trays.

Based on observation, interview, review of facility policy, and review of the Ohio Uniform Food Safety Code, the facility failed to ensure food items were stored at least six inches off the floor. This had the potential to affect all 109 residents who received food from the kitchen and excluded Resident #98 who received nothing by mouth. The census was 110. Findings include: On 10/16/23 at 8:42 A.M., observation of the kitchen revealed a crate containing 12 cartons of milk was on the floor of the walk-in refrigerator, one box of chopped spinach was on the floor of the walk-in freezer, and the following items were observed on the floor of the dry storage room: one box of pasta, one case containing 12 cans of tomato juice, one box of cranberry juice, one box containing 150 packets of hot cocoa mix, and one box containing three gallons of pancake and waffle syrup. On 10/16/23 at 8:58 A.M., interview with Dietary Aide #824 verified the multiple boxes of food items that were on the floor of the dry storage room. Dietary Aide #824 stated new staff did not get the appropriate training to know how to put away food items after they were delivered to the facility. On 10/16/23 at 9:15 A.M., interview with Human Resources (HR) Manager #808 verified there was a crate containing 12 cartons of milk on the floor of the walk-in refrigerator. HR Manager #808 stated there was no dietary manager and the corporate dietary manager was out sick. She stated the facility management team took turns overseeing the kitchen and she was overseeing the kitchen on this day. HR Manager #808 said she did not know all the rules of the kitchen and did not know food could not be stored on the floor. On 10/16/23 at 9:17 A.M., interview with Cook #826 verified there was a box of spinach on the floor of the walk-in freezer. Review of the facility policy titled Receiving and Storage of Food, not dated, revealed foods must be stored at least six inches off the floor. Review of the State of Ohio Uniform Food Safety Code indicated food should be stored at least six inches above the floor to protect from contamination.

Based on observation, record review and interviews, the facility administrator did not ensure a qualified activity director was hired to administer a therapeutic activity program to meet the needs and interests of the residents. This had the potential to affect all 110 residents living in the facility. Findings include: Review of the position description for the executive director, signed by the Administrator on 11/23/2020, revealed it was the Administrator's responsibility to provide leadership to all staff to ensure care standards were met in accordance with state and federal regulations and the highest degree of quality resident care was provided at all times. Review of the employee file for the Activity Director (AD) #805 revealed a hire date of 03/28/23 with a signed job description dated for 03/28/23. It was stated in the AD job description her direct report was the Administrator. As listed in the Qualifications/Knowledge/Skills and Abilities section the AD role required either a bachelor's degree in therapeutic recreation or related field or 90 hour course for activity professionals and continuing education, prior management, supervisory, leadership experience preferably in a health care environment, prior work/life experiences, preferably in a healthcare setting, they must be knowledgeable of activity practices, standards of practice, state practice acts and procedures, as well as laws, regulations, and guidelines that pertain to long-term care. They must be able to plan, organize, and conduct a variety of activities and must be willing to seek out new methods and principles and be willing to incorporate then into existing activity practices. There was no evidence found in the employee file for AD #805 to verify AD #805 had any of the qualifications in the job description. Interview on 10/17/23 at 4:15 P.M. with AD #805 revealed she did not have a bachelor's degree in therapeutic recreation or related field, she did not complete the 90-hour course for activity professionals and had no continuing exudation. She stated Social Service Director (SSD) # 802 had her activity qualification and the facility had her working under that certification but SSD #802 did not over see any of the activity department. AD #805 stated she made all the activity calendars, and scheduled all of the activity department staff. AD #805 stated she attended the Quality Assurance Performance Improvement (QAPI) meetings as the AD. AD #805 stated she did not receive over-site by SSD #802 and received very little over-site by the Administrator. Observations made throughout the survey from 10/16/23 to 10/25/23 revealed there was no over site by the Administrator or by SSD # 802 over the activity department. Interview on 10/19/23 at 11:35 A.M. with the Administrator revealed she sent AD #805 to activities boot camp which was a 13.5 hour training. The Administrator stated AD #805 did not have any of the requirements described in the job description for the Activities Director, but SSD #802 had the qualifications so the Administrator felt this was sufficient.

Based on review of the resident council meeting minutes and resident and staff interviews, the facility failed to ensure ongoing communication to residents about their various rights at the resident council meetings. This affected 15 residents (Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) of 15 residents present at the resident council meeting. The facility census was 110. Findings include: Review of the facility Resident Council Meeting minutes from January 2023 to October 2023 revealed there was not a new resident right reviewed at each meeting. Meetings conducted on 01/30/23 revealed they reviewed smoking rights. Meetings conducted on 02/24/23, 04/13/23, 05/18/23, 06/15/23, and 07/20/23 revealed they reviewed the right to have resident council meetings. Meetings conducted on 08/17/23, 09/21/23 and 10/05/23 revealed they did not review any resident rights during the council meetings. Interview on 10/17/23 at 4:15 P.M. with Activities Director (AD) #805 revealed she was unaware she was to review a different resident right at each resident council meeting. AD #805 confirmed she only spoke to the residents regarding the right to smoke and the right to have a resident council meeting and there were several months she did not review any resident rights at the resident council meetings. Interviews conducted on 10/23/23 at 2:00 P.M. with Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87 #103, and #362 during the resident council meeting conducted by the state surveyor as part of the annual survey process revealed all residents were alert and oriented, actively participated in the meeting and expressed the staff did not go over a resident right at each meeting. They stated they only review the right to have a resident council meeting and the facility smoking policy. They stated there were meetings where they did not go over any rights at all.

