Every finding on record at The Gardens of St. Francis

Based on medical record reviews, staff interviews, and review of facility policies, the facility failed to ensure pneumococcal and influenza vaccinations were up to date. This affected five (Residents #13, #17, #33, #36, and #56) of five residents reviewed for immunizations. The facility census was 57.Findings include:1.Review of the medical record for Resident #13 revealed he was admitted on [DATE] with diagnoses including cardiomegaly, hypertension, type two diabetes mellitus, stage 3B chronic kidney disease, chronic obstructive pulmonary disease, and obstructive sleep apnea.Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] for Resident #13 revealed he was cognitively impaired and did not display any behaviors nor refusals of care at the time of this assessment. He required moderate assistance with ambulation and activities of daily living. Resident #13 had chronic lung disease and experienced shortness of breath when lying down. This assessment indicated his pneumococcal vaccine was up to date.Review of the care plan for Resident #13 revealed focus areas dated 11/11/25 for risk of altered respiratory status related to respiratory disorders and risk for infection related to communal living and medically complex diagnoses.2. Review of the medical record for Resident #17 revealed she was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke, muscle weakness, dementia, stage three chronic kidney disease, anxiety, depression, and a personal history of brain cancer.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] for Resident #17 revealed she utilized a walker independently up to 50 feet and required set-up to moderate assistance with activities of daily living. This assessment indicated she experienced shortness of breath when lying down, had received her influenza vaccine outside the facility, and her pneumococcal vaccine was up to date. Resident #17 had not experienced any falls since her prior MDS assessment dated [DATE].Review of the most recent care plan for Resident #17 revealed interventions related to being at risk for falls, infections due to communal living, verbally abusive behaviors, altered respiratory status and difficulty breathing.3. Review of the medical record for Resident #33 revealed she was admitted on [DATE] with diagnoses including dementia, dysphagia, hypertension, hyperlipidemia, muscle wasting, protein-calorie malnutrition, pain to lower extremities, and reduced mobility.Review of the quarterly Minimum Data Set 3.0 dated 01/04/26 for Resident #33 revealed she was cognitively impaired, did not exhibit behaviors, and did not refuse care. She utilized a wheelchair and was dependent for transfers and mobility. Resident #33 required maximal to dependent level of care with activities of daily living. This assessment indicated she was at risk for developing pressure injuries and her pneumococcal vaccine was up to date.Review of the care plan for Resident #33 revealed a goal dated 09/25/25 to maintain intact skin through the next review. Related interventions did not include the ordered heel protector boots to bilateral feet every shift. Additionally, there was a focus area dated 12/27/25 for risk for infection related to communal living and a focus area dated 01/08/26 for the potential for altered respiratory status related to respiratory disorder.4. Review of the medical record for Resident #36 revealed she was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, heart failure, pleural effusion, obstructive sleep apnea, shortness of breath, and type two diabetes mellitus.Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] for Resident #36 revealed she experienced moderate cognitive impairment, displayed verbal behavioral symptoms toward others, and did not refuse care. She utilized a wheelchair, was dependent for transfers and mobility, and required maximal assistance with activities of daily living. Resident #36 experienced shortness of breath while lying down. This assessment indicated her pneumococcal vaccine was not up to date because it had not been offered.Review of the care plan for Resident #36 revealed a focus area dated 12/18/25 indicating she was at an increased risk for infections due to communal living and chronic obstructive pulmonary disease. Additionally, the care plan included a focus area dated 12/27/25 related to Resident #36 being at risk for altered respiratory status.5. Review of the medical record for Resident #56 revealed she was admitted on [DATE] with diagnoses including retroperitoneal hematoma, chronic kidney disease, non-pressure chronic ulcer of right lower leg, atrial fibrillation, dilated cardiomyopathy, atrioventricular block, heart failure, iron deficiency anemia, intestinal malabsorption, and type two diabetes mellitus.Review of the admission assessment dated [DATE] for Resident #56 revealed she was alert and oriented to person, place, and time, pleasant and cooperative. Review of the pressure ulcer risk tool revealed she was at risk for skin breakdown.Review of the care plan for Resident #56 revealed a focus area dated 03/24/26 indicating she was at risk for infection due to communal living.Review of the influenza immunization record for Resident #56 revealed the absence of evidence regarding this resident having received this vaccine, nor was the vaccine offered when she was admitted to the facility on [DATE].Review of pneumococcal immunization records for Residents #13, #17, #33, #36, and #56 revealed their pneumococcal immunizations were not up to date.Interview on 03/25/26 at 8:15 A.M. with the Director of Nursing confirmed pneumococcal immunizations for Residents #13, #17, #33, #36 were not up to date. Continued interview confirmed there was no documentation regarding Resident #56 having received this vaccine, nor was the vaccine offered when she was admitted to the facility.Review of a facility policy dated 03/01/23 and titled Influenza Vaccination revealed the facility would offer residents immunization against influenza disease annually between October 1st and March 31st. Additionally, the policy stated residents' medical records would include documentation if the vaccine was received, not received due to medical contraindications, or declined.Review of a facility policy dated 03/02/23 and titled Pneumococcal Vaccine (Series) revealed the facility would offer residents immunization against pneumococcal disease in accordance with CDC guidelines. Additionally, the policy stated residents' medical records would include documentation if the vaccine was received, not received due to medical contraindications, or declined.

Based on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects and adverse effects. This affected four (#16, #6, #38, and #68) of five residents reviewed for unnecessary medications. The facility identified 39 residents receiving psychotropic medications. The facility census was 57.Findings include: 1. Resident #16 admitted to the facility on [DATE] with the diagnoses including major depression and anxiety disorder. According to the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #16 with moderately impaired cognition, no resistive behaviors, required supervision or touching assistance with eating, and dependent for completion of activities of daily living. On 11/18/25 a nursing plan of care was revised to address Resident #16's mood disorder related to her diagnoses of cyclothymic disorder, insomnia, anxiety, and depression. Currently being seen by psychiatric services. Has had crying episodes and refusals of care and will refuse to eat when she is upset about something. Is not always easy to redirect. Refused medications if she is already in bed at times. Interventions included; Provide adequate rest periods throughout the day. Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report to Nurse/Physician (MD) signs/symptoms (s/sx) of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Monitor/record/report to MD as needed (prn) risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Pharmacy review monthly. Review of physician orders noted the following; 03/04/26 lamotrigine 100 milligrams (mg) give one table by mouth once daily for depression/anxiety. Give 100 mg by mouth in the evening for depression/anxiety. 03/21/26 sertraline 100 mg by mouth daily with 25 mg total dose 125 mg for anxiety/depression. 01/15/26 duloxetine 60 mg give two capsules by mouth one time daily for depression to equal 120 mg. There were no orders for monitoring for medication effectiveness, adverse effects and side effects. Review of the nurses' notes, medication administration records (MARs), and treatment administration records (TARs) from 01/01/26 through 03/25/26 revealed no documentation the resident was monitored for medication effectiveness, adverse effects, and side effects of the psychotropic medications. Interview of 03/25/26 at 10:02 A.M., the Director of Nursing (DON) verified there was no documentation Resident #16 was monitored for adverse effects and side effects of the psychotropic medications. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, major depressive disorder, anxiety disorder. Review of the quarterly MDS assessment for Resident #6, dated 02/04/26, revealed a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive deficits. Further review of the MDS revealed Resident #6 exhibited wandering behaviors one to three days a week. Review of the admission care plan for Resident #6, dated 07/31/25, revealed interventions for nursing staff to administer antidepressant and psychotropic medications as ordered by the physician. Additionally, care plan for Resident #6 contained interventions to monitor, document and report adverse reactions of psychotropic medications. Review of orders for Resident #6 revealed an order entered on 07/31/25 for Lexapro oral tablet 5 mg by mouth one time a day for anxiety. Additionally, an order was entered on 01/20/26 for Risperdal oral tablet 0.5 mg, give one tablet by mouth one time a day for bipolar. No order was entered to monitor the side effects of psychotropic medications. Interview on 03/25/26 at 10:02 A.M. with the DON revealed verification of monitoring for psychotropic side effects was not being done for Resident #6. 3. Record review revealed Resident #38 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, major depressive disorder, chronic embolism and thrombosis of deep veins of lower extremity, and contracture of joint. Review of the quarterly MDS dated [DATE] revealed Resident #38 was cognitively intact and received psychotropic medications. Review of Resident #38's medication orders revealed an order dated 04/02/25 for Sertraline HCL Oral Tablet 25mg one tablet three times a day for depression or anxiety and an order dated 02/18/26 for buspirone HCL Oral Tablet 2.5mg by mouth three times a day for anxiety. Review of the nurses' notes, MARs, and TARs from 02/22/26 through 03/25/26 revealed no documentation the resident was monitored for medication effectiveness, adverse effects, and side effects of the psychotropic medications. Interview on 10/25/26 at 10:02 A.M. with the Director of Nursing (DON) confirmed that psychotropic medication side effect monitoring was not in place for Resident #38. 4. Review of Resident #68's medical record revealed an admission date of 11/19/25 and a discharge date of 06/02/25. Diagnoses included type II diabetes, protein calorie malnutrition, muscle wasting, cognitive communication deficit, symbolic disfunctions, reduced mobility, anxiety disorder, fracture of upper end of left humerus subsequent encounter, major depressive disorder, Alzheimer's disease, and peripheral vascular disease. Review of Resident #68's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #68 was moderately cognitively impaired. Resident #68 required maximal assistance with toilet use, bathing, and parts of dressing. Resident #68 was independent with bed mobility and transfer with supervision. Resident #68 displayed no behaviors at the time of the review. Resident #68 was on hospice at the time of the review. Review of Resident #68's care plan revised 06/03/25 revealed supports and interventions for psychotropic medications use including antidepressant medications, antianxiety medications. Resident #68 was at risk for adverse reactions. Interventions included administer medications as ordered and monitor, document, and report as needed adverse reactions. Review of Resident #68's physician orders revealed Resident #68 was ordered Mirtazapine (antidepressant) 15 milligrams (mg), lorazepam (antianxiety) 0.5 mg, Ativan (antianxiety) 1 mg, and Seroquel (antipsychotic) 25 mg. Review of Resident #68's 05/29/25 geriatric mental health stabilization documentation from his acute stay from 05/13/25 to 05/29/25 revealed Resident #68 was monitored for psychotropic medication side effects during his stay at the acute care geriatric psychiatric facility. Resident #68 was monitored for potential side effects for antidepressant medication use, antipsychotic medication use, and antianxiety medication use every shift. Review of Resident #68's medical record from 11/19/25 to 05/14/25 and 05/29/25 to 06/02/25 found no evidence Resident #68 was monitored by the facility for psychotropic medication side effects. Interview on 03/25/26 at 10:02 A.M. with the Director of Nursing (DON) verified monitoring for side effects of psychotropic medications had not been completed. Review of the facility policy titled, Use of Psychotropic Medications, revised 08/29/25 revealed the residents response to the medications including progress toward goals and presence or absence of averse consequences should be documented in the resident's medical record. Review of the facility policy titled, Medication Administration, revised 05/03/22 revealed the facility would report and document any adverse side effects or refusals of medications.

Based on resident and staff interviews and record review, the facility failed to respect a resident's preference to sleep in. This affected one (#16) of one resident reviewed for sleep preferences. The facility census was 57. Resident #16 admitted to the facility on [DATE] with the diagnosis including, chronic obstructive pulmonary disease, myasthenia gravis, epilepsy, dysphagia, major depression, pseudosarcomatous fibromatosis, hypertension, anxiety disorder, coronary artery disease, insomnia, congestive heart failure, and neurofibromatosis.According to the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #16 with moderately impaired cognition, no resistive behaviors, required supervision or touching assistance with eating, dependent for completion of activities of daily living, and utilized a wheelchair for mobility propelled by staff. On 11/17/25 a nursing plan of care was revised to address Resident #16 activity of daily living (ADL) self care performance deficit d/t weakness, lower extremities, balance problems, muscle atrophy, cognitive deficit and immobility. Interventions included; two person assist with transfers using Hoyer lift. ADLs are moderate to maximum assist. ADLs may vary from day to day. Anticipate my needs. Assist with meals as needed. Coordinate care with hospice. Encourage resident to use bell to call for assistance. Head of the bed elevated to comfort to prevent shortness of breath if lying flat. Wheelchair for mobility. Interview on 03/23/26 at 11:25 A.M. with Resident #16 revealed staff wake them early in the morning, provide morning activities of daily living and place them in their wheelchair. This occurs in the morning at approximately 5:00 A.M. Resident #16 states they prefer to sleep in. On 03/24/26 at 5:40 A.M. interview with Certified Nurse Aide (CNA) #387 revealed Resident #16 was woken up at 5:15 A.M. dressed, groomed, and left in bed. CNA #387 stated Resident #16 is resistant at times. On 03/24/26 at 2:00 P.M. interview with CNA #377 noted a hand written instruction with the heading 6:00 P.M. to 6:00 A.M. Get ups. Each unit/hall is to have three (3) patients up prior to 6:00 A.M. to 6:00 P.M. arriving. Thank you for your cooperation. A second handwritten list with the heading A hall get ups. Five residents were listed including Resident #16. Instruction noted Resident #16 to be washed and dressed in bed, then get into wheelchair at 5:00, if she refuses try again or get nurse. Whirlpool Tuesday, Thursday, Saturday. On 03/24/26 at 2:35 P.M. interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) during a review of the list revealed they were unaware of the get-up list. On 03/24/26 at 2:42 P.M. telephone interview with Resident #16's Responsible Party (RP) was unaware resident was to be risen from bed during the 6:00 P.M. to 6:00 A.M. shift. Resident #16 RP stated if resident was sleeping, leave resident sleeping.