Based on record review, observations and interviews the facility failed to provide therapeutic activities as scheduled on the activity calendar and failed to provide evening activities to meet the needs and preferences of all the residents in the facility. This affected 15 residents (#12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362) residing on the A,B and C units and had the potential to affect all residents residing on the A, B, C units excluding Residents #16, #41, #264, #80, #2, #77, #45, #39, #66, #15, #42, #74, #89, #38, #86, #35, #37, #90, #91, #69, #93, #92, #75, #97 and #6 who resided on the secured unit D. The facility census was 110. Findings include: Review of the facility activity calendars for October 2023 for the A, B, and C units, revealed on all 31 days in October 2023, the last activity was scheduled at 4:00 P.M., and no evening activities were offered during the month. The scheduled activities for 9:30 A.M. included coffee and chit chat. On Sunday the activity was listening to gospel music at 10:30 A.M. and church service and music in the dining room with one-to-one at 4:00 P.M On Monday the activities included coffee and chit chat, 10:30 A.M. was listen to the oldies and color, and at 2:00 P.M. trivia fun. Tuesday's activities consisted of coffee and chit chat, craft time and bingo with the last activity at 4:00 P.M. Wednesday's activities included coffee and chit chat, fun with yarn craft and a movie with the last activity at 2:00 P.M. Thursday's activities included coffee and chit chat, 10:30 A.M. travel the world, 2:00 P.M. bingo and on some Thursdays 1:1's was offered. Fridays activities included at 10:30 A.M. listen to classical music and color, 2:00 P.M. movie and on some Fridays 1:1 was offered. Review of the activity staff schedule for 10/01/23 revealed there was only one Activity Aide (AA) from 9:00 A.M. to 5:00 P.M. and one AA 1:00 P.M. to 8:00 P.M. On 10/07/23 from 9:00 A.M. to 5:00 P.M. there were only two AA's, on 10/09/23 from 9:00 A.M. to 5:00 P.M. there was one AA scheduled, and on 10/14/23 there were two AAs from 9:00 A.M. 5:00 P.M. and one AA from 1:00 P.M. to 8:00 P.M On 10/21/23,10/22/23 and 10/28/23 there was only one AA from 9:00 A.M. to 5:00 P.M. scheduled with activities on the calendar for 6:00 P.M. and 7:00 P.M. Interview conducted on 10/17/23 at 4:15 P.M. with Activity Director (AD) #805 who revealed she did not have the proper education to hold the role of Activity Director. The facility did not send her to receive any of the proper education required by law although they stated they would. AD #805 verified there were no therapeutic activities provided after 4:00 P.M. on the A, B, and C units. Observation and interview were conducted on 10/23/23 at 10:30 A.M. with the AD #805 regarding the pumpkin painting activity that was to occur at 10:30 A.M. AD #805 revealed she could not find any pumpkins for the activity, she did not inform the Administrator so she changed the activity to coloring a black and white printed paper pumpkin. The residents were upset and left the activity. Interviews were conducted on 10/23/23 from 2:00 P.M. to 3:15 P.M. with Residents #12, #17, #23, #51, #58, #62, #67, #70, #71, #76, #79, #85, #87, #103, and #362 present at the resident council meeting. The residents were alert and oriented to person, place, time, and situation. All residents present at the meeting stated the activity calendar listed more activities than what was actually provided in the facility. For example, they were supposed to paint actual pumpkins on 10/23/23 at 10:30 A.M. however they were told by the AD #805 she was unable to find any pumpkins available to paint so she printed black pumpkins on white paper and handed them out. All residents in attendance left and did not participate. All residents who participated in the resident council meeting revealed they were tired of coloring or crafts with yarn. They felt these activities did not meet their intellectual needs or wants. The residents in attendance at the meeting were mobile throughout the facility and agreed they do not see the activities being done at the scheduled times, and when they go to the activity room to see what was going on the activity aide (AA) #812, AA #813, AA #814, AA #815, AA #816, and AA #817 are sitting in the office on their cell phones. The residents in attendance at the resident council meeting revealed they have brought these issues up in the meeting many times, but nothing is ever done about it. The residents have asked for more activities on the weekends and at night and it was just not being addressed as requested. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00147820.

Based on review of a closed medical record, review of the facility's investigation, review of the policy for General Code Status, and interview with staff, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) and contact Emergency Medical Services (EMS) for one resident (Resident #105) who was a Full Code status and found unresponsive without vital signs. Life threatening harm and death occurred when Resident #105 did not receive CPR or EMS services and expired in the facility. This resulted in Immediate Jeopardy for one (Resident #105) of three residents reviewed for death in the facility. The facility census was 103. On [DATE] at 6:45 P.M., the Administrator, Director of Nursing (DON), and Regional Nurse, Registered Nurse (RN) #500 were notified Immediate Jeopardy began on [DATE] at 5:00 A.M. when Resident #105 was found in bed, unresponsive and without vital signs by Licensed Practical Nurse (LPN) #410. LPN #410 immediately ran and summoned RN #400, who entered Resident #105's room and observed and felt the resident. RN #400 walked out of the room to the nurse's station and began making phones calls. LPN #410 asked RN #400 in between the phones calls, what Resident #105's code status was, and RN #400 responded Resident #105 was full code status. LPN #410 asked RN #400 if there was something he wanted or needed her to do and RN #400 responded he was okay and has it. LPN #410 then went back to her unit. RN #400 notified Resident #105's physician, the local county coroner's office, responsible party, and the DON. Neither RN #400 or LPN #410 initiated CPR or called EMS after learning Resident #105 was a full code status. The Immediate Jeopardy was removed on [DATE] at 10:00 A.M. when the facility implemented the following corrective actions: · On [DATE] at 5:20 A.M., the DON verbally educated RN #400 and LPN #410 on code status protocol over the phone. · On [DATE] at 5:30 A.M., the DON and Staff Development Coordinator (SDC) #420 began education on code status protocol. Nurses at the facility at the time of the occurrence were educated immediately. · On [DATE] at 6:00 A.M., verbal education was provided to those nurses who were not at the facility via phone by the DON and SDC #420. · On [DATE] at 7:00 A.M., the DON and SDC #420 provided education to the day shift nurses on-coming shift. · On [DATE] at 7:15 A.M., the DON validated CPR attestation was completed by all nurses prior to [DATE]. · On [DATE] at 7:00 A.M., the DON continued education to nurses on code status protocol. · On [DATE] at 8:00 A.M., the Assistant Director of Nursing (ADON) completed a crash cart audit. · On [DATE] at 6:00 P.M., the DON completed the last education to nurses on the code status protocol. One hundred percent of nurses were educated at this time. · On [DATE] at 8:00 A.M., the DON and SDC #420 completed a whole house audit of resident code status and determined all were correct. This audit was included in the facility's Quality Assessment and Performance Improvement (QAPI) meeting for ongoing follow up. In addition, nightly crash cart audits and monthly mock code status drills were initiated and would be included in the facility's QAPI meetings. · On [DATE] at 10:00 A.M., RN #400 and LPN #410 signed off on the previously provided verbal education. Written education was provided to them upon returning to work. The DON gave corrective counseling to RN #400 and LPN #410 prior to working the floor. · There have been no additional deaths of residents who had Advance Directives indicating they were Full Code in the facility between [DATE] and [DATE]. · Interviews on [DATE] from 5:48 P.M. to 5:55 P.M. and on [DATE] from 11:18 A.M. to 11:36 A.M. with LPNs #440, #460, #490, RN #450, and State tested Nurse Aides (STNAs) #470, #480, and #510 revealed they were aware of the facility's policy and procedure for code status. 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) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #105 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had memory problems and had moderately impaired cognitive skills for daily decision making. Resident #105 required supervision and set up help for bed mobility and transfers, and supervision of one staff for eating and toilet use. Review of Resident #105's (MONTH) 2019 physician orders [REDACTED]. Review of Resident #105's plan of care initiated [DATE] revealed the resident was a Full Code status. The goal indicated Resident #105's Advanced Directives were in effect and the wishes and directions would be carried out in accordance with the advanced directives on an ongoing basis through the next review date. Interventions included review of Advance Directives with Resident #105 and/or family/responsible party on admission and at least quarterly. Review of the nursing progress note dated [DATE] at 6:15 A.M. revealed Resident #105 had been given medication at 11:00 P.M. Resident #105 was checked and changed at 2:30 A.M. by the STNAs. At 3:00 A.M., RN #400 checked on the resident and she was fine. At 5:00 A.M. Resident #105 was found unresponsive and absent of vital signs which was verified by two nurses, RN #400 and LPN #410. The emergency contact and Power of Attorney (POA) was notified. The physician was notified and stated he wanted the last progress report faxed to him. The DON was notified. The local county Medical Examiner was notified and wanted to know what funeral home Resident #105 was going to. The POA did not know at that time and the nurse would follow up to find out the choice of funeral home. Review of the nursing progress note dated [DATE] at 6:24 A.M. revealed the POA informed RN #400 the remains were to be sent to named funeral home. The nursing progress note dated [DATE] at 7:15 A.M. revealed the local county Medical Examiner was notified the family had chosen a named funeral home for Resident #105's cremation and the progress note dated [DATE] at 8:10 A.M. revealed the named funeral home representative was there to pick up Resident #105's remains. Review of the facility's investigation regarding the death of Resident #105 initiated on [DATE] revealed the facility obtained statements from staff members who were working at the time Resident #105 was found unresponsive. A summary dated [DATE] typed and signed by the DON revealed Resident #105 was checked on by an STNA at 2:30 A.M. and by RN #400 at 3:00 A.M. and at those times she was fine. At 5:00 A.M. the resident was found non-responsive and cold to touch. RN #400 and LPN #410 both verified absence of vitals. RN #400 then called the physician to notify him of absence of vitals. The local county coroner was notified of expiration and released the body to the funeral home. The DON was notified of expiration and upon review of the code status of Resident #105 it was noted she was full code. Immediate education was provided to both nurses, RN #400 and LPN #410, regarding immediately beginning CPR and calling emergency medical services (911), and only the physician or EMS could stop CPR once started. Both nurses acknowledged understanding of the education. Review of the undated and untimed statement obtained from RN #400 revealed he went in Resident #105's room with another nurse at 11:00 P.M. to give Resident #105 medication and the resident stated she was fine. The STNAs checked on the resident at 2:30 A.M. and RN #400 checked on the resident at 3:00 A.M. At 3:00 A.M. the resident stated she was fine. At 5:00 A.M. when LPN #410 was about to give the resident her morning medication she noticed the resident was cold and lifeless. She lacked vital signs. RN #410 notified the DON, the physician, POA, and the local county medical examiner. Review of the statement dated [DATE] at 5:10 A.M. obtained from LPN #410 revealed she had gone over to unit D to help RN #400 with passing the morning narcotics and she did not know the residents. RN #400, the nurse on that unit, had the Medication Administration Record [REDACTED]. RN #400 walked to the rooms with LPN #410 to point out the correct residents as he explained how they took their medication. When they got to Resident #105's room, RN #400 explained she took her medication whole. As they walked, LPN #410 got to the door, knocked, introduced herself and called Resident #105 by name. The lighting in the room was dim and it appeared at first look like Resident #105 was sleeping. LPN #410 turned back to ask RN #400 if he was sure the resident usually awakened enough to take the medication, RN #400 was not there. LPN #410 stated she called Resident #105's name again and as she got closer it looked like she was not breathing. LPN #410 gently shook her arm while calling her by name, as her hand touched her, she felt ice cold. LPN #410 immediately ran and yelled for RN #400 and he entered the room and looked at and felt the patient. RN #400 then walked out to the nurse's station and began to make phone calls. In between phone calls, LPN #410 asked what Resident #105's code status was, not being familiar with the unit or residents. LPN #410 thought maybe the resident had been a Do Not Resuscitate Comfort Care (DNRCC). RN #400 answered the resident was a full code. LPN #410 asked what RN #400 wanted to do or what he needed her to do and RN #400 said he was okay and he had it. LPN #410 let RN #400 know if he needed her to call as she was going back to her unit to take care of her residents and pass medication. Interview on [DATE] at 1:57 P.M. with the DON revealed the nurse last checked on Resident #105 two hours prior to being found unresponsive and without vitals. When the resident was last observed, prior to the nurses entering with medication she was not in distress. The two nurses who found the resident unresponsive were LPN #410 and RN #400. When found the resident was cold and had no vitals. The resident had been ill but was improving and had an appointment on (MONTH) 1st to see the nephrologist. Interview on [DATE] at 2:22 P.M. with RN #400 revealed he had given Resident #105 medication at 11:00 P.M. and the STNAs had completed incontinence care at 2:30 A.M. RN #400 stated he had checked on her at 3:00 A.M. and asked how she was doing, and she had responded she was fine. RN #400 stated he then continued his walk through and checked on other residents. RN #400 stated he and another nurse found Resident #400 cold and without vitals. RN #400 stated he checked for a pulse, observed her chest was not rising and placed his ear near her nose and mouth to see if she was breathing. RN #400 stated he did not hear any breath sounds and a did manual blood pressure check and there was nothing there. RN #400 stated he did not initiate CPR, he called the doctor. RN #400 stated he went to the chart and there was nothing there regarding code status, so he went on computer and learned that Resident #105 was full code status. RN #400 stated he was kind of shook up and did not know what to do, the resident was cold. RN #400 stated the physician told him to fax him the progress notes and date and time Resident #105 was found. RN #400 stated the other nurse, LPN #410 did not initiate CPR and EMS was not called. Interview on [DATE] at 4:36 P.M. with STNA #430 revealed she and another STNA had checked Resident #105 at 2:30 A.M. but she did not need to be changed because she was dry. STNA #430 stated she went on break and when she returned she had learned from the other STNA Resident #105 was found by LPN #410. STNA #430 stated LPN #410 was helping RN #400 because another resident who was on hospice had passed that evening. STNA #430 and the other STNA cleaned up Resident #105 before the family arrived. STNA #430 stated that was about 4:30 A.M. because it was right after she came off break. STNA #430 indicated the front side of Resident #105's body felt cold, her back side was warm, she was easy to move and she was not stiff. STNA #430 said the resident couldn't have been gone that long. STNA #430 stated she had done a lot of postmortem care in the past. Interview on [DATE] at 5:06 P.M. with LPN #410 revealed she was fairly new, and this was the first night on her own. LPN #410 stated at about 5:00 A.M. she was helping RN #400, they walked into Resident #105's room together. LPN #410 had walked in first, the room was dim and Resident #105 appeared to be sleeping. LPN #410 said Resident #105's name and touched her arm, giving her a shrug. When asked if Resident #105 was cold, LPN #410 said she felt kind of cold then said pretty cold and stiff. LPN #410 stated she did not feel any warmth and the resident's eyes were closed. LPN #410 checked for a pulse and did not feel anything and there were no signs of breathing. LPN #410 watched to see if her chest was rising