Based on medical record review, staff interview and policy review, the facility failed to have a required Preadmission Screening and Resident Review (PASARR) in place prior to admission. This affected one resident, #6, out of four residents reviewed for PASARR. The facility census was 57. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, bipolar disorder, major depressive disorder and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment for Resident #6, dated 02/04/26, revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficits. Further review of the MDS revealed Resident #6 exhibited wandering behaviors one to three days a week. Review of the admission care plan for Resident #6, dated 07/31/25, revealed interventions included, staff are to distract resident from wandering by offering pleasant diversion. Further review of the care plan revealed staff were to administer antidepressant and psychotropic medications as ordered by physician.Review of the medical record for Resident #6 revealed no PASARR was completed and resident had mental illness diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. Interview on 03/25/26 at 11:03 A.M. with Director of Marketing (DOM) revealed PASARR was completed on 03/24/26. DOM stated a search was done through the Healthcare Electronic Notification System ([NAME]) and was unable to find that a PASARR was completed prior to 03/24/26. DOM verified that Resident #6 did not have a PASARR complete prior to admission to the facility. Review of the policy titled Resident Assessment- Coordination of PASARR Program dated 03/01/23, revealed all applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions. Further review of the policy revealed the initial pre-screening would be completed prior to admission to the facility.

Based on observation, medical record review, staff interview, and policy review, the facility failed to apply anti-emboli stockings (TED hose) as ordered by the physician. This affected one resident (#6) out of one reviewed for application of TED hose. The facility census was 57.Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbance, muscle wasting and atrophy, generalized osteoarthritis, rheumatic tricuspid insufficiency and cardiomegaly. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #6, dated 02/04/26, revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficits. Further review of the MDS revealed functional abilities for Resident #6 included substantial/max assist for toileting hygiene, shower/bathing, upper/lower body dressing and personal hygiene.Review of the admission care plan for Resident #6, dated 07/31/25, revealed the resident was at risk for edema of the lower extremities with interventions of applying support stockings and elevation of legs. Additional care plan in place for self- care deficit. Review of the orders entered on 08/01/25 at 7:00 A.M. for Resident #6 revealed an order for the application of TED hose to bilateral lower extremities every day for edema. Additional order entered on 07/31/25 to remove TED hose at bedtime for edema. Review of the Treatment Administration Record for Resident #6 revealed TED hose have been applied to the resident every morning and removed every evening. Further review of the TAR revealed Resident #6 had TED hose applied the mornings of 03/24/26 and 03/25/26. Observation on 03/24/26 at 7:30 A.M. revealed Resident #6 was sitting in the recliner in the common area with eyes closed. No TED hose was seen on lower extremities. Observation on 03/24/26 at 10:16 A.M. revealed Resident #6 was sitting in the recliner in the common area. No TED hose was seen on lower extremities. Observation on 03/24/26 at 1:00 P.M. revealed Resident #6 was sitting in the recliner in the common area with eyes closed. No TED hose was seen on lower extremities. Observation on 03/25/26 at 9:41 A.M. revealed Resident #6 sitting in the recliner in the common area with eyes closed. No TED hose was seen on lower extremities.Interview on 03/25/26 at 9:41 A.M. with the Assistant Director of Nursing (ADON) verified that Resident #6 did not have TED hose on lower extremities as ordered by the physician. Interview on 03/25/26 at 9:50 A.M. with Registered Nurse (RN) #407 revealed Certified Nursing Assistants (CNAs) are to place TED hose on the residents in the morning and CNAs are to remove TED hose at bedtime. RN #407 continued to state it is the nurses' responsibility to document in the TAR if the TED hose had been applied and removed. RN #407 was asked if TED hose were placed on Resident #6 on the morning of 03/25/26, RN #407 stated he has not yet verified the placement of the TED hose. Review of the TAR with RN #407 verified his initials were entered on 03/25/26 as verification that TED hose was in place. Review of policy titled, Applying Ant-Emboli Stockings (TED Hose), last revised 10/2010 revealed the purpose of anti-emboli stockings are to improve venous return to the heart, to improve arterial circulation to the feet, to minimize edema to the legs and feet, and to prevent complications associated with deep vein thrombosis and pulmonary embolism. Further review of the policy revealed anti-emboli stockings should be applied in the morning, prior to the resident getting out of bed. Additionally, a supervisor is to be notified if the resident refuses to wear the anti- emboli stockings.

Based on medical record reviews, observations, resident interview, staff interview, and review of facility policy, the facility failed to ensure pressure ulcer prevention measures were utilized. This affected three Residents #3, #33, and #56) of five residents reviewed for pressure ulcers. The facility census was 57.Findings include:1. Resident #3 admitted to the facility on [DATE] with the diagnosis including, congestive heart failure, hypertension, chronic kidney disease stage 3, major depression, atrial fibrillation, left hip bursitis, polyneuropathy, osteoporosis, and anemia. According to the most current minimum data set assessment dated [DATE] Resident #3 was assessed with intact cognition, lower extremity impairment on one side, required substantial to maximal assistance with activities of daily living, independently mobile using an electric wheelchair, frequently incontinent of urine, continent of bowel, received a therapeutic mechanically altered diet, at risk for pressure ulcer development with open lesions and skin tears. Review nursing plan of care dated 08/07/25 addressing Resident #3 potential for impairment to skin integrity of the related to incontinence, decreased mobility and fragile skin. Interventions included; Air mattress to bed to help with skin integrity (added 03/18/26). Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. On 10/15/25 Resident #3 was assessed at moderate risk of developing a pressure sore with a numeric score of 14. On 02/19/26 physician orders initiated wound care to right buttock- cleanse with wound wash, apply hydrocolloid paste (triad paste) twice daily and as needed, every shift for blister to right buttock and as needed for right buttock wound/blister. Review of Resident #3 weight noted on 03/23/26 a weight of 209.5 pounds. Physician order on 03/17/26 air mattress to bed every shift for pressure reduction. No addition instruction or settings were ordered. Observation on 03/24/26 at 8:49 A.M. noted Resident #3 assisted to the bathroom. Certified Nurse Aide (CNA) #377 exposed Resident #3 buttock after removing an adult incontinence brief. Observation noted a open area of skin breakdown to the right buttock with a scant amount of blood tinge drainage. Triad past residue was in place. Review of the medical record between 03/24/26 at 8:49 A.M. and 03/25/26 at 6:45 A.M. revealed no evidence indicating the open wound was assessed or reported for treatment modification. On 03/25/26 at 6:47 A.M. interview with wound physician during assessment of Resident #3 noted a stage 2 (II) pressure ulcer to the right buttock. Description noted measurements of 1.0 centimeters (cm) long by (x) 0.3 cm wide x 0.1 cm deep with light light Serosanguinous drainage. Further observation noted wound physician to decrease the weight setting of the air mattress from 250 pounds to 180 pounds. Review of air advance mattress and bariatric owners manual dated 2017. Common method of sizing an air mattress is to check to see if suitable pressure is selected by sliding one hand between the air mattress and the air/foam base under the residents buttocks. Users should be able to feel the space between their hand and the residents buttocks with the acceptable range being from 25 to 50 millimeters or 1 inch to 1.5 inches. Review of Air Mattress compressor control unit undated. Installation instructions determine the patients weight and set control knob to that weight setting on the control unit. On 03/25/26 at 6:59 A.M. interview with Licensed Practical Nurse (LPN) #428 during a review of Resident #3 medical record verified the air mattress physician order did not include mattress settings or function. LPN #428 went on to state maintenance staff place the air mattresses to the beds and nurses observe them in place. LPN #428 was unaware if mattress settings were required or how to ensure mattresses were monitored for proper function. 2. Review of the medical record for Resident #33 revealed she was admitted on [DATE] with diagnoses including dementia, dysphagia, hypertension, hyperlipidemia, muscle wasting, protein-calorie malnutrition, pain to lower extremities, and reduced mobility. Review of the quarterly Minimum Data Set 3.0 dated 01/04/26 for Resident #33 revealed she was cognitively impaired, did not exhibit behaviors, and did not refuse care. She utilized a wheelchair and was dependent for transfers and mobility. Resident #33 required maximal to dependent level of care with activities of daily living. This assessment indicated she was at risk for developing pressure injuries. Review of physician orders for Resident #33 revealed an order dated 02/05/26 for heel protectors to bilateral feet every shift. Review of the care plan for Resident #33 revealed a goal dated 09/25/25 to maintain intact skin through the next review. Related interventions did not include the ordered heel protector boots to bilateral feet every shift. Observation on 03/23/26 at 10:55 A.M. of Resident #33 in her room sitting in her wheelchair revealed her feet were resting on foot pedals, she had white socks on but did not have heel protectors on. Observation on 03/23/26 at 4:43 P.M. of Resident #33 in her room revealed she was in bed with white socks on her feet but did not have heel protectors on. Interview on 03/23/26 at 4:45 P.M. with Registered Nurse (RN) #407 confirmed Resident #33 did not have heel protectors on and should have. 3. Review of the medical record for Resident #56 revealed she was admitted on [DATE] with diagnoses including retroperitoneal hematoma, chronic kidney disease, non-pressure chronic ulcer of right lower leg, atrial fibrillation, dilated cardiomyopathy, atrioventricular block, heart failure, iron deficiency anemia, intestinal malabsorption, and type two diabetes mellitus. Review of the admission assessment dated [DATE] for Resident #56 revealed she was alert and oriented to person, place, and time, pleasant and cooperative. Review of the pressure ulcer risk tool revealed she was at risk for skin breakdown. Review of physician orders for Resident #56 revealed an order dated 03/17/26 for heel protectors to bilateral feet when in bed or in a recliner. Review of the care plan for Resident #56 revealed a goal dated 03/18/26 to maintain intact skin through the next review. Related interventions included heel protector boots to bilateral feet as tolerated. Observation on 03/23/26 at 4:40 P.M. of Resident #56 in her room resting in bed revealed she had elastic compression bandages applied to both lower extremities but did not have heel protectors on. Interview on 03/23/26 at 4:40 P.M. with Resident #56 revealed staff did not always ensure her heel protectors were on, and she denied refusing to wear them or asking for them to be removed. Interview on 03/23/26 at 4:45 P.M. with Registered Nurse (RN) #407 confirmed Resident #56 did not have heel protectors on and should have. Review of a facility policy dated 10/24/22 and titled, Pressure Injury Prevention and Management revealed the facility would implement resident-specific interventions to prevent pressure injuries.

Based on observation, review of late medication reports, staff interview, and policy review, the facility failed to ensure medications administered in a timely manner as ordered. This affected three (Residents #1, #4, and #43) of four residents reviewed for late medications. The facility census was 49. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including but not limited to frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage, normal pressure hydrocephalus, cognitive communication deficit, cardiac arrhythmia, epilepsy, heart failure, anxiety, and major depressive disorder. Review of The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was rarely understood. Resident #1 required maximum assistance to total dependence on staff for activities of daily living. Review of the late medication report for 03/05/24 revealed the following medications were due between 7:00 A.M. and 10:00 A.M. losartan potassium (heart) 50 milligrams (mg), multiple vitamin, lactulose 10 grams (gm)/15 milliliter (ml) 10 ml for constipation, escitalopram 10 mg (depression), ferrous sulfate 325 mg, aspirin 81 mg, depakote delayed release (behaviors) 250 mg, vitamin D3 50 micrograms (mcg), and house supplement were administered at 12:58 P.M. Review of the late medication report for 03/06/24 revealed following medications were due between 7:00 A.M. and 10:00 A.M. losartan potassium (heart) 50 milligrams (mg), multiple vitamin, lactulose 10 grams (gm)/15 milliliter (ml) 10 ml for constipation, escitalopram 10 mg (depression), ferrous sulfate 325 mg, aspirin 81 mg, depakote delayed release (behaviors) 250 mg, vitamin D3 50 micrograms (mcg), and house supplement were administered at 12:25 P.M. 2. Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses including but not limited to unspecified foreign body in the bronchus causing other injury, dysphagia, depression, personal history of malignant neoplasm of bladder, umbilical hernia, diverticulitis, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #4 was moderately cognitively impaired. Resident #4 required substantial/maximal assistance for activities of daily living. Review of the late medication report for 03/05/24 revealed the following medications were due between 7:00 A.M. and 10:00 A.M. potassium chloride extended release 20 milliequivalent (MEQ), senna 8.6 mg (constipation), lasix 40 mg (water pill), ocuvite-lutein capsule, oyster-cal 500 mg, aspirin 325 mg, amlodipine besey-benazeprile capsule 10/20 mg (blood pressure), and celexa 20 mg (depression) were given at 11:13 A.M. 3. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including but not limited to heart failure, unspecified convulsions, type two diabetes, coronary artery disease, dementia, anxiety, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #43 required supervision/touching assistance for activities of daily living. Review of physician orders for Resident #43 revealed an order for Carvedilol 6.25 mg twice daily at 8:00 A.M. and 5:00 P.M. Review of the late medication report for Resident #43 revealed on 03/04/24 carvedilol 6.25 mg was administered at 10:30 A.M. Review of the late medication report for Resident #43 revealed on 03/05/24 the following medications scheduled between 7:00 A.M. and 10:00 A.M. ferrous sulfate 325 mg, multivitamin with minerals, claritin 10 mg (allergies), plavix 75 mg (blood thinner), omeprazole 20 mg (stomach), gabapentin 100 mg (neuropathy), rexulti 0.5 mg (mood), klonopin 0.5 mg (anxiety), keppra 500 mg (seizures), sertraline 100 mg (depression) were administered at 1:02 P.M. Review of the late medication report for Resident #43 revealed on 03/06/24 carvedilol 6.25 mg was administered at 9:13 A.M. and the 5:00 P.M. dose was administered at 6:12 P.M. Observation on 03/07/24 at 9:21 A.M. revealed Licensed Practical Nurse (LPN) #647 administering carvedilol 6.25 mg (heart) to Resident #43 at 9:21 A.M. and the medication was ordered for 8:00 A.M. Interview on 03/07/24 at 9:24 A.M. LPN #647 verified Resident #43's carvedilol 6.25 mg was to be administered at 8:00 A.M. and was administered late. Interview on 03/07/24 at 2:55 P.M. with the Director of Nursing (DON) verified there were late medication reports showing late medication administration for Residents #1, #4, and #43. The DON stated she believed the medications were given on time but the nurses were not signing them out as they were administered, however the DON verified there was no evidence to support medications were administered on time. Review of policy titled, Medication Administration, revised 05/03/22 revealed medications would be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. This deficiency represents non-compliance investigated under Complaint Number OH00150807 and is an example of continued noncompliance from the survey dated 02/01/24.