and then listened, got down close to hear if she was breathing. LPN #410 stated she did not have her stethoscope. LPN #410 stated RN #400 was behind her and followed up to do his check. LPN #410 and RN #400 walked out of Resident #105's room together and RN #400 immediately checked the chart and called the doctor. LPN #410 stated she just followed RN #400 and at this point she did not know what Resident #105's code status was. LPN #410 stated she thought RN #400 knew what it was. LPN #410 was not sure if they had talked about the resident's code status but later found out Resident #105 was full code status. LPN #410 stated she did not initiate CPR on Resident #105 because she was not familiar with the resident and it was not her assigned unit; it was RN #400's unit and she was just there helping. LPN #410 stated they should have initiated CPR on Resident #105. Interview on [DATE] at 11:59 A.M. with the DON revealed the physician pronounced death over the phone when RN #400 called him. The DON indicated that is why the physician wanted information faxed to him. On [DATE] at 3:04 P.M. and 4:20 P.M. attempts to contact Resident #105's physician by phone were unsuccessful. Review of the facility's policy titled, General Code Status effective [DATE] revealed CPR (Cardiopulmonary Resuscitation) was defined as an emergency response treatment that included calling 911, initiating compression of the chest, initiating suction as appropriate, supplying artificial oxygenation, and use of Automated External Defibrillator (AED) if available and appropriate, for the purpose of circulating oxygen to the vital organs until a higher level of care could be accessed. The policy defined Code Status as the notation in the electronic medical record that served as a source of information to the facility staff for the proper response by the staff for treatment in the event the resident's heart ceases and/or respirations cease, whether by natural or unnatural means. The code status was based on the decision of the resident/representative, the regulatory requirements being met or not met and the physician/provider. The intent of the facility was to honor the wishes and rights of the resident/representative to make the determination of what, if any, resuscitative measures would be implemented in the event the resident's respirations and/or pulse ceased either by natural or unnatural causes. The policy indicated the staff would provide basic CPR for those desiring this treatment. This deficiency substantiates Complaint Number OH 333.

Based on medical record review, review of the facility's notification and Medical emergency response policy, and staff interview, the facility failed to provide necessary care and services for Resident #4 by monitoring a critically high blood glucose level, providing timely assessment of the resident's responsiveness, notifying emergency services and initiating cardiopulmonary resuscitation. This resulted in Immediate Jeopardy for Resident #4, one of 12 residents identified as requiring blood glucose monitoring. On [DATE] at 12:30 P.M., the Administrator, Director of Nursing (DON) #1, as well as Corporate Nurse, Regional Nurse and Registered Nurse #15, were notified Immediate Jeopardy began on [DATE] at 5:45 P.M., when the facility failed to adequately address Resident #4's critically high blood glucose level (584 mg/dL). Licensed Practical Nurse (LPN) #10 administered an ordered insulin dose to the resident and placed a call to the resident's physician to notify him of the abnormal value. The resident's physician (Physician #30) did not respond to the call and the resident's blood sugar was not rechecked or monitored. There was no documentation of the resident's activity or status again until [DATE] at 6:22 A.M., when Registered Nurse (RN) # 11 found the resident unresponsive in the bathroom of his room, kneeling in front of the toilet, with his left arm between the hand rail and wall and his head resting down on the toilet. RN #11 went down the hall to find State tested Nursing Assistant, (STNA) #13. When they returned the two staff members could not move Resident #4, so RN #11 called for LPN #12 to assist them but did not explain that Resident #4 was unresponsive. LPN #12 arrived; he assisted the other staff to move the resident and started compressions. Emergency services were not called until between 6:40 A.M. and 6:42 A.M. EMS services took over care of the resident when they arrived and assessed that he had no obvious signs of life, including fixed pupils, rigor and pooling in his bilateral knees. He was pronounced deceased by an EMS physician through the EMS services at 6:57 A.M. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] through [DATE], the director of nursing provided an in service regarding notification of change, prompt notification to physicians with blood sugar levels out of parameters, cardio-pulmonary resuscitation, code status and emergency procedures to 23 of 23 licensed nursing staff (LPN's and RN's) prior to working their next shift. · On [DATE], RN #11 and LPN #10 employment was terminated by the facility. · On [DATE], a standing order was implemented by the facility medical director for all residents who were diabetic, to provide guidelines of treatment and notification of blood sugar levels out of parameters and notification guidelines to physicians. These standing orders were to be added to the records of all diabetic residents residing in the facility. Additionally, a reminder of notification guidelines and blood sugar monitoring related to blood sugars would be placed in the medication administration record. · On [DATE] through [DATE], the director of nursing completed an audit of all residents residing in the facility to verify code status accuracy. · On [DATE] through [DATE], the director of nursing completed an audit of all residents with blood sugar monitoring residing in the facility to verify proper treatment and notification of changes. · On [DATE], the facility instituted a practice to review residents with blood sugar monitoring in the morning clinical meeting. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy), as the facility is in the process of implementing and evaluating the ongoing monitoring through the addition of the standing order from the Medical Director and the addition of the review of the blood glucose monitoring during the clinical meeting is effective. Findings include: Review of the record revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was a full code. Review of the admission assessment dated [DATE] at 8:03 P.M. revealed the resident was a high fall risk and had abrasions on his right arm. Review of the orders revealed he was ordered [MEDICATION NAME] ,[DATE], 30 units every day in the morning and 32 units before dinner. Both orders indicated an additional 5 units was to be given if the blood sugar was greater than 250. Review of the information from the hospital indicated the resident had been admitted on [DATE] to the hospital with a history of decreased mental status as well as falls over the course of the days prior to admission. The information indicated the resident was 74 inches tall and weighed 176 pounds. Review of the admission note dated [DATE] from the hospital indicated his initial blood glucose when tested at the hospital was 400 mg/dL. He was admitted there with [DIAGNOSES REDACTED]. Review of laboratory testing from the hospital, in the facility record, indicated on [DATE] at 4:23 AM his glucose level was 190 mg/dL and was indicated to be high. A test on [DATE] at 9:56 A.M. revealed his glucose level to be 324 mg/dL, also indicated as high. Review of blood sugars obtained at the hospital four times a day from [DATE] at 1:06 P.M. through [DATE] at 6:32 A.M. revealed blood sugars ranging from a low of 108 mg/dL on [DATE] at 5:27 P.M. to a high of 324 mg/dL on [DATE] at 9:56 A.M. Review of the facility admission nursing note, from the computer dated [DATE] at 5:30 P.M. indicated the resident was alert and oriented with some confusion, and able to make his needs known. He ambulated with a cane and one person assist. Review of a hand written nursing note revealed the resident had a fall on [DATE] when he was reaching for his cane and slipped. The note indicated neurological checks were started and q 15 (every 15 minute) checks were in place. The resident did not have an injury. The note indicated the resident's physician was called at 6:00 P.M. to inform him of the fall. Interview with the evening shift nurse, (LPN #10), on [DATE] at 11:40 A.M. revealed she was the nurse who had admitted the resident. She stated the resident arrived at the facility on [DATE] at 5:30 P.M., and after checking on him briefly, she got his dinner tray and was sitting at the nurse's station, processing his orders when she heard a noise from his room. She stated the resident had slipped off the side of the bed when reaching for his cane. He did not have an injury but was started on neurological checks since the fall was unwitnessed. The resident was put on every 15 minute checks as a precaution. She stated she paged the doctor, who did not return a call to her. She did state she had previously verified the resident's admission orders [REDACTED].M. Review of the next note in the record dated [DATE] at 9:00 P.M., (written as a late entry on [DATE] at 1:28 P.M.) revealed the resident's blood sugar was 584 mg/dL per the glucometer check and the resident's doctor was paged. The note indicated the resident was given his insulin as ordered. During the interview on [DATE] at 11:40 A.M., LPN #10 verified that she had checked the resident's blood sugar at 9:00 P.M. She stated she followed the order for the insulin administration, and paged the resident's physician to inform him of the blood sugar level. She stated she did not get a phone call back, so was unable to inform him of the blood sugar. She stated she did inform the nurse on the next shift of the resident's blood sugar. The DON was present during the surveyor's interview with LPN #10. During a second interview on [DATE] at 10:10 A.M. by phone, with the DON present and listening on speaker, LPN #10 stated that she had actually checked the resident's blood sugar around 5:45 P.M. on [DATE]. She stated the resident's meal was available to him when he arrived at the facility at 5:30 P.M. and that he ate when he arrived. She stated that she checked his blood sugar after he ate, administered his insulin at that time and then paged the resident's physician. She verified the order was to check the blood sugar before dinner. She further verified her documentation that was entered on [DATE] at 1:28 P.M., as a late entry, indicated the blood sugar check and insulin administration was at 9:00 P.M. She had stated on a previous interview the blood sugar check was at 9:00 P.M. She stated the time documented was an error. An interview with the DON on [DATE] at 11:50 A.M. revealed she was unable to determine if the resident's blood sugar was obtained at 9:00 P.M. as LPN #10 had stated to the surveyor during the interview on [DATE] at 11:40 A.M. or if the blood sugar was obtained at 5:45 P.M. as LPN #10 stated in the interview on [DATE] at 10:10 A.M. The DON verified the employee gave contradicting information, and although the first interview and documentation would indicate the blood sugar was checked at 9:00 P.M., she was unable to determine the exact time from the employee's comments and could only state the blood sugar was obtained after the resident ate dinner. Interview with RN #11, on [DATE] at 2:40 P.M., who was Resident #4's nurse on the night shift after his evening admission, revealed she was told in the report that his blood sugar was high and the other nurse had paged the physician but had not heard back. RN #11 stated she checked the resident's vital signs on [DATE] at 12:45 A.M. for the last set of vitals required for the neuro checks after the fall, but did not check a blood sugar. She stated she knew he had a blood sugar check in the morning. Review of the 15 minute check list indicated initials in the boxes indicating the checks were performed through [DATE] at 5:15 A.M. A note by the nurse dated [DATE] written at 4:40 A.M. indicated the resident was in bed resting, that neuro checks were continued and remained within normal limits and the resident denied pain and was observed with no acute distress. The note indicated a set of vital signs at 12:45 A.M. The vital signs at that time were stable and revealed a blood pressure of ,[DATE], temperature of 98.7 degrees, pulse of 78 and respirations of 18. Review of the next nursing note dated [DATE] at 8:38 A.M. revealed the resident was observed on the floor of the bathroom in his room by the nurse (RN #11) at 6:00 A.M. The note indicated the resident was on his knees forward facing the toilet. The nurse attempted to arouse the resident, who was unarousable. The nurse tried to move the resident, but he was diff (difficult) to move. The note indicated the nurse called the other unit for assistance and the nurse (LPN #12) came to assist the resident to bed and immediately began compressions until 911 arrived. The note indicated the facility staff were instructed to stop CPR once the paramedics arrived and took over the CPR. The note indicated the resident was pronounced deceased by a physician. The resident's family, medical director and coroner were all notified. The note indicated the resident's physician was also notified by call and pager, and they continued to await a call. The medical director indicated the staff should continue to try to notify the resident's physician. A note on [DATE] at 3:38 P.M. indicated the body was to be released to the funeral home. Interview with RN #11 on [DATE] at 2:40 P.M. revealed she wrote a statement concerning her actions on the morning of [DATE], which was reviewed with her during the interview. The statement indicated the resident was last seen by the state tested nursing assistant at 5:,[DATE]:15 A.M. and was last seen by the nurse at 4:50 A.M. in bed and without distress. The statement indicated prior to finding the resident on the floor, RN #11 had went to another unit to assist residents, and then came back on the unit to obtain morning blood sugar readings. The note indicated the nurse entered Resident #4's room and observed the resident on the floor in the bathroom and attempted to arouse the resident, who was unresponsive. It indicated the resident was on his knees, bending/hunched face down in the toilet as if vomiting. The statement indicated the resident was difficult to move and the nurse called other nursing stations for assist. The nurses assisted in helping the resident into the bed and began chest compressions until 911 arrived. The nurse continued CPR until instructed by 911 personnel that they would take over. Review of a typed summary of an interview with RN #11 revealed more details of the incident. The summary indicated an interview on [DATE] at 7:45 A.M. revealed RN #11 entered the resident's room around 6:12 A.M. on [DATE] and noted he was not in his bed, and his bathroom door was shut with the light on. She left the room and continued to perform morning blood sugars. When she returned to the room at 6:22 A.M. she noted the bathroom door still closed and after knocking on the door with no answer, stated she opened the door to find the resident on his knees in front of the commode. She stated she called his name and shook him with no response. She attempted vital signs but was unable to move the resident so she left to get the state tested nursing assistant (STNA #13). She and the nursing assistant entered the room and attempted to move the resident, but due to size and weight, they were unable, so the nurse left the room to call LPN #12 from the other unit. The statement indicated the LPN #12 arrived on the unit, and around 6:30 A.M., RN #11, LPN #12 and STNA #13 moved the resident to the bed and LPN #12 started CPR. The statement indicated RN #11 called 911 around 6:40 A.M. and CPR was continued until emergency personnel arrived around 6:45 A.M. Interview with RN #11 verified the above information. She verified the time on the written statement was an estimate and the times on the interview dated [DATE] at 7:45 A.M. were more exact. She stated that when she entered the room initially, she shook the resident and called his name. When he did not respond, she was unable to find a pulse. She stated she went to find STNA #13 to help her position the resident. She stated they both entered the room, but were unable to move the resident due to the small bathroom. She went to the desk to call for the nurse on the B unit to assist in moving the resident. When LPN #12 arrived on the unit, the three staff members pulled the resident from the bathroom and lifted him to the bed. RN #11 stated she went for the backboard and ambu bag while LPN #12 started compressions. She stated after bringing those items back, she went to the desk to call 911, and then returned to the resident ' s room. She stated she did not call 911 upon first discovering the resident unresponsive because she thought he may be ok if he was just repositioned and she wanted to be sure before she called the paramedics. Review of the statement dated [DATE] (untimed) of STNA #13 revealed she was in with a resident and