Based on observation, medical record review, hospital document review, staff interview, policy review, and sit-to-stand lift instructions, the facility failed to ensure sufficient fall interventions were put into place to promote resident safety and prevent falls. This resulted in actual harm when Resident #1 fell on [DATE] and sustained a fracture to her right ankle and had a subsequent fall on 01/02/24 and sustained a head laceration which required two staples with no immediate interventions implemented. In addition, the facility failed to ensure transfer equipment was utilized in a safe manner for one (#8) resident. This affected two (#1 and #8) of four residents reviewed for accidents. The facility census was 52. Findings Include: 1. Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included dementia, emphysema, cerebral infarction, hemiplegia and hemiparesis, seizures, anxiety disorder, major depressive disorder, insomnia, and spinal stenosis. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 indicating Resident #1 was moderately cognitively impaired. Resident #1 required limited assistance of one person for transfers and toilet use. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating Resident #1 continued to be moderately cognitively impaired. Resident #1 required set up only with one person assistance for toilet use. Resident #1 required extensive assistance with transfer. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating Resident #1 continued to be moderately cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, eating, and toilet use. Resident #1 displayed no behaviors during the review period. Resident #1 was on hospice at the time of the review and used a wheelchair for mobility. Review of Resident #1's care plan revised 01/24/24 revealed supports and interventions for impaired cognitive function, fall with injury including an ankle fracture on 01/02/24, hospice services for terminal diagnosis of cerebral disease, used antipsychotic medications with risk for adverse reactions, chronic pain, seizure disorder, self-care deficit, and risk for falls. Fall interventions included to anticipate Resident #1's needs, ensure the call light was in reach, provide a safe environment including the bed in low position and personal items in reach, encourage to participate in activities, and ensure the resident wore appropriate footwear. Review of Resident #1's progress notes and fall investigation reports revealed on Saturday, 12/30/23 at 7:27 P.M., it was documented Resident #1 was lowered to the ground by a nurse aide while using the bathroom. Resident #1 had asked for help to the bathroom, and the nurse aide was helping Resident #1 to stand when the resident's legs were shaky, and she could not support herself. The nurse aide lowered Resident #1 to the ground. Resident #1 was assessed with no skin abnormalities were found. Resident #1 reported no pain. Resident #1's physician, family, and management were notified. Further review of the progress notes and fall investigation revealed on Saturday, 12/30/23 at 8:30 P.M., it was noted Resident #1 had an unwitnessed fall in her room. The resident was found lying on her back on the floor in front of her recliner. Resident #1 was unable to bear weight and fell during an unsupervised transfer. Resident #1 denied pain at the time. Resident #1 was assessed with no injuries were found. Neurological checks were initiated. Resident #1 was assisted off the floor, assisted to the toilet, and returned to the recliner. Resident #1 was educated on using the call light for assistance. A fall assessment was completed, and Resident #1 was determined to be a high risk for falls with a score of 12. Review of the previous fall risk assessment from 03/05/23 revealed the resident was assessed at low risk for falls. The interdisciplinary team (IDT) reviewed the fall and it was determined Resident #1 was ambulating on her own and did not ask for assistance. No injuries were found at the time. The new intervention was to refer Resident #1 to occupational therapy (OT) for a toileting program. A moderately cognitively impaired resident was educated on using the call light and no additional immediate interventions were added though Resident #1 had been identified as needing to use the bathroom for both instances. Review of Resident #1's entire medical record revealed the intervention of OT for a toileting program was never initiated for the resident. Review of progress notes and fall investigation revealed on Monday, 01/01/24, it was noted Resident #1 was found on the floor in her room at 7:28 A.M. by a nurse aide. The fall was not witnessed. Resident #1 was assessed, and an injury was noted on assessment. Notifications were made to Resident's family and physician. Resident #1 was noted to be confused at the time and had a strong odor to her urine. Resident #1 complained of right hip pain, her right foot was observed to be swollen and she had redness to the ankle. In addition, the middle of the right side of her back also had redness and Resident #1 also had a bump to the right side of her head. It was documented Resident #1 was confused, lethargic, had a bruise, and reported pain. Emergency medical service (EMS) was called at 7:33 A.M. and Resident #1 was transferred to the hospital. The IDT team discussed Resident #1's fall from 01/01/24 and it was determined the root cause of the fall was Resident #1 attempted to ambulate on her own, and she lost her balance and had a fall. Notifications were made and Resident #1 was sent to the emergency room (ER) for evaluation. Resident #1 returned from the hospital and Resident #1 was diagnosed with a fracture to the right ankle. Resident #1 was provided a soft cast and was to follow up with orthopedic as soon as possible to have a hard cast put on. Resident #1 was to elevate her right lower leg and be non-weight bearing. Resident #1 was also diagnosed with a urinary tract infection (UTI) and had a new order for the antibiotic Keflex 500 milligrams (mg) three times a day for ten days. Resident #1 received her first dose at the hospital. The noted intervention was sending her to the ER. A fall risk assessment was completed, and Resident #1 was assessed to be at moderate risk for falls with a score of 9. The noted intervention was to send Resident #1 to the ER for evaluation and treatment. In addition, the intervention was to continue Resident #1 on the prescribed the antibiotic. There were no interventions implemented for increased supervision or additional interventions to reduce Resident #1's risk for falls. Review of Resident #1's hospital discharge summary dated 01/01/24 revealed Resident #1 was seen following a fall for hip pain and altered mental status. Resident #1 was diagnosed with a closed fracture of her right ankle and a urinary tract infection. A new order for Keflex 500 mg one capsule three times a day for 10 days was ordered. The resident's last dosage was at 12:54 P.M. at the hospital. Resident #1 was also provided an occlusal splint (plaster splint roll) for her right ankle. Review of progress notes and fall investigation revealed on 01/02/24, Resident #1 had another unwitnessed fall in her room. Resident #1 was found on her right side up against her bed. Resident #1 was assessed with an injury was noted. Resident #1 was on the floor on her right side with bleeding noted from the back of her head on the right side. Pressure was applied to Resident #1's head to stop the bleeding, and EMS was called. Resident #1's physician and family were notified. Resident #1 could not explain what happened. Resident #1 was sent to the hospital for evaluation and treatment. Resident #1 was noted in her bed prior to the fall and was alert but not completely orientated at the time of the fall. There were no witnesses to the fall. A fall risk assessment was completed, and Resident #1 was found to be at high risk for falls with a score of 16. The IDT met and discussed Resident #1 falls. It was determined the root cause of the fall was due to Resident #1's cognitive decline related to a UTI and weakness. Resident #1 was attempting to get up on her own and lost her balance. The interventions put in place were to send Resident #1 to the emergency room to be evaluate, refer to physical therapy (PT) for strengthening, place the bed in the lowest position when she was in it along with a fall mat next to the bed. On 01/04/24, Resident #1 returned from the hospital and was noted to have had a scalp laceration which required two staples. Review of Resident #1's hospital discharge summary dated 01/04/24 revealed Resident #1 was admitted to the hospital on 01/02/24. Resident #1 was admitted with recurrent falls with mild delirium secondary to a UTI and neurological disorder along with a laceration in the back of the head and scalp which required staples. Resident #1 reported she was trying to transfer from her bed into her wheelchair when she fell and hit her head. At the time of Resident #1's discharge from the hospital on 01/04/24 to return to the nursing home with recommendations for physical therapy. Resident #1 was determined to be a high fall risk and had the barrier to learning of dementia. Resident #1 was orientated to person only. Review of Resident #1's medical record and nurse aide tasks revealed no documentation of two-hour checks completed for toileting, and documentation of two-hour checks for repositioning was not consistent during the review period. Interview on 01/29/24 with Resident #1 found her alert and able to answer basic questions. Resident #1 was not aware she had any falls. Interview on 01/30/24 at 8:31 A.M. with State tested Nurse Aide (STNA) #471 reported Resident #1 was able to make her basic needs known and required extensive assistance with transfer and toilet use. STNA #471 reported Resident #1 knew when she needed to use the bathroom but was not safe in transferring herself. STNA #471 stated the staff made sure Resident #1 had her call light in reach at all times, but she did not always use it. STNA #471 verified Resident #1 had had a couple falls that resulted in injuries. STNA #471 reported Resident #1 had no other falls since she fell and had to have staples in her head from falling and hitting her head on the bed. STNA #471 reported Resident #1 was declining since the end of December 2023 and was now on hospice. STNA #471 was not sure of the exact day Resident #1 began on hospice, but it was earlier in the month shortly after the resident returned from her hospital stay following her fall. Interview on 02/01/24 at 1:49 P.M. with the Director of Nursing (DON) revealed she was familiar with Resident #1 and her falls. The DON reported in March 2023, Resident #1 was evaluated and determined to be low risk for falls. On 12/30/23, Resident #1 was found on the floor in front of her recliner when the resident attempted to transfer herself. Resident #1 was assessed, and no injury was found. Neurological checks were initiated, and notifications were made. The DON verified the only intervention implemented at the time was education with Resident #1 to use her call light. The DON reported Resident #1 then had another fall on 01/01/24 at 7:28 A.M. when the resident was found by a nurse aide on the floor of her room. Resident #1 was confused, complained of pain, and her right foot was swollen and red. Resident #1 also had a bump on the back of her head. EMS was called and Resident #1 was sent to the hospital. Notifications were made and Resident #1 returned to the facility with a soft cast to her right ankle for a closed fracture, and an order for follow up for a hard cast and an antibiotic for a UTI. The DON reported the interventions put into place included to send Resident #1 to the ER, and when the resident returned to complete the antibiotic for the UTI and refer Resident #1 to OT for a toileting program. The DON verified they were not able to implement the referral to OT prior to Resident #1's fall on 01/02/24 and verified no other fall interventions were implemented. The DON stated on 01/02/24 Resident #1 had another unwitnessed fall in her room when she was found on her right side up against her bed. Resident #1 had a laceration to her head and was complaining of right-sided hip pain. Notifications were made to Resident #1's son and physician and Resident #1 was sent out to the hospital. The DON stated when the resident returned to the facility, she had staples in place to the laceration and they updated her interventions to include having her bed in the lowest position and a fall mat next to her low bed. The DON reported Resident #1 had no subsequent falls and completed the ordered antibiotic on 01/10/24. A follow up interview on 02/01/24 at 4:10 P.M. with the DON and Assistant Director of Nursing (ADON) reiterated the interventions implemented for Resident #1 following her falls. They verified Resident #1 had been on two-hour checks with toileting assistance provided prior to her falls and there had been no increases or changes to the checks or toileting assistance following the falls. Review of the facility policy titled, Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current data the staff would identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try and minimize complications from falling. Review of the facility policy titled, Fall Prevention Program, revised 10/20/22, revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized risk to minimize the likelihood of falls. 15816 2. Review of the medical record revealed Resident #8 admitted to the facility on [DATE] with the diagnoses including, generalized osteoarthritis, cerebral infarction, sprain ligaments lumbar spine, wedge compression fracture lumbar vertebra, collapsed vertebra thoracic region, low back pain, displaced fracture of left femur, and osteoporosis. Review of the MDS assessment dated [DATE] assessed Resident #8 with intact cognition, and revealed the resident utilized a wheelchair for mobility propelled by staff and was dependent on staff for activities of daily living (ADL) including sit to stand and chair to bed transfer. On 05/04/23, a nursing plan of care was implemented addressing Resident #8's ADLs deficit related to limited mobility and joint pain due to history of cerebral vascular accident and diagnoses of arthritis and osteoporosis. Further review revealed an updated intervention for staff to utilize a mechanical lift (Hoyer) lift with two staff assistance for transfers. Observation on 01/30/24 at 6:13 A.M. revealed STNA #461 with Resident #8 suspended in a stand-up lift. The resident was unable to stand up right and was slumping to the right while resting on the sling. STNA #461 proceeded to propel Resident #8 in the lift approximately 60 feet down the common hall to the shower room. At 6:20 A.M., an interview with STNA #461 revealed Resident #8 required two staff to assist with transfers and uses a mechanical (Hoyer) lift. STNA #461 confirmed Resident #8 was not safely placed in the stand-up lift and the stand-up lift was not to be used for transporting residents outside their rooms. On 01/30/24 at 6:43 A.M., an interview with the DON verified the stand-up lift was not to be utilized for transferring distances. The DON verified Resident #8 was unable to bear weight and required the use of a Hoyer lift with two staff present for transfers. Review of the Using a Mechanical Lifting Machine policy, revised July 2017, noted at least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of the Sit and Stand Lift ([NAME] Flex) instructions for use, dated 2022, revealed the resident must be able to bear weight on at least one leg and have some trunk stability, be able to sit on the edge of the bed to meet criteria for use. Alternative equipment or system shall be used if criteria is not meet.

Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility to failed to ensure medications were stored in a safe and secure manner. This affected one (#5) of one residents observed for medication storage. The census was 52. Findings included: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses which included diabetes mellitus, anxiety disorder, and insomnia. Review of the physician orders for Resident #5 revealed an order for the antianxiety medication Klonopin 0.5 milligrams (mg) to take one tablet by mouth twice daily, the pain medication gabapentin capsule 100 mg to give one capsule by mouth twice daily, and the sleep aid melatonin three (3) mg by mouth at bedtime for insomnia. Review of the medication administration record (MAR) for January 2024 revealed Resident #5 received Klonopin, gabapentin, and melatonin at bedtime on 01/29/24 which were signed as given by Licensed Practical Nurse (LPN) #479. Interview with Resident #5 on 01/30/24 at 8:15 A.M. verified there were medications left on the counter in her room in a cup, and stated she did not know if the facility gave her the bedtime medications. Observation on 01/30/24 at 8:18 A.M, revealed three pills, one capsule and two tablets, in a pill cup with Resident #5's name written on it in the resident's room. Interview with LPN #445 on 01/30/23 at 8:26 A.M. verified she had not been in Resident #5's room because she started her medication pass on the B-hall. LPN #445 was not aware where the medications came from in Resident #5's room. Interview with Director of Nursing (DON) on 01/30/24 at 10:38 A.M. verified there were three medications left in Resident #5's room on her counter. The DON stated the three medications were the resident's bedtime medications which included Klonopin, gabapentin and melatonin. Review of the facility policy titled, Storage of Medications, dated 11/20, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure residents were treated with dignity and respect. This affected one (#2) of three residents reviewed for dignity. The facility census was 52. Findings Include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included type II diabetes, morbid obesity, Alzheimer's disease, heart failure, peripheral vascular disease, paranoid personality disorder, major depressive disorder, heart failure, and chronic kidney disease. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #2 was cognitively intact. Resident #2 required extensive assistance with bed mobility, transfer, and toilet use. Resident #2 was independent with eating. Resident #2 received a therapeutic diet at the time of the review and had no significant weight changes. Review of Resident #2's care plan revised 12/13/23 revealed supports and interventions for risk for changes in mood, edema, diuretic therapy, impaired cognitive function, resistive to care, depression, self-care deficit, and chronic renal failure. Interventions included give medications as ordered, and fluids as ordered. Review of Resident #2's physician orders revealed an order dated 05/02/22 for a 1500 milliliters (ml) fluid restriction. Observation on 01/29/24 at 10:08 A.M. of Resident #2's room found a paper sign taped to the right side of Resident #2's door frame. The posted sign read, Liquid Restrictions. Please ask a nurse or dietary before giving anything to drink. Interview on 01/29/24 at 10:11 A.M. with Resident #2 revealed she was alert and aware. Resident #2 verified she had a fluid restriction sign on the outside of her door. Resident #2 stated she did not know why it was posted there and did not want it out there for everyone to know. Observation on 01/30/24 at 8:30 A.M. of Resident #2's room found the paper fluid restriction sign was still posted on the right side of the door frame and was visible from the common area of the hall. Interview on 01/30/24 at 8:34 A.M. with State tested Nurse Aide (STNA) #471 verified Resident #2 had a sign posted on the outside of her door indicating Resident #2 was on a fluid restriction. STNA #471 stated Resident #2 was noncompliant with her fluid restriction so they posted the sign so people entering her room were aware she was on a restriction. Review of the facility policy titled, Dignity, revised February 2021, revealed signs indicating the resident's clinical status or care needs were not to be openly posted.

Based on record review, staff interview, and review of the facility guidelines, the facility failed to issue notifications of the ending of skilled Medicare Part A services for residents who remained in the facility. This affected one (#24) of three residents reviewed for liability notices. The facility census was 52. Findings Include: Review of Resident #24's Beneficiary Notice Form revealed Resident #24 began Medicare Part A skilled services on 07/26/23 and Medicare Part A skilled services ended on 09/21/23. The facility initiated the discharge from services and it was noted Resident #24 remained in the facility. There was no indication Resident #24 or her representative were provided a Notice of Medicare Non-Coverage (NOMNC) or an Advanced Beneficiary Notice of Non-Coverage (ABN). Interview on 01/30/24 at 2:08 P.M. with the Director of Nursing (DON) revealed she confirmed with Licensed Social Worker (LSW) #410 the forms had not been provided. Review of the facility guidelines titled, Beneficiary Notice Guidelines, dated 2021, revealed if the Part A stay ended because the facility determined the beneficiary no longer required daily skilled services and the resident remained in the facility, the facility was to provide a Skilled Nursing Facility Advanced Beneficiary Notice and Notice of Medicare Non-Coverage forms.

Based on observation, medical record review, staff interview, wound treatment management policy, and manufacturer indications for use, the facility failed to ensure skin breakdown treatments were applied as ordered by the physician. This affected one (#19) of one resident reviewed for non-pressure skin impairments. The census was 52. Findings include: Review of the medical record revealed Resident #19 admitted to the facility on [DATE] with the diagnoses including, type II diabetes mellitus with diabetic chronic kidney disease, obstructive and reflux uropathy, anxiety disorder, heart failure, gastroenteritis and colitis, major depression, coronary artery disease, Alzheimer's disease, vascular dementia, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was assessed with moderately impaired cognition, was dependent on staff for activities of daily living (ADLs), required substantial to maximum assistance with side to side positioning, was dependent with transfers, and was assessed at risk for pressure ulcer development with a stage four pressure ulcer (full-thickness skin and tissue loss) present on admission, and moisture associated skin damage (MASD). Review of a pressure sore risk assessment completed on 12/22/23 revealed Resident #19 was assessed at moderate risk of pressure sore development. On 03/28/23 a plan of care addressing Resident #19 risk of developing skin breakdown was revised due to diagnoses of diabetes mellitus, cardiovascular disease, chronic kidney disease, dependence of staff for bed mobility and transfers, and incontinence of bowel. Interventions included to apply protective ointments after incontinent episodes, protect skin on skin between bony prominences, and turn and reposition at regular intervals. In addition, on 06/08/23, a nursing plan was revised due to Resident #19's actual skin breakdown on the coccyx related to MASD with an intervention to perform treatments as ordered. Review of a physician order dated 11/01/24 revealed the physician directed staff to clean Resident #19's sacrum area, make sure the area was dry, and apply Dermaseptine cream (barrier cream to use to prevent irritation due to moisture and promote healing) to the area two times daily for MASD. On 11/22/23 the physician ordered a wound treatment to the left heel including the application of leptospermum honey (MediHoney) three times a week, and cover with a absorbent dressing, and wrap with kerlix. The treatment was to be applied one to three times weekly, and on 12/13/23 the treatment was discontinued. Review of a wound physician evaluation dated 01/23/24 documented Resident #19 with a partial thickness non-pressure wound of the sacrum with an etiology related to moisture associated skin damage, and a duration greater than 207 days. The wound measured 5.0 centimeters (cm) long by (x) 3.5 cm wide x 0.1 cm deep. There were open areas with exposed dermis. Further review revealed treatment included application of Dermaseptine cream twice daily for 30 days. Observation on 01/30/24 at 1:57 P.M. revealed State tested Nurse Aide (STNA) #456 entered Resident #19's room to complete an incontinence check and reposition the resident. STNA #456 positioned the resident to the left exposing an area of MASD to the sacrum and obtained a tube of MediHoney. STNA #456 proceeded to apply the MediHoney to the sacrum, positioned the resident, and departed the room. On 01/30/24 at 2:03 P.M. interview with STNA #456 verified no barrier cream (Dermaseptine) was available in Resident #19's room, so MediHoney was used on Resident #19's MASD due to two tubes being available in the room at the bedside. On 01/30/24 at 2:20 P.M. interview with the Director of Nursing (DON) confirmed STNA #456 applied a wound treatment (MediHoney) that was ordered for the treatment of a stage four pressure ulcer to Resident #19's heel and not the physician ordered skin barrier cream (Dermaseptine) that was to be applied to the MASD. The DON additionally verified the MediHoney was a wound treatment to be applied by a licensed nurse. Review of a wound physician assessment dated [DATE] revealed Resident #19 had a partial thickness non-pressure wound of the sacrum with an etiology related to moisture associated skin damage, and a duration greater than 215 days. The wound measured 7.0 cm long x 5.0 cm wide x 0.1 cm deep with open areas of exposed dermis. The treatment included application of Dermaseptine cream apply twice daily for 22 days. Review of the manufacturer indication for Dermaseptine cream revealed the cream was designed to treat skin irritations from incontinence episodes, feeding tube leaks, wound exudates, and perspiration. The cream helped prevent moisture based irritation. Review of the manufacturer indications for leptospermum honey (MediHoney) revealed MediHoney use was for application to wound and burn care. MediHoney supports autolytic debridement and a moist wound healing environment in acute and chronic wound and burns. Review of a wound treatment management policy, revised 11/23/2022, revealed wound treatments will be provided in accordance with physician orders. Dressings will be applied in accordance with manufacturer recommendations.

Based on observation, medical record review, staff interview, and a facility catheter care policy, the facility failed to ensure an indwelling urinary catheter was maintained in a manner to prevent infection and care plan interventions were maintained to prevent dislodgement. This affected one (#7) of two residents reviewed for indwelling urinary catheters. The census was 52. Findings include: Review of the medical record revealed Resident #7 admitted to the facility on [DATE] with the diagnoses including, urinary tract infection, sepsis secondary to urinary tract infection, obstructive and reflux uropathy, ureter stent placement, coronary artery disease, coronary artery bypass graph, cerebral vascular accident, hypertension, moderate protein calorie malnutrition, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with moderate cognitive impairment, utilized a wheelchair or walker for mobility, required partial to moderate assistance with activities of daily living, substantial to maximum assistance with transfers, and was assessed with an indwelling urinary catheter. Review of a physician order dated 12/18/23 revealed Resident #7 was ordered the placement of an indwelling urinary catheter due to obstructive uropathy. Review of a nursing plan of care dated 09/27/23 revealed a care plan was initiated to address Resident #7's indwelling catheter related to urinary obstruction and infection. Goals of the care plan were noted as the resident will be/remain free from catheter-related trauma. Interventions included to check tubing for kinks as needed and keep the bag lower then bladder level, position the catheter bag and tubing below the level of the bladder and away from entrance room door, provide catheter care routinely and as needed, change as ordered and as needed, and secure catheter to the thigh to decrease trauma and bladder spasms. Observation on 01/29/24 at 9:04 A.M., revealed Resident #7's indwelling catheter bag was on floor of the room under the resident's bed. At 4:39 P.M., Resident #7 was up in a wheelchair at the bedside with the catheter tubing resting on the floor. Observation on 01/30/24 at 10:23 A.M., revealed Resident #7 was seated in the wheelchair with the catheter bag on the floor. At 1:38 P.M. and 2:14 P.M., the catheter bag remained on the floor under the resident's bed. On 01/30/24 at 2:14 P.M. interview with State tested Nurse Aide (STNA) #456 verified Resident #7's urinary catheter bag was on the floor. STNA #456 confirmed the catheter bag and associated tubing are to remain suspended in a privacy bag and not in contact with the floor. Observation on 01/31/24 at 9:08 A.M. with STNA #460 during indwelling catheter care to Resident #7 noted the associated catheter tubing was unsecured from the Resident #7's thigh. There were no securing mechanism in place to prevent accidental dislodgment of the catheter. Interview with STNA #460 at the time of the observation confirmed the catheter was to be secured to the resident's thigh. On 01/31/24 at 10:15 A.M. interview with the Director of Nursing confirmed catheter tubing was to be secured to the resident's thigh and the catheter drainage bag with tubing was to be stored off the floor. Review of the catheter care policy, revised 05/10/23, revealed privacy bags will be available and catheter drainage bags will be covered at all times while in use.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident pain was effectively managed. This affected one (#23) of two residents reviewed for pain management. The facility census was 52. Findings Include: Review of Resident #23's medical record revealed an admitted [DATE]. Diagnoses included major depressive disorder, visual hallucinations, dysphagia, dementia, anxiety disorder, osteoarthritis, adjustment disorder, and pseudobulbar affect. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #23 was rarely or never understood. A Staff Assessment for Mental Status was completed and Resident #23 was assessed with memory problems. Resident #23 required extensive assistance with bed mobility, transfers, eating, and toilet use. Resident #23 received scheduled and as needed pain medications. Resident #23 displayed facial expressions of pain one to two days during the review period. Resident #23 displayed physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others one to three days during the review period. Resident #23 was on hospice at the time of the review. Review of Resident #23's care plan revised 01/18/24 revealed supports and interventions for the need for monitoring of multiple medical conditions, self-care deficit, impaired cognitive function, and hospice services for terminal diagnosis of dementia for comfort management. Review of an order dated 10/14/22 revealed staff were to document Resident #23's pain level and medicate as needed two times a day for pain rated on a scale of one to ten. If the resident was unable to give a number, the staff were to assess the resident for physical signs of pain. Review of an order dated 03/28/23 revealed Resident #23 was ordered the narcotic pain medication Dilaudid one (1) milligram per milliliter (mg/ml), to give 0.5 ml by mouth every four hours for pain/shortness of breath with scheduled times of 12:00 A.M, 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of an order dated 03/28/23 revealed Resident #23 was also ordered Dilaudid liquid 1 mg/ml, to give 0.5 ml by mouth every hour as needed for pain and dyspnea. The order revealed to give 0.5 mg that equals 0.5 ml, and if three doses were given in 24 hours the staff were to call hospice. Observation on 01/29/24 at 9:38 A.M. of Resident #23 found her calling out with the resident saying, Someone help me. An interview was attempted with Resident #23 and she was found to be confused and not able to be interviewed. Interview on 01/30/24 at 9:14 A.M. with State tested Nurse Aide (STNA) #471 revealed Resident #23 was cognitively impaired and not able to make her needs known. STNA #471 reported Resident #23 would holler out in pain or if she had a bowel movement and was uncomfortable. STNA #471 reported Resident #23 required total care from staff for all her activities of daily living. Observation on 01/31/24 at 9:43 A.M. of Resident #23 found her yelling and calling out with the resident saying, Help me. Observation on 01/31/24 at 10:02 A.M. of Resident #23 found her still yelling and calling out from her bed. On 01/31/24 at 10:03 A.M., revealed STNA #471 entered Resident #23's room and STNA #471 was heard reassuring Resident #23 the nurse was coming with her pain medications soon and it will be okay. No other pain management interventions were noted to be attempted. Interview on 01/31/24 at 10:05 A.M. with STNA #471 verified Resident #23 was calling out in pain. STNA #471 stated the nurse was on the other hallway and was running behind with Resident #23's pain medications. STNA #471 reported she repositioned Resident #23 to try and help with her discomfort, but Resident #23 was uncomfortable and the repositioning was not helpful to her. Observation on 01/31/24 at 10:16 A.M. of Resident #23 found she was still calling out in pain and there was no nurse on the hall. Observation on 01/31/24 at 10:25 A.M. revealed Licensed Practical Nurse (LPN) #444 arrived on the hallway and went right to Resident #23's room. Resident #23 continued to call out in pain. LPN #444 reassured Resident #23 she would get her pain medication and her other medications. Interview on 01/31/24 at 10:27 A.M. with LPN #444 verified Resident #23 was calling out and that was how Resident #23 expressed pain. LPN #444 reported Resident #23 was not able verbally express her pain levels and they determined her level by her behaviors. Observation on 01/31/24 at 10:30 A.M. revealed LPN #444 accidentally spilled Resident #23's medications and went to get the Assistant Director of Nursing (ADON) to sign off on the wasted medications and redraw Resident #23's medications. Interview on 01/31/24 at 10:33 A.M. with LPN #444 revealed she spilled Resident #23's antianxiety medication Ativan and Dilaudid, and verified Resident #23 continued calling out in pain. Observation on 01/31/24 at 10:36 A.M. revealed LPN #444 prepared Resident #23 Ativan and Dilaudid again while Resident #23 continued to call out. Observation on 01/31/24 at 10:39 A.M. revealed Resident #23's medications were administered. Interview on 01/31/24 at 10:41 A.M. with LPN #444 verified the medications she administered at 10:40 A.M. were Resident #23's scheduled 8:00 A.M. medications. Review of the facility policy titled, Pain- Clinical Protocol, revised March 2018, revealed the physician would order appropriate medication interventions to address the individual's pain. The staff would use a consistent approach and standardized pain assessment appropriate for the resident's cognitive level. The staff were to provide the elements of a comforting environment and appropriate physical and complementary interventions.

Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered within ordered time frames. This affected one (#203) of two residents reviewed for medications. The facility census was 52. Findings Include: Review of Resident #203's medical record revealed an admitted [DATE]. Diagnoses included multiple fractures of right side ribs, respiratory disorder, protein calorie malnutrition, muscle weakness, chronic obstructive pulmonary disease (COPD), and pleurodynia (pain in upper abdomen or chest when breathing). Review of Resident #203's care plan revised 01/23/24 revealed supports and interventions for risk for pain, risk for decline for activities of daily living, behavior of being verbally aggressive, COPD, and desire to return back home. Review of Resident #203's physician orders revealed Resident #203 had medications ordered for one time a day, two times a day, three times a day, four times a day, at bed time, and as needed (PRN). Further review of the physician orders revealed an order dated 01/20/24 for Resident #203 was receive the aerosol medication ipratropium bromide inhalation solution 0.002 percent (%) to inhale 2.5 milliliters (mL) four times a day related to pleurodynia. Review of Resident #203's corresponding medication administration record (MAR) for January 2024 revealed Resident #203 was to receive her ipratropium bromide 2.5 mLs inhaled four times a day at 7:00 A.M., mid-day, evening, and 7:00 P.M. Interview on 01/29/24 at 10:00 A.M with Resident #203 found her to be alert and aware. Resident #203 reported she was frustrated because she was not getting her morning medications and inhaled medications like she should. Resident #203 reported her morning medications were ordered for 7:00 A.M. which meant the facility had until 8:00 A.M. to administer them. Resident #203 stated it was now 10:00 A.M. and she had not gotten her medications. Resident #203 also stated her inhaled medications were ordered four time a day and she did not get her morning inhaled medication until lunch time, and was not able to get all four treatments the way she should. Resident #203 stated she was not sure all of what she took but she knew she was still waiting on her heart medication and her breathing treatment. Interview on 01/30/24 at 9:11 A.M. with State tested Nurse Aide (STNA) #471 revealed Resident #203 was cognitively intact and able to make her needs known. STNA #471 reported Resident #203 had complained about the timeliness of her medications and verified she was aware Resident #203 was not getting her medications during the specified timeframes. Interview on 01/31/24 at 8:55 A.M. with Resident #203 revealed she had not gotten medications yet and she should have gotten them by now. Resident #203 stated she wanted her morning inhaled medication at 7:00 A.M. with 8:00 A.M. being the latest it should be given and the rest of her medications medications by 8:00 A.M. Resident #203 stated it was now close to 9:00 A.M. and she had not gotten her morning medications. Observation on 01/31/24 at 10:42 A.M. found Licensed Practical Nurse (LPN) #444 was on Resident #203's hallway and was passing medications. Resident #203 was observed asking LPN #444 for her morning medications and LPN #444 responded telling Resident #203 she would get to her but she had two other residents to pass medications to first. Interview on 01/31/24 at 10:50 A.M. with Resident #203 found her sitting in her wheelchair leaning forward with her head in her hands. Resident #203 stated she was frustrated because she had not gotten her morning medications yet and she had wanted them by 8:00 A.M. Resident #203 reported she let the nurse know and she also asked a therapy staff member who stopped by about her medications. Resident #203 reported the therapy staff told her it would be another half an hour or so before the nurse would get to her. Resident #203 stated it was almost time for lunch and her medications were not given to her on time. Observation on 01/31/24 at 10:58 A.M. of LPN #444 found she moved her medication cart outside Resident #203's door and began preparing Resident #203's medications. Interview on 01/31/24 at 11:00 A.M. with LPN #444 verified she was preparing Resident #203's morning medications and that the medications were outside the ordered time frames. Observation on 01/31/24 at 11:10 A.M. revealed Resident #203 was still waiting for her morning medications. At 11:11 A.M., LPN #444 had all of Resident #203's oral medications prepared in a cup and at 11:20 A.M. Resident #203 was provided her morning medications. At 11:28 A.M., LPN #444 provided Resident #203 with her aerosol medication. Review of the facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, revealed the purpose of the procedure was to safely administer aerosolized particles of medication into the resident's airway. The facility staff was to obtain a physician order and administer the medication as ordered.

Based on observation, medical record review, staff interview, and facility medication administration policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames producing a medication error rate greater than five (5) percent (%). This resulted in three medication errors out of 27 opportunities for a medication error rate of 11.11%. This affected one (#154) of three residents observed for medication administration. The facility census was 52. Findings include: Observation on 01/30/24 at 10:38 A.M. revealed Licensed Practical Nurse (LPN) #445 obtained Resident #154's medications from the medication cart and preparing for administration. LPN #445 placed medications including the medication for bone health alendronate sodium oral tablet 70 milligrams (mg) and the diuretic Bumex oral one (1) mg, and proceeded into Resident #154's room administering the medications at 10:48 A.M. Interview with Resident #154 at this time confirmed she had previously consumed breakfast between 8:00 A.M. and 9:00 A.M. Observation at 11:10 A.M. noted LPN #445 was unable to locate Resident #154's aluminum hydroxide 200 mg, magnesium hydroxide 200 mg, and anti-bloating medication Simethicone 20 mg, and proceeded to confirm in interview the medication was not available in the facility. Additional interview at that time with LPN #445, during a review of physician orders, verified Resident #154 was to receive alendronate sodium oral tablet 70 mg at least 30 minutes before the first food or drink of the day, and Bumex 1 mg was scheduled twice daily with the first dose to be administered at approximately 8:00 A.M. Review of Resident #154's physician orders revealed an ordered dated 01/21/24 for aluminum hydroxide 200 mg magnesium hydroxide 200 mg, and Simethicone 20 mg to give 30 milliliters (ml) four times a day for indigestion after meals, and at bedtime with scheduled times 8:00 A.M., between 12:00 P.M. and 1:00 P.M., 5:00 P.M., and between 7:00 P.M. and 10:00 P.M. On 01/22/24, Resident #154 was ordered Bumex oral tablet 1 mg scheduled two times a day for hypertension at 8:00 A.M. and 5:00 P.M. On 01/21/24, Resident #154 was ordered alendronate sodium oral tablet 70 mg, to give one tablet by mouth one time a day every seven (7) days for bone health, and administer with eight (8) ounces of plain water at least 30 minutes before the first food or drink of the day. The resident should be in an upright position and avoid lying down for 30 minutes after administration. The resident was not to eat for at least 30 minutes after administration which was scheduled at 7:30 A.M. On 01/30/24 at 1:10 P.M. interview with the Director of Nursing, during a review of the medical record and facility medication policy, confirmed medications were administered to Resident #154 on 01/30/24 outside of prescribed timeframes. Review of the person-centered medication administration policy, implemented 03/2023, revealed the facility will consult with the pharmacist or prescriber to identify time critical scheduled medications and medications that require special administration times and may not apply to their established by the facility. The facility will communicate the administration times to the resident and allow the resident to select personalized times of administration within time frames established by the facility.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident, family, and staff interview, pharmacy interview, review of pharmacy delivery manifest, review of facility policy, and review of hospital neurology notes, the facility failed to ensure Resident #01 was free of significant medication errors when Resident #01 had not received physician ordered anti-anxiety medication (Klonopin) for three days. Actual Harm occurred to Resident #01 when the facility failed to ensure medications were available for administration resulting in the resident experiencing a seizure attributed to medication withdrawal requiring hospitalization with additional testing, monitoring, and restarting of the ordered medication as a result of the medication error. This affected one (Resident #01) of three residents reviewed for medications. The facility census was 54. Findings include: Review of Resident #01's medical record revealed an admitted [DATE] and a re-admitted [DATE]. Diagnoses included major depressive disorder, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact and received anti-anxiety medications seven of the seven days of the look-back period. Review of the plan of care, initiated 05/25/23, revealed Resident #01 used anti-anxiety medications. Interventions included to administer anti-anxiety medications as ordered by physician. Review of the physician orders revealed Resident #01 was prescribed Klonopin oral tablet 0.5 milligrams (mg) two times daily for anxiety. Review of the Medication Administration Record (MAR) from 09/01/23 through 09/30/23 revealed Klonopin 0.5 mg was documented as 9 on 09/08/23 evening dose, 09/09/23 morning dose, 09/10/23 evening dose, and 09/11/23 morning dose. Further review of the MAR revealed 9 indicated to see nurses notes. Review of the nursing progress notes revealed on 09/08/23, Klonopin was on order; on 09/09/23 the facility was waiting on delivery; on 09/10/23 awaiting supply; and 09/11/23, Klonopin was not available and waiting on pharmacy. Further review of the medical record from 09/08/23 through 09/11/23 revealed no evidence of communication with the physician or pharmacy regarding Klonopin being unavailable for administration to Resident #01. Review of the nursing progress note dated 09/11/23 at 4:20 P.M. revealed Resident #01 was with her daughter in her room and the daughter stated she was shaking a little like she does and then all of a sudden her head went back and started shaking harder and foaming at the mouth. Daughter yelled for help and aide found writer. Resident #01 was in a safe position and was watched until it was over. Emergency 9-1-1 service was called and Resident #01 was transported to the hospital. Review of a hospital neurology progress note, dated 09/12/23, revealed Resident #01 presented to the Emergency Department (ED) for complaints of seizure of two minutes, witnessed by family who described resident's eyes rolling back, followed by jerking, non-responsive, foaming at the mouth, while seated. Resident #01 had some facial twitching, jerking hand movements, stuttering, small seizure examined by bedside nurse that lasted five to ten seconds, and a incontinent episode. Resident #01 was brought to the hospital because of an apparent witnessed seizure. The description was of generalized convulsive activity lasting several minutes and she was confused afterwards. She had a normal Computed Tomography Scan (CT) of the brain. Per the history, she had been on Klonopin and was apparently off of this for three days. The impression was Resident #01 had a new onset seizure and given the available history, this was likely benzodiazepine (Klonopin is in this medication class) withdrawal. Anticonvulsant therapy was deferred and recommended the resident follow-up in the physician's office post-discharge. Review of a Pharmacy Delivery Manifest (PDM) revealed on 08/07/23, there were 60 - 0.5 mg clonazepam (Klonopin) tablets delivered to the facility for Resident #01. On 09/12/23, the next order of clonazepam was delivered to the facility for Resident #01. Interview on 10/11/23 at 8:15 A.M. with Resident #01 revealed she had a seizure and was in the hospital. Resident #01 stated Evidently for three days I could not get my pills and I had a seizure. That was kind of scary. Resident #01 stated she had no recollection of the seizure and had no prior history of seizures. Resident #01 confirmed she was currently receiving her medications as ordered and had no further concerns. Interview on 10/11/12 at 8:47 A.M. with Resident #01's family member revealed the facility did not have the resident's Klonopin for three days. The family member was visiting when Resident #01 had a seizure at the facility and was taken to the ED. The family member stated Resident #01 had no prior history of seizures and the hospital said the seizure was due to Klonopin withdrawal. Interview on 10/11/23 at 10:47 A.M. with the Director of Nursing (DON) verified the facility did not have Klonopin available for administration to Resident #01 from the evening dose on 09/08/23 through the morning dose on 09/11/23, for a total of six missed doses. Additionally, Resident #01 had a seizure the afternoon of 09/11/23 and was transferred to the hospital. The DON stated she investigated the incident and learned the resident's Klonopin was not delivered by the pharmacy as a new controlled substance form was needed by the pharmacy. Nursing staff had e-mailed the document to the physician on Friday, 09/08/23, but failed to follow-up with the physician to ensure he received, signed, and returned the document. Over the weekend, including 09/09/23 and 09/10/23, none of the nursing staff who worked with Resident #01 contacted the physician or the pharmacy regarding the medication. The DON confirmed Klonopin was in the facility's contingency medication box (c-box), however, since it was a controlled substance, nursing would have needed to call the pharmacy to be given an authorization code in order to pull the medication. The DON verified nursing staff did not contact the pharmacy to get authorization to pull the medication for administration to the resident. On Monday, 09/11/23, the physician was contacted and the controlled substance form was signed and returned to the pharmacy in order for the medication to be delivered to the facility. The DON verified Resident #01 had seizure-like activity that afternoon, was sent to the ED, and the treating neurologist at the hospital believed the seizure was likely the result of benzodiazepine withdrawal. The DON stated every licensed nurse who worked with Resident #01 from 09/08/23 through 09/11/23 was disciplined and all licensed nursing staff were re-educated on the process for ordering medications, follow-up with the physician and pharmacy, and accurate and complete documentation related to medication administration. Telephone interview on 10/11/23 at 12:39 P.M. with Quality Assurance Pharmacist (QAP) #200 confirmed the pharmacy had filled Resident #01's Klonopin order on 08/07/23 and stated it made sense the facility did not have any medication to administer to the resident from 09/08/23 through 09/11/23. QAP #200 stated the pharmacy did not have a valid controlled substance form for Resident #01 and a new one was needed before any additional medication could be delivered. QAP #200 verified the facility was responsible for obtaining the controlled substance form. QAP #200 verified the facility had Klonopin in their c-box and, had the facility contacted the pharmacy indicating a need for the medication, the pharmacy would have paged the physician to obtain a verbal order and provided an authorization code for the facility to pull the medication for Resident #01. QAP #200 confirmed there was no record anyone from the facility had contacted the pharmacy regarding Resident #01's Klonopin from 09/08/23 through 09/11/23. Interview on 10/11/23 at 1:50 P.M. with the Administrator verified Resident #01 did not have Klonopin available for administration from 09/08/23 through 09/11/23. The Administrator stated when administration learned of the medication error on 09/11/23, a plan of correction was developed and implemented to prevent any further significant medication errors. Review of the facility policy titled Administering Medications, revised April 2019, revealed medications are administered in accordance with prescriber orders. The deficient practice was corrected on 09/30/23 when the facility implemented the following corrective actions: On 09/11/23, the DON followed-up with the physician and received the controlled substance form in order to obtain Resident #01's medication. On 09/11/23, Resident #01 was transferred to the ED for assessment following a seizure. Resident #01 was restarted on her medication. On 09/12/23, the DON completed an audit of all residents on benzodiazepine medications and found no other concerns related to medications being available or administered per physician orders. On 09/12/23, the pharmacy delivered Resident #01's medication to the facility. From 09/13/23 through 09/21/23, the DON met with each of the four licensed nursing staff (Licensed Practical Nurses (LPN) #100, #105, #110, and #115) who were responsible for medication administration during the time Resident #01 did not receive her medication and provided re-education and disciplinary action related to the medication not being available, administered, and lack of follow-up with the physician and/or pharmacy. From 09/13/23 through 09/30/23, the DON re-educated all licensed nursing staff on re-ordering medications, medication administration, follow-up with the physician and/or pharmacy, and complete and accurate documentation. On 09/13/23, the Administrator provided education to the Medical Director on the process of ordering medications, signing controlled substance forms timely, and being in compliance with timely ordering of medications. On 09/13/23, Assistant Director of Nursing (ADON) #150 audited all residents to ensure all ordered medications were available for administration, were administered as ordered, and accurately documented in the medical record. Additional audits conducted on 09/19/23, 10/02/23, and 10/10/23 revealed no additional concerns related to medications administration and documentation. Audits will continue for a total of six weeks and any additional concerns will be presented to the Quality Assurance and Performance Improvement (QAPI) team members. On 09/28/23, an ad hoc QAPI meeting was held to review the audits that had been completed to ensure medications were administered correctly and free of error. This deficiency represents non-compliance investigated under Complaint Number OH00146724.

Based on record review, review of in room video surveillance footage, staff interview, and policy review, the facility failed to ensure the medical record contained the name of the nurse who administered the medications and that the medication administration record (MAR) was accurately documented for one (#25) of three residents reviewed for medication administration. The facility census was 57. Findings include: Review of Resident #25's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's medical record revealed a physicians order dated 05/29/21 for [MEDICATION(S)] ([CONDITION(S)] replacement hormone) tablet 25 micrograms (mcg) to be administered by mouth one time a day at 7:30 A.M. for [CONDITION(S)]. Review of Resident #25's medical record revealed a physician order dated 08/29/19 for [MEDICATION(S)] 17 grams one time daily at 7:00 A.M. for constipation. Review of Resident #25's medical record revealed a physician order dated 09/26/20 for a multivitamin once a day for a supplement to be administered at 1:00 P.M. Review of Resident #25's medical record revealed a physician order dated 01/12/17 for Vitamin D-400 to be given once a day for low vitamin D. This was to be administered at 1:00 P.M. Review of Resident #25's medical record revealed a physician order dated 05/10/22 for Tylenol 325 milligrams (mg) one tablet daily at 7:00 P.M. for leg pain. Review of Resident #25's medical record revealed a physician's order dated 06/22/22 for [MEDICATION(S)] Solution (used to treat pressure in eye from [CONDITION(S)]) 0.2-0.5 % ([MEDICATION(S)]-[MEDICATION(S)]) eye drops to instill one drop in both eyes two times a day for unspecified [CONDITION(S)] and to ensure the drops were spaced five to ten minutes apart. The medication was to be administered at 7:30 A.M. and 7:30 P.M. Review of Resident #25's medical record revealed a physician order dated 06/22/22 for [MEDICATION(S)] solution (used to treat pressure in eye from [CONDITION(S)]) 0.004 % eye drops. The drops were to be dispensed as written and instill one drop in both eyes at bedtime for [CONDITION(S)]. The drops were to be administered at 8:00 P.M. Review of Resident #25's medical record revealed a physician order dated 08/04/20 for [MEDICATION(S)] (HCl) Solution (used to treat pressure in eye from [CONDITION(S)]) 1 % one drop was to be placed in both eyes for pressure in the right eye. The medications was to be given at 8:00 A.M. and 5:00 P.M. Review of Resident #25's medical record revealed a physician order dated 07/17/22 for [MEDICATION(S)] Balance Solution (lubricant) 0.6 % eye drops. One drop was to be instilled in both eyes two times daily for [CONDITION(S)]. The drops were to be administered at 12:00 P.M. and 4:00 P.M. Review of Resident #25's medical record revealed a physician order dated 08/04/20 for [MEDICATION(S)] HCI Solution (used to treat pressure in eye from [CONDITION(S)]) 2% to instill one application in both eyes two times a day for pressure in right eye. The medication was scheduled to be administered at 8:00 A.M. and 5:00 P.M. Review of the in room video surveillance camera footage dated 07/28/22 beginning at 10:14 A.M. revealed the nurse was in Resident #25's room assisting with toileting. There were no visual observations or verbal interactions indicating any medications were administered. The video revealed the family fed the resident her lunch in the room. The nurse never entered the room through 5:02 P.M. when the resident was taken out of the room. At 5:22 P.M. Resident #25 returned to the room and no nurse entered the room to administer medications from 5:22 P.M. through 12:00 A.M. on 07/29/22 when the video ended. The videos revealed Resident #25 was not administered her multivitamin, Vitamin D, and [MEDICATION(S)] eye drops at 12:00 P.M. and 1:00 P.M. Resident #25 was not administered her [MEDICATION(S)] eye drops at 4:00 P.M., the Tylenol at 7:00 P.M., the [MEDICATION(S)] eye drops at 7:30 P.M., or the [MEDICATION(S)] eye drops at 8:00 P.M. Review of the MAR for July 2022 revealed all the medications observed not to be administered on the video tape were signed off as administered on 07/28/22 with the initials gsf. Review of the in room video surveillance camera footage dated 07/30/22 for 5:45 A.M. through 5:33 P.M. revealed from 8:25 A.M. through 8:52 A.M. Resident #25 was out of her room. No medications were observed administered prior to the resident leaving the room. At 9:08 A.M. Licensed Practical Nurse (LPN) #240 was observed in Resident #25's room administering an unknown eye drop and medications. LPN #240 can be heard telling Resident #25 the medications were a stool softner, [MEDICATION(S)] and [MEDICATION(S)]. From 12:10 P.M. through 12:53 P.M. Resident #25 was out of her room. At 5:19 P.M. Resident #25's family fed the resident dinner in the room. From 9:08 A.M. through 5:33 P.M. when the video ended, no staff entered Resident #25's room to administer medications. The video revealed Resident #25 [MEDICATION(S)] was not administered on an empty stomach. Resident #25's 4:00 P.M. [MEDICATION(S)] eye drops and 5:00 P.M. [MEDICATION(S)] HCl and [MEDICATION(S)] HCl eye drops were not observed to have been administered. Review of the MAR for July 2022 revealed on 07/30/22 Resident #25's 7:00 A.M. [MEDICATION(S)] and [MEDICATION(S)], 7:30 A.M. [MEDICATION(S)], were signed as administered with the initials gsf. All the eye drops scheduled to be administered at 4:00 P.M. and 5:00 P.M. on 07/30/22 were signed as administered with the initials gsff. Review of the in room video surveillance camera footage dated 07/31/22 from 5:20 A.M. through 9:10 P.M. revealed LPN #240 was in Resident #25's room at 11:53 A.M. and administered medications and eye drops. No staff entered the room after this time and administered any medications until 5:38 P.M. when LPN #240 was observed in the room and administered one unidentified eye drop to Resident #25. Resident #25 did not leave the room during this time, being fed her evening meal by visitors. No other staff was observed to enter the room to administer any medications until 7:11 P.M. Resident #25 was scheduled to receive [MEDICATION(S)] eye drops at 4:00 P.M., [MEDICATION(S)] HCl eye drops at 5:00 P.M., and [MEDICATION(S)] HCl eye drops at 5:00 P.M. Two of these three ordered eye drops were not administered. Review of the MAR for July 2022 revealed all the eye drops scheduled to be administered at 4:00 P.M. and 5:00 P.M. on 07/31/22 were signed as administered with the initials gsff. Review of the in room video surveillance camera footage dated 08/27/22 from 6:00 A.M. through 5:30 P.M. Resident #25 was fed her breakfast in the room and finished eating at 9:13 A.M. No staff was observed to enter the room and administer any medications until 11:33 A.M. when LPN #240 administered one scoop of something in applesauce, gave one drink of a liquid from a cup, and administered one unidentified eye drop. The liquid in the cup was not all consumed and LPN #240 removed it from the area. Resident #25 did yell out once during the eye drop administration but was not heard making a statement of refusal of the eye drops. At 12:02 P.M. Resident #25 was fed lunch in the room by visitors. From 1:28 P.M. through 3:17 P.M. Resident #25 was out of the room. Resident #25's family fed her dinner in the room. The video ends at 5:30 P.M. with no staff observed to enter the room to administer any additional medications after 11:33 A.M. Review of Resident #25's August 2022 MAR revealed on 08/27/22 the resident's 7:00 A.M. [MEDICATION(S)], 7:30 A.M. [MEDICATION(S)] and [MEDICATION(S)] eye drops, 8:00 A.M. [MEDICATION(S)] HCl eye drops, 12:00 P.M. [MEDICATION(S)] eye drops, 1:00 P.M. multivitamin and Vitamin D, an 5:00 P.M. [MEDICATION(S)] HCl eye drops were signed as administered with the initials gsf. The MAR revealed Resident #25's [MEDICATION(S)] HCI solution eye drops at 8:00 A.M. and 5:00 P.M. and the 4:00 P.M. [MEDICATION(S)] eye drops were refused. Review of the in room video surveillance camera footage dated 08/28/22 revealed at 11:04 A.M. LPN #240 was speaking to Resident #25's family in the room. LPN #240 stated on 08/27/22 she tried to give Resident #25 her eye drops when she was at breakfast. The family asked if LPN #240 had given any eyedrops on 08/27/22 in the afternoon. LPN #240 replied she did not and marked them as refused. LPN #240 stated the resident had refused her eye drops when she tried to give them in the morning so LPN #240 identified she marked the eye drops refused for the entire day. LPN #240 stated the medications given at 11:00 A.M. were the resident's morning medications. The family then asked if Resident #25 had gotten her vitamins on 08/27/22 and LPN #240 stated What vitamins? The family responded the vitamins she gets at lunch. LPN #240 stated she crushed them and put them in her lunch. When the family reminded LPN #240 the resident didn't leave the room for lunch, LPN #240 stated she did not give them but may have included them when she gave medications at 11:00 AM. Review of the video surveillance camera footage revealed on 08/27/22, Resident #25 did not receive her [MEDICATION(S)] on an empty stomach, did not receive a full dose of [MEDICATION(S)], did not receive two of three eye drops documented as administered between 7:30 A.M. and 12:00 P.M., did not receive her 8:00 A.M. [MEDICATION(S)] HCl eye drops, did not receive her 1:00 P.M. multivitamin and Vitamin D, did not receive her 4:00 P.M. [MEDICATION(S)] eye drops, and 5:00 P.M. [MEDICATION(S)] HCl and [MEDICATION(S)] HCl eye drops. Telephone interview with LPN #240 on 08/29/22 at 4:46 P.M. revealed she was an agency nurse who used to work at the facility. LPN #240 stated she was assigned to Resident #25 on 08/27/22 and 08/28/22 and she signed the MAR using a generic agency nurse initials that all agency staff are assigned and not her own signature. Review of Resident #25's August 2020 MAR revealed the Tylenol was signed as administered with either the initials gsf or gsff on 08/01/22, 08/02/22, 08/05/22, 08/06/22, 08/07/22, 08/10/22, 08/11/22, 08/15/22, 08/18/22, 08/19/22, 08/20/22, 08/21/22, and 08/24/22. Review of Resident #25's August 2020 MAR revealed Resident #25's 7:00 A.M., 7:30 A.M., and 1:00 P.M. medications were signed as administered with either the initials gsf or gsff on 08/05/22, 08/13/22, 08/14/22, 08/18/22, 08/19/22, 08/23/22, 08/25/22, 08/26/22, 08/27/22 and 08/28/22. The 1:00 P.M. medications were also signed in this manner on 08/22/22 and 08/30/22. Review of Resident #25's August 2020 MAR revealed the [MEDICATION(S)] eye drops were signed as administered with either the initials gsf or gsff in the morning on 08/05/22, 08/13/22, 08/14/22, 08/18/22, 08/19/22, 08/22/22, 08/23/22, 08/25/22, 08/26/22, 08/27/22, 08/28/22, and 08/30/22. The eye drops were signed with the gsf and gsff signature in the evening on 08/05/22, 08/09/22, 08/13/22, 08/14/22, 08/18/22, 08/19/22, 08/22/22, 08/23/22, 08/25/22, 08/26/22, 08/27/22, and 08/28/22. Review of Resident #25's August 2020 MAR revealed the [MEDICATION(S)] HCl eye drops were signed as administered with either the initials gsf or gsff in the morning on 08/05/22, 08/13/22, 08/14/22, 08/18/22, 08/19/22, 08/23/22, 08/25/22, 08/26/22, 08/27/22, and 08/28/22 and the evening on 08/09/22, 08/14/22, 08/18/22, 08/19/22, 08/22/22, 08/23/22, 08/27/22, and 08/28/22. Review of Resident #25's August 2020 MAR revealed the [MEDICATION(S)] eye drops were signed as administered with either the initials gsf or gsff by an agency staff for the doses on 08/01/22, 08/02/22, 08/05/22, 08/06/22, 08/07/22, 08/10/22, 08/11/22, 08/15/22, 08/18/22, 08/19/22, 08/20/22, 08/21/22, and 08/24/22. Interview on 08/30/22 at 1:50 P.M. with the Director of Nursing verified that agency staff continued to used generic agency initials in the MAR to sign medication administration and did not sign the MAR with the initials of the nurse who actually administered the medications. Review of the facility policy titled Administering Medications, dated April 2019, revealed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication, records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug. Review of the facility policy titled Instillation of Eye Drop, revised January 2014, revealed the following information should be recorded in the resident's medical record: the date and time the eye drops were instilled, the name and title of the individual(s) who instilled the eye drops, and the type of solution instilled in the eye. This deficiency substantiates Complaint Number OH 456.

Based on record review, review of manufacturer's directions, video surveillance review, and policy review, the facility failed to administer medications as ordered and per manufacturer's specifications. This effected one (#25) of three residents reviewed for medication administration. The facility census was 57. Findings include: Review of Resident #25's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's quarterly Minimum Data Set (MDS) assessment, dated 07/29/22, revealed the resident had a low cognitive function. Review of Resident #25's medical record revealed a physicians order dated 05/29/21 for [MEDICATION(S)] ([CONDITION(S)] replacement hormone) tablet 25 micrograms (mcg) to be administered by mouth one time a day at 7:30 A.M. for [CONDITION(S)]. Review of the medication insert directions reveal the to take [MEDICATION(S)] tablets as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. [MEDICATION(S)] absorption was increased on an empty stomach. Due to the medication rapidly disintegrating patients must take the tablet with a full glass of water. Calcium or iron supplements may be taken at least four hours apart so the medication was absorbed properly. Review of Resident #25's medical record revealed a physician order dated 08/29/19 for [MEDICATION(S)] 17 grams one time daily at 7:00 A.M. for constipation. Review of the manufacturer's directions on the bottle of [MEDICATION(S)] revealed to dissolve in four to eight ounces of a beverage and drink. Review of Resident #25's medical record revealed a physician order dated 09/26/20 for a multivitamin once a day for a supplement to be administered at 1:00 P.M. Review of Resident #25's medical record revealed a physician order dated 01/12/17 for Vitamin D-400 to be given once a day for low vitamin D. This was to be administered at 1:00 P.M. Review of Resident #25's medical record revealed a physician order dated 05/10/22 for Tylenol 325 milligrams (mg) one tablet daily at 7:00 P.M. for leg pain. Review of Resident #25's medical record revealed a physician order dated 06/22/22 for [MEDICATION(S)] Solution (used to treat pressure in eye from [CONDITION(S)]) 0.2-0.5 % ([MEDICATION(S)]-[MEDICATION(S)]) eye drops to instill one drop in both eyes two times a day for unspecified [CONDITION(S)] and to ensure the drops were spaced five to ten minutes apart. The medication was to be administered at 7:30 A.M. and 7:30 P.M. Review of Resident #25's medical record revealed a physician order dated 06/22/22 for [MEDICATION(S)] solution (used to treat pressure in eye from [CONDITION(S)]) 0.004 % eye drops. The drops were to be dispensed as written and instill one drop in both eyes at bedtime for [CONDITION(S)]. The drops were to be administered at 8:00 P.M. Review of Resident #25's medical record revealed a physician order dated 08/04/20 for [MEDICATION(S)] (HCl) Solution (used to treat pressure in eye from [CONDITION(S)]) 1 % one drop was to be placed in both eyes for pressure in the right eye. The medications was to be given at 8:00 A.M. and 5:00 P.M. Review of Resident #25's medical record revealed a physician order dated 07/17/22 for [MEDICATION(S)] Balance Solution (lubricant) 0.6 % eye drops. One drop was to be instilled in both eyes two times daily for [CONDITION(S)]. The drops were to be administered at 12:00 P.M. and 4:00 P.M. Review of Resident #25's medical record revealed a physician order dated 08/04/20 for [MEDICATION(S)] HCI Solution (used to treat pressure in eye from [CONDITION(S)]) 2% to instill one application in both eyes two times a day for pressure in right eye. The medication was scheduled to be administered at 8:00 A.M. and 5:00 P.M. Review of the in room video surveillance camera footage dated 07/28/22 beginning at 10:14 A.M. revealed the nurse was in Resident #25's room assisting with toileting. There were no visual observations or verbal interactions indicating any medications were administered. The video revealed the family fed the resident her lunch in the room. The nurse never entered the room through 5:02 P.M. when the resident was taken out of the room. At 5:22 P.M. Resident #25 returned to the room and no nurse entered the room to administer medications from 5:22 P.M. through 12:00 A.M. on 07/29/22 when the video ended. The videos revealed Resident #25 was not administered her multivitamin, Vitamin D, and [MEDICATION(S)] eye drops at 12:00 P.M. and 1:00 P.M. Resident #25 was not administered her [MEDICATION(S)] eye drops at 4:00 P.M., the Tylenol at 7:00 P.M., the [MEDICATION(S)] eye drops at 7:30 P.M., or the [MEDICATION(S)] eye drops at 8:00 P.M. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the in room video surveillance camera footage dated 07/30/22 for 5:45 A.M. through 5:33 P.M. revealed from 8:25 A.M. through 8:52 A.M. Resident #25 was out of her room. No medications were observed administered prior to the resident leaving the room. At 9:08 A.M. Licensed Practical Nurse (LPN) #240 was observed in Resident #25's room administering an unknown eye drop and medications. LPN #240 can be heard telling Resident #25 the medications were a stool softner, [MEDICATION(S)] and [MEDICATION(S)]. From 12:10 P.M. through 12:53 P.M. Resident #25 was out of her room. At 5:19 P.M. Resident #25's family fed the resident dinner in the room. From 9:08 A.M. through 5:33 P.M. when the video ended, no staff entered Resident #25's room to administer medications. The video revealed Resident #25's [MEDICATION(S)] was not administered on an empty stomach. Resident #25's 4:00 P.M. [MEDICATION(S)] eye drops and 5:00 P.M. [MEDICATION(S)] HCl and [MEDICATION(S)] HCl eye drops were not observed to have been administered. Review of the MAR for July 2022 revealed on 07/30/22 all the eye drops scheduled to be administered at 4:00 P.M. and 5:00 P.M. on 07/30/22 were signed as administered. Review of the in room video surveillance camera footage dated 07/31/22 from 5:20 A.M. through 9:10 P.M. revealed LPN #240 was in Resident #25's room at 11:53 A.M. and administered medications and eye drops. No staff entered the room after this time and administered any medications until 5:38 P.M. when LPN #240 was observed in the room and administered one unidentified eye drop to Resident #25. Resident #25 did not leave the room during this time, being fed her evening meal by visitors. No other staff was observed to enter the room to administer any medications until 7:11 P.M. Resident #25 was scheduled to receive [MEDICATION(S)] eye drops at 4:00 P.M., [MEDICATION(S)] HCl eye drops at 5:00 P.M., and [MEDICATION(S)] HCl eye drops at 5:00 P.M. Two of these three ordered eye drops were not administered. Review of the MAR for July 2022 revealed all the eye drops scheduled to be administered at 4:00 P.M. and 5:00 P.M. on 07/31/22 were signed as administered. Review of the in room video surveillance camera footage dated 08/27/22 from 6:00 A.M. through 5:30 P.M. Resident #25 was fed her breakfast in the room and finished eating at 9:13 A.M. No staff was observed to enter the room and administer any medications until 11:33 A.M. when LPN #240 administered one scoop of something in applesauce, gave one drink of a liquid from a cup, and administered one unidentified eye drop. The liquid in the cup was not all consumed and LPN #240 removed it from the area. Resident #25 did yell out once during the eye drop administration but was not heard making a statement of refusal of the eye drops. At 12:02 P.M. Resident #25 was fed lunch in the room by visitors. From 1:28 P.M. through 3:17 P.M., Resident #25 was out of the room. Resident #25's family fed her dinner in the room. The video ends at 5:30 P.M. with no staff observed to enter the room to administer any additional medications after 11:33 A.M. Review of Resident #25's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. [MEDICATION(S)], 7:30 A.M. [MEDICATION(S)] and [MEDICATION(S)] eye drops, 8:00 A.M. [MEDICATION(S)] HCl eye drops, 12:00 P.M. [MEDICATION(S)] eye drops, 1:00 P.M. multivitamin and Vitamin D, an 5:00 P.M. [MEDICATION(S)] HCl eye drops were signed as administered. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 5:00 P.M. and the 4:00 P.M. [MEDICATION(S)] eye drops were refused. Review of the in room video surveillance camera footage dated 08/28/22 revealed at 11:04 A.M. LPN #240 was speaking to Resident #25's family in the room. LPN #240 stated on 08/27/22 she tried to give Resident #25 her eye drops when she was at breakfast. The family asked if LPN #240 had given any eyedrops on 08/27/22 in the afternoon. LPN #240 replied she did not and marked them as refused. LPN #240 stated the resident had refused her eye drops when she tried to give them in the morning so LPN #240 identified she marked the eye drops refused for the entire day. LPN #240 stated the medications given at 11:00 A.M. were the resident's morning medications. The family then asked if Resident #25 had gotten her vitamins on 08/27/22 and LPN #240 stated What vitamins? The family responded the vitamins she gets at lunch. LPN #240 stated she crushed them and put them in her lunch. When the family reminded LPN #240 the resident didn't leave the room for lunch, LPN #240 stated she did not give them but may have included them when she gave medications at 11:00 AM. Review of the video surveillance camera footage revealed on 08/27/22, Resident #25 did not receive her [MEDICATION(S)] on an empty stomach, did not receive a full dose of [MEDICATION(S)], did not receive two of three eye drops documented as administered between 7:30 A.M. and 12:00 P.M., did not receive her 8:00 A.M. [MEDICATION(S)] HCl eye drops, did not receive her 1:00 P.M. multivitamin and Vitamin D, did not receive her 4:00 P.M. [MEDICATION(S)] eye drops, and 5:00 P.M. [MEDICATION(S)] HCl and [MEDICATION(S)] HCl eye drops. Review of the facility policy titled Administering Medications, dated April 2019, revealed the individual administering the medication initials the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 456.

Based on record review, review of video surveillance footage, and staff interview, it was determined the facility failed to answer call lights timely for dependent residents. This affected one (Resident #25) of three residents reviewed for staff response to call lights. The facility census was 57. Findings include: Review of Resident #25's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's quarterly Minimum Data Set (MDS) assessment, dated 07/29/22, revealed Resident #25 had a low cognitive function and required extensive one-person physical assistance with all activities of daily living including eating. She was noted to frequently be incontinent of bowel and bladder. Review of Resident #25's most recent care plan revealed the resident was aware of where her call lights were located. The resident used the wall call light while in the room. Resident #25 required frequent reminders to use the call light prior to ambulating. The resident tended to call out frequently during the day due to an impaired cognition related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the video surveillance recordings dated 07/31/22 revealed Resident #25 activated her call light at 6:18 A.M. and no staff responded until 7:42 A.M. The video footage was a view across the room which included the refrigerator to the left of the room, the resident's recliner, the sofa, and the resident's bed. The call light was directly above the bed. There was a clock present over the bed. The video had audio and Resident #25 did not call out. No staff were viewed entering the room past the refrigerator nor was the call light alarm disengaged. Review of the video surveillance recording dated 08/27/22 at 6:41 A.M. revealed Resident #25 initiated the call light and no staff responded to the alarm until 7:21 A.M. The video had audio and Resident #25 did not call out. No staff were viewed entering the room past the refrigerator nor was the call light disengaged. Telephone interview with the Administrator on 09/06/22 at 12:08 P.M. verified the staff failed to answer Resident #25's call light timely on 07/31/22. He stated there was no audio on the video so he felt the resident may have yelled out and due to the way the camera was positioned staff may have entered the room but you wouldn't be able to see them. This deficiency substantiates Complaint Number OH 456.

Based on review of physician orders, review of the nurses notes, review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused harm when one resident (#36) who was administered antibiotics for more than 120 days in the past eight months for asymptomatic urinary tract infections from developing [CONDITION(S)] (antibiotic associated diarrhea infection). This affected one (#36) of three residents reviewed for urinary tract infections. The facility census was 53. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/21 revealed the resident had impaired cognition. Review of a laboratory test dated 09/10/20, revealed a urinalysis (UA) was completed but no culture and sensitivity (C&S) as the specimen did not meet criteria for culture. The resident had no documented signs or symptoms of a UTI. Review of a physician order dated 09/15/20 revealed the resident was ordered the antibiotic [MEDICATION(S)] 500 milligrams (mg) by mouth three times per day for seven days for a urinary tract infection (UTI) . Review of the nurse progress notes revealed no documentation the resident had signs and symptoms of a UTI prior to receiving ordered laboratory urinalysis testing and the administration of ordered antibiotics. Review of a laboratory UA C&S dated 10/07/20, revealed the bacteria Proteus Mirabilis greater than 100,000 colony forming units (cfu)/milliliter (ml). The resident had no documented signs of a UTI. On 10/10/20 the physician ordered [MEDICATION(S)] 500 mg three times per day for 10 days. Review of a laboratory UA C&S dated 10/31/20, revealed Proteus Mirabilis greater than 100,000 cfu/ml. The resident had no documented signs of a UTI. On 11/04/20 the physician ordered [MEDICATION(S)] 500 mg three times per day for seven days. Review of laboratory UA C&S dated 11/23/20, revealed the bacteria Proteus Mirabilis 10 to 50,000 cfu/ml and Escherichia Coli 50 to 100,000 cfu/ml. The resident had no documented signs of a UTI. On 12/02/20 the physician ordered the antibiotic [MEDICATION(S)] 500 mg three times a day for seven days. Review of the bowel documentation from 11/28/20 through 12/07/20 revealed the nursing assistants documented the resident's stools were loose/watery/diarrhea on 11/22/20, 11/23/20, 11/24/20, 11/25/20, 11/26/20, 11/28/20, 11/29/20, 11/30/20, 12/01/20, 12/02/20, 12/03/20, 12/04/20, 12/05/20, 12/06/20, and 12/07/20. Review of a nurse progress note dated 12/03/21 at 4:51 P.M. revealed the physician's office was called regarding the resident's diarrhea. The office staff stated the physician was not in and they would send him a message. Review of a nurse's note dated 12/04/20 at 6:24 P.M. revealed new orders were obtained from the physician to hold the resident's [MEDICATION(S)] and [MEDICATION(S)] until 12/09/20, when the antibiotic was complete. Review of the physician orders revealed on 12/14/20 the physician ordered [MEDICATION(S)] 100 mg every Monday, Wednesday and Friday. The nurse progress notes revealed a urine sample was obtained but the laboratory had not picked up the sample. The resident had no documented signs or symptoms of a UTI. A second urine sample was collected on 12/16/20. Review of laboratory UA C&S dated 12/16/20 revealed the presence of Proteus Mirabilis 50 to 100,000 cfu/ml. On 12/18/20 the physician ordered [MEDICATION(S)] 500 mg three times per day for seven days. The nurse progress notes revealed no documentation the resident had signs and symptoms of a UTI prior to receiving ordered laboratory urinalysis testing. Review of the bowel documentation from 12/25/20 through 01/27/21 revealed the resident's bowel movements were noted as loose/watery/diarrhea from 12/25/20 12/26/20, 12/27/20, 12/29/20, 12/30/20, 01/01/21, 01/03/21, 01/05/21 through 01/11/21 and 01/13/21 through 01/27/21. Review of laboratory UA C&S dated 01/04/21 revealed Proteus Mirabilis greater than 100,000 cfu/ml. The nursing notes revealed the resident had no signs or symptoms of a UTI. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician noted the resident had problems emptying her bladder and had dysuria, frequency and urgency. On 01/06/21 the physician discontinued the [MEDICATION(S)] and ordered [MEDICATION(S)] 250 mg twice a day for seven days and a follow up urinalysis. The physician then ordered to continue the [MEDICATION(S)] daily for one year for prophylaxis of recurrent UTI's. Review of antibiotic notes dated 01/11/21 at 3:52 P.M., 01/14/21 at 12:06 A.M., and 01/15/21 at 2:06 P.M., noted the resident had diarrhea. Review of the nurses notes dated 01/07/21, revealed the resident refused stool softeners due to several occurrences of diarrhea throughout the day. Review of laboratory UA dated 01/20/21, revealed no C&S was completed. The nurse progress notes revealed no documentation the resident had signs and symptoms of a UTI. Review of the laboratory test dated 01/21/21 revealed the resident tested positive for [CONDITION(S)] (C. diff). On 01/22/21 the physician ordered [MEDICATION(S)] 500 mg three times a day for ten days. Review of laboratory UA C&S dated 01/24/21, the urinalysis testing indicated several types of bacteria present and urine recollection was recommended if clinically indicated. The resident remained on the prophylactic dose of [MEDICATION(S)]. The resident had no documented UTI symptoms. Review of a consultant pharmacist's medication regimen review recommendation dated 01/27/21 revealed the resident was noted with [CONDITION(S)] (C.Diff) and diarrhea. The recommendation revealed the resident was recently started on the antibiotic [MEDICATION(S)] 250 milligrams twice a day for seven days, then 250 mg daily for urinary tract infection (UTI) prophylaxis and was also started on [MEDICATION(S)] for C. Diff. The recommendation revealed few studies support antibiotic use for UTI prophylaxis, especially in older adults and many studies have shown this antibiotic exposure increased the risk of resistant organisms and side effects, including increased risk of C.Diff [CONDITION(S)]. Therefore, please reevaluate the [MEDICATION(S)] or provide a benefit versus risk assessment. Perhaps the addition of a [MEDICATION(S)] would be beneficial as well. There was no physician response to this recommendation. Review of laboratory UA C&S dated 02/01/21, the UA C&S revealed the bacteria Pseudomonas Aeruginosa 10 to 50,000 cfu/ml. The physician discontinued the [MEDICATION(S)] and ordered [MEDICATION(S)] 250 mg twice daily for seven days. The resident had no documented signs of a UTI. Review of a laboratory test dated 02/14/21 revealed the resident still positive for C. diff. The physician ordered no treatment. Review of laboratory UA C&S dated 02/15/21, revealed Proteus Mirabilis greater than 100,000 cfu/ml. The resident had no documented signs of a UTI. The C&S report revealed the bacteria was resistant to the antibiotic [MEDICATION(S)]. On 02/24/21 the physician ordered [MEDICATION(S)] 800 mg/160 mg twice daily for seven days. Review of a laboratory test dated 02/14/21, 03/01/21, and 03/18/21 revealed the resident was still positive for C. diff. The physician ordered no treatment. Review of a consultant pharmacist's medication regimen review recommendation dated 03/12/21 revealed the resident was currently being treated with [MEDICATION(S)] twice a day every Monday, Wednesday and Friday. However she is noted positive C. Diff without treatment. Her last urinalysis was negative. Please reevaluate the [MEDICATION(S)] for UTI prophylaxis due to C. Diff and increased risk of resistant organisms. The pharmacist documented a note was written to Physician #04. There was no response to the recommendation. Review of a laboratory test result dated 03/20/21 revealed the resident had a formed stool and no testing was completed. Review of laboratory UA C&S dated 03/19/21, revealed Proteus Mirabilis 10 to 50,000 cfu/ml-several types of bacteria were identified and urine recollections was recommended if clinically indicated. The resident had no documented signs of a UTI. On 03/22/21 the physician again ordered [MEDICATION(S)] twice daily for five days then continue every Monday, Wednesday and Friday. Review of laboratory UA dated 03/29/21 the urinalysis showed no significant growth. On 04/01/21 the physician ordered [MEDICATION(S)] twice daily for five days then continue twice daily on Monday, Wednesday and Friday. The resident had no documented signs of a UTI. Review of laboratory UA C&S dated 04/13/21 revealed Proteus Mirabilis greater than 100,000 cfu/ml. On 04/20/21 the physician ordered [MEDICATION(S)] twice daily for five days. Again the resident had no documented signs of UTI. Interview on 05/03/21 at 11:45 A.M., Physician #04 denied the facility communicated to him the resident care policies and antibiotic stewardship protocols in place at the facility. Physician #04 could not recall receiving any pharmacy recommendations from the facility regarding antibiotic use for Resident #36. Physician #04 denied ordering Resident #36 the antibiotic [MEDICATION(S)] for an asymptomatic UTI where the sensitivity report indicated the cultured bacteria was resistant to [MEDICATION(S)]. Physician #04 stated the resident had confusion and had reported abdominal pain (not documented). Physician #04 stated the resident's UTI were related to the resident reported sitting in feces for four hours. Physician #04 also revealed the resident's daughter reported the facility had neglected care for the resident. Physician #04 stated the resident's daughter had requested the repeat urinalysis testing following antibiotic treatment. Interview on 05/03/21 at 3:00 P.M., the Medical Director (MD) #01 revealed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD #01 also revealed follow up repeat testing was not recommended unless a resident was symptomatic. MD #01 stated the Director of Nursing (DON) had notified him of a physician treating a resident that had not met the criteria for antibiotic use. MD #01 stated he had instructed staff to call the physician. MD #01 stated he was unaware of the amount of antibiotics Resident #36 had been prescribed without meeting treatment guidelines. Interview on 05/03/21 at 2:15 P.M. with the DON and Clinical Coordinator (CC) #301 revealed the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the resident never met Mcgeers criteria for a UTI. The DON stated the resident was regularly asked about her pain and signs and symptoms of urinary tract infections. The DON stated the resident had not reported any signs or symptoms of a urinary tract infection. CC #301 revealed all physicians were sent letters regarding the antibiotic stewardship program. The DON stated she had not contacted Resident #36's physician regarding the antibiotics being ordered without the resident meeting treatment criteria. The DON stated she notified the resident's POA of the concern and recommended discussion with the resident's physician. Interview on 05/03/21 at 4:20 P.M., the DON revealed the physician prescribed antibiotics and the use of prophylactic antibiotics which caused the resident's [CONDITION(S)] infection. Review of the facility policy titled [CONDITION(S)], revised 10/2018, revealed [CONDITION(S)] infection is suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours) Residents considered at high risk of developing symptoms associated with C. Difficile include those with advancing age, gastrointestinal manipulation, previous confirmed infection with C. Difficile and antibiotic or anti-neoplastic therapy. Review of the facility policy titled Urinary Tract Infection/Bacteriuria-Clinical Protocol, revised 04/2018, revealed the staff and practitioner would identify individual with possible signs and symptoms of a UTI. Signs and symptoms of a UTI may be specific to the urinary tract and/or generalized. The presentation of symptomatic UTIs varies. Nurses should observe, document and report signs and symptoms (fever, hematuria) in detail and avoid premature diagnostic conclusion. New onset of nonspecific or general symptoms alone (changes in mental status, decline in appetite) is not enough to diagnose a UTI. Urine odor, color and clarity also are not adequate to indicated bacteriuria or a UTI. A positive urine culture in someone with chronic [CONDITION