the supervisor (RN #11) came and got me to go check on (Resident #4). She stated he was found kneeling in the bathroom over the toilet like he was vomiting. Interview with STNA #13 on [DATE] at 3:45 P.M. revealed she was in another room, assisting a resident, with the door shut on [DATE] about 6:20 P.M. She stated RN #11 came into the room and said Resident #4 was in the bathroom and not responding to her. She stated she was done with the resident she was assisting and just needed to dispose of dirty laundry/trash, so after doing that, she went to room [ROOM NUMBER]. She stated upon entering the room, she saw Resident #4 over the toilet, like he was throwing up. He was wearing a gown. She stated she called his name and touched his back to shake him and he was cold. She stated she and RN #11 were unable to move the resident, so RN #11 left the room to call for another nurse and I just stood there, I was in shock. After the LPN #12 arrived, he started to move the resident and tried to start CPR with the resident positioned on the floor. We then moved him to the bed. She stated after the nurse called 911, she stood in the hall by the desk so 911 would know which way to come when they entered the building. STNA #13 stated she didn't anticipate the resident was in distress from the way she was asked by RN #11 to come assist with the resident. She denied hearing RN #11 call for assistance prior to coming into the room. She stated she was the only STNA on the unit at the time. Interview with LPN #12 on [DATE] at 6:50 A.M. revealed he was working on the 200 unit on the morning of [DATE]. He stated he was passing his medications when he received a phone call from RN #11 stating that she needed help with Resident #4. He stated he did not know what was needed, did not know a resident was on the floor or unresponsive. He stated we went down the hall and into Resident #4's room. He stated the resident was on the floor on his knees, in front of the toilet, with his left arm between the wall and handrail and his head leaning against his arm. He stated he stood behind the resident and attempted to arouse him, moving his head, which just fell back against his body. He stated he grabbed the resident under his arms and tried to lay him down in the bathroom to start CPR. He stated he tried to start CPR there on the floor, but there was not enough room, so he, RN #11 and STNA #13 moved him from the bathroom floor onto the bed. He stated he started chest compression, and RN #11 went to get the backboard and ambu bag. He stated she started to use the ambu bag, but he took over doing both compressions and ventilations. He stated RN #11 told him she had called 911 but he wasn't ' t sure if it was when she went to get the back board or if she left the room to call after bringing in the backboard. He stated he continued CPR until 911 staff arrived. They told him to continue while the attached leads to the resident and got out their supplies, and then told him they would take over the CPR. He stated they continued with CPR for a time, and were in contact by radio with someone, and then he heard them say the resident was deceased and they stopped CPR. LPN #12 stated he noted some bruising to one of the resident's knees and a small abrasion/skin tear to the other knee. Review of LPN #12 statement verified the information as above, except the statement indicated he was called to the A wing around 6:10 A.M. He stated that time was an estimate, he was not sure of the exact time, but knew that it was after 6 because he had started his medication pass at 6:00 A.M. and had completed most of it when he was called. Review of a typed statement by the DON (not timed), indicated on [DATE] she spoke with LPN #12 about his observation of the resident when he entered the bathroom. The statement indicated the resident was on his knees and his body was facing the commode with the seat up. His left arm was resting on the hand grip located on the wall next to the commode, and the resident was lying across the commode, with his head leaning towards the wall. His cane was leaning against the bathroom sink. Review of the EMS report dated [DATE] indicated they were notified by the facility at 6:42 A.M. and were enroute at the same time. The report indicated they arrived at the facility at 6:45 A.M. The note indicated staff were performing CPR when they arrived, the resident was last seen by staff at approximately 4:50 P.M. The note indicated the facility staff had found the resident unresponsive kneeling over the toilet; staff put the resident in bed and started CPR, then stopped and called EMS. The report indicated the resident was found by EMS with no signs of life, supine in bed. The report indicated an EKG (electrocardiogram) showed asystole in 2 levels and the resident had no vital signs. A further assessment indicated the resident had + (positive) fixed pupils, + rigor and + pooling in the bilateral knees. The report indicated the time of death was given by the emergency room physician in a local hospital at 6:57 A.M. Interview with the DON stated she was called about the resident's condition and arrived at the facility around 8:00 A.M. She stated she examined the resident briefly, but found no signs of trauma. She stated she noted the bruise and abrasion on his knees, but stated the family told her those were injuries from an earlier fall. She verified the nursing admission assessment did not indicate the presence of the bruise or the abrasion. Interview with the Medical Director on [DATE] at 2:00 P.M. revealed he was available by phone to assist staff with any needs concerning residents. He stated that if a staff member was unable to contact the resident's own physician, he would expect staff to call him for guidance or medical direction. He stated he been not called concerning any issues with Resident #4 and knew nothing of his care until he was notified in the morning on [DATE] that the resident had expired. He stated if the nurse had called him with the elevated blood sugar for Resident #4, he would have given orders to recheck the blood sugar at least every two hours to ensure it was returning to normal limits. Review of the facility policy on Notification of Change (dated ,[DATE]) revealed the physician should be notified immediately for a blood sugar level of over 300 mg/dL. Review of the Medical Emergency Response policy (dated [DATE]) revealed that a resident with a full code status who was found unresponsive, the nurse should begin CPR after performing a quick assessment to determine responsiveness and request emergency response (911). The policy also indicated that an AED device should be placed. Interview with the DON on [DATE] at 11:45 A.M. verified LPN #10 did not check the resident's blood sugar prior to his meal per order and despite paging the physician, did not notify the physician of the resident's blood sugar of 584 mg/dL or recheck the resident's sugar at any time. She verified the facility policy for notification of change required immediate notification for blood sugars greater than 300. She verified that nursing judgment would have allowed LPN #10 to recheck the blood sugar to ensure it was within normal limits, after such a high reading, even if there was no order to check the level. She further verified the resident was not observed after a 15 minute check documented at 5:15 A.M. on [DATE] and that even when RN #11 saw he was not in his bed at 6:12 A.M., she did not check him until 6:22 A.M., although the resident was to be assisted when up and was not noted in the bathroom with a staff member. She further verified there was no evidence of urgency in the response of RN #11, who, after assessing the resident to be unresponsive, went down the hall to gain the assistance of STNA #13, and then after they were unable to move the resident, called LPN #12, not informing him of the urgency of the situation. She further verified that although the resident was determined to be unresponsive, CPR was not started until approximately 6:30 A.M. and the EMS service was not called until 6:,[DATE]:42 A.M. Interview with the regional nurse, RN #16, on [DATE] at 2:15 P.M. verified facility staff may page overhead in the event of a medical emergency, as outlined in the facility policy on Cardiopulmonary Resuscitation dated [DATE]. She verified the policy indicated that an overhead announcement was to be made, repeating three times, the phrase Code blue followed by the general location of the medical emergency. She verified the paging system was not utilized when Resident #4 was found unresponsive on [DATE] at 6:22 A.M. This certification deficiency substantiates Complaint Number OH 552.

Based on observations, staff and resident interviews, review of the facility's smoking policy, and record review, the facility failed to provide adequate supervision and interventions related to smoking and failed to enforce smoking policy rules. This resulted in Immediate Jeopardy for six of 23 residents reviewed for safe smoking. Resident #37 smoked while using oxygen, and Residents #11, #21, #32, #38 and #64 were all assessed to require supervision while smoking and were observed smoking unsupervised, smoking without a smoking apron, or carrying cigarette lighters unsupervised. There were 23 residents identified as smokers in the facility. The census was 105. On 07/13/15 at 2:55 P.M., the Administrator, Director of Nursing (DON), Chief Clinical Officer #20, Vice President of Clinical Services #21, Regional Nurse #22, and Regional Nurse #23 were notified that Immediate Jeopardy began on 07/01/15 at 9:30 A.M. when Resident #37, who was not to have smoking materials in his possession, was found smoking unsupervised in his room while using oxygen. The Immediate Jeopardy continued on 07/02/15 at 3:05 P.M. when Residents #32, #38, and #64 who were assessed to require supervision, were observed outside lighting their own cigarettes and smoking unsupervised. The Immediate Jeopardy continued on 07/13/15 at 9:11 A.M. when Resident #11, who required supervision, was observed outside lighting his own cigarette and not wearing a smoking apron and Resident #21, who required supervision, was observed smoking and not wearing a smoking apron. The Immediate Jeopardy continued on 07/13/15 at 10:00 A.M. when Resident #38, who required supervision, was observed outside smoking unsupervised and not wearing a smoking apron. The Immediate Jeopardy was removed on 07/14/15 when the facility implemented the following corrective actions: · On 07/06/15, the smoking policy and procedure was revised to include requirements for all smokers including violations of the policy that may subject a resident to discharge. · On 07/06/15, Social Worker #28 completed new assessments of the 23 residents in the facility who smoked, (Residents #1, #5, #9, #10, #11, #15, #21, #26, #30, #32, #36, #37, #38, #45, #58, #62, #64, #74, #75, #76, #78, #80 and #82). ' Unsafe smokers' (those who required supervision) were identified as Residents #11, #21, #30, #32, #37, #38, #45, #64, #74, #78 and #82. · On 07/06/15 and 07/07/15, the DON and Minimum Data Set (MDS) Nurse #29 revised the 23 residents' smoking care plans based on their smoking assessments. · On 07/13/15 at 9:20 A.M., Regional Nurse #22 supplied a bin containing seven new smoking aprons to the outside smoking area. · On 07/13/15 at 9:40 A.M., Regional Nurse #22, accompanied by the surveyor, conducted room audits of smokers' rooms, and removed one lighter from a resident room. Regional Nurse #22 counseled the resident that he was not to have a lighter. This audit will continue every shift to be completed by the shift supervisor, until the residents who smoked demonstrated compliance with the revised smoking policy and procedure for 72 hours. · On 07/13/15 at 10:15 A.M., Regional Nurse #22 designated one assigned staff person per shift to the designated smoking area all shift. This assignment would continue until staff and smokers were in compliance with the revised smoking policy and procedure for 72 hours. · On 07/13/15 at 4:00 P.M., the Administrator distributed 13 individual lock boxes for the smoking materials, cigarettes and lighters of 'Safe smokers', to the locked medication rooms on each unit. The smoking materials of the supervised 'Unsafe smokers' were placed in a locked mobile cart on the B unit, with the key held by the staff person assigned to supervise the designated smoking area. · On 07/06/15, 07/13/15 and 07/14/15, Employee in-services were conducted by the Administrator, the DON, Regional Nurse #22 and Payroll Manager #26, regarding the revised Smoking policy and procedure, the designated smoking times and staff supervision assignments, and all smokers assessments of their level of supervision. On 07/06/15 the in-services were attended by three Registered Nurses (RNs), five Licensed Practical Nurses (LPNs) and eight State-tested Nurse Aides (STNAs). On 07/13/15 the in-services were attended by eight administrative staff, five RNs, 10 LPNs, 41 STNAs, seven Housekeepers, two Laundry Staff, four Activity Staff, one Maintenance Staff, 14 Dietary Staff, and six Therapy Staff. On 07/14/15 the in-services were attended by two Therapy Staff and one STNA. All employees except for Human Resources Staff #152 and Social Worker #153, who are on leave of absence, have been inserviced. Although the Immediate Jeopardy was removed the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is continuing to provide in-service education to all staff and is in the process of evaluating the system to ensure residents and staff comply with the revised smoking policy and procedure. Findings include: 1. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #37 used oxygen continuously. Review of a smoking assessment dated [DATE] revealed Resident #37 needed supervision with smoking because he was observed smoking in undesignated areas. The resident's cigarettes were to be kept at the nurses station. Review of the care plan for smoking initiated 03/23/15 included interventions that Resident #37 was to smoke in the designated area and under direct supervision of a staff member. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #37's cognition was moderately impaired. The resident had no identified behaviors. Review of a progress note written by LPN #150 indicated that on 07/01/15 at 9:30 A.M., she observed Resident #37 in his room smoking while using oxygen. Review of the care plan for smoking updated on 07/01/15 revealed the resident was educated on the risks to himself and others when smoking around oxygen, and in a designated no smoking area. An interview with Resident #37 on 07/02/15 at 11:00 A.M. revealed he kept his cigarettes and lighter on his person but denied ever smoking in the facility or wearing oxygen while smoking. During the interview the resident was receiving oxygen via a nasal cannula in his nose, connected to an oxygen concentrator. An interview with LPN #150 on 07/02/15 at 5:25 P.M. revealed Registered Dietitian #151 reported she thought Resident #37 was smoking in his room on 07/01/15. LPN #150 went into the resident's room and observed him wearing oxygen and holding a lit cigarette in his hand. She immediately removed the cigarette, flushed it down the toilet, and informed the Administrator. LPN #150 verified Resident #37 was not permitted to keep smoking materials. 2. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #32's cognition was moderately impaired. She exhibited no behaviors but had functional limitations to range of motion to upper and lower extremities on one side. The record contained no smoking assessment completed prior to 06/22/15. Review of a progress note written by LPN #25 indicated on 06/22/15 at 11:58 A.M., she noted Resident #32 lit a cigarette in the front lobby. The cigarette was extinguished and removed immediately and the resident was counseled by the Administrator at that time. Review of the care plan for smoking initiated 06/23/15 indicated Resident #32 was non-compliant at times with the smoking policy. The care plan included interventions that Resident #32 was to smoke in designated areas and under direct supervision of a staff member. Review of a progress note written by LPN #150 indicated on 07/01/15 at 2:30 P.M., staff observed Resident #32 smoking in the front lobby. The cigarette was extinguished and the Administrator met with the resident immediately to review the smoking policy. An interview with Resident #32 on 07/02/15 at 1:50 P.M. confirmed she kept both her cigarettes and lighter in her pocket. Observation on 07/02/15 at 3:05 P.M., revealed Resident #32, was outside lighting her own cigarettes and smoking unsupervised. Review of the initial smoking assessment dated [DATE] indicated Resident #32 was an unsafe smoker and needed supervision with smoking. Interview with LPN #150 on 07/14/15 at 11:55 A.M. confirmed Payroll Manager #26 observed Resident #32 smoking in the front lobby of the facility on 07/01/15. (LPN #150 had received a call from Payroll Manager #26). By the time LPN #150 got to the front lobby, the resident was in a meeting with the Administrator. An interview with Regional Nurse (RN) #22 on 07/14/15 at 12:10 P.M. confirmed Resident #32 had been observed on two occasions smoking inside the building. 3. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#64 needed supervision while smoking. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #64's cognition was moderately impaired. Observation on 07/02/15 at 3:05 P.M., revealed Resident #64 was outside lighting a cigarette and smoking unsupervised. 4. Medical record review revealed Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for smoking initiated 01/12/15 indicated Resident #11 was non-compliant at times and had been found smoking in his room. Interventions included all smoking was to be supervised in designated smoking areas and staff was to keep all smoking materials for the resident. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] indicated Resident #11 was cognitively intact and had functional limitations to range of motion to upper and lower extremities on one side. Review of the smoking assessment dated [DATE], indicated Resident #11 needed supervision with smoking. An interview with Resident #11 on 07/02/15 at 11:20 A.M. confirmed he kept his own lighter. On 07/06/15, Resident #11's care plan for smoking was updated to include provide resident with smoking apron. During an observation of the designated smoking hut on 07/13/15 at 9:11 A.M., Resident #11 pulled a cigarette and lighter from his pocket. He lit his own cigarette then placed the lighter back into his pocket. Activity Aide #27 informed the resident he was not to have a lighter and removed it at that time. Resident #11 smoked two cigarettes. Staff did not offer or encourage him to wear a smoking apron. In an interview on 07/13/15 at 3:03 P.M., the Administrator confirmed Resident #11 was not wearing a smoking apron. 5. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] indicated Resident #21 was cognitively intact with highly impaired vision and had no corrective lenses. The smoking assessment dated [DATE] indicated Resident #21 was an unsafe smoker and needed supervision. Review of the care plan for smoking initiated 07/10/15 indicated interventions including all smoking to be supervised and to provide resident with smoking apron. During an observation on 07/13/15 at 9:11 A.M., Resident #21 was seated in a wheelchair in the outside smoking hut with his eyes closed. He was not wearing a smoking apron. Activity Aide #27 provided him a cigarette and light. Resident #21 jokingly said, You see I'm wearing my smoking apron. Only Resident #78 was wearing a smoking apron. At 9:20 A.M., Regional Nurse #22 brought out a bin containing more smoking aprons. Resident #21 was then provided a smoking apron while he was smoking his second cigarette. 6. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 admission assessment dated [DATE] revealed Resident #38 was cognitively intact with highly impaired vision with no corrective lenses. Review of the smoking assessment dated [DATE] indicated Resident #38 was an unsafe smoker and needed supervision due to being blind and needing assistance. Review of the care plan for smoking initiated 07/06/15 indicated interventions including all smoking to be supervised in designated smoking areas and provide resident with smoking apron. On 07/13/15 at 10:00 A.M., an observation revealed Resident #38 was seated in the outside smoking area. There were no facility staff outside and he was not wearing a smoking apron. In an interview on 07/03/15 at 10:03 A.M., Regional Nurse #22 confirmed Resident #38 was not supervised while smoking and was not wearing a smoking apron. Review of the facility's smoking policy dated June 2008, revealed each resident who wanted to smoke would be assessed for safety during smoking and the level of assistance required. Direct supervision would be provided to all residents that smoked. The resident would be alerted at the beginning of the scheduled smoke break and given cigarettes in the designated smoking area. Residents were not permitted to have lighters. The staff member who supervised the smoke break would be responsible for lighting all cigarettes according to the policy. Residents were prohibited from storing their own smoking materials. All material would be kept in a central location under lock and key and available only to staff or family. Residents with oxygen would not be permitted to smoke with their oxygen on near the smoking area. Residents assessed to be safe smokers were alert and oriented and their own responsible party, and could smoke as they desired 50 feet from the facility door. Review of the Resident Smoking Schedule Staff Supervision Assignment form, updated 08/09/13, revealed smoking times were 6:30 A.M., 9:00 A.M., 11:00 A.M., 2:00 P.M., 6:30 P.M., 9:00 P.M., and 11:15 P.M., and listed the staff person assigned to supervise smoking at each time. This deficiency substantiated Complaint Number OH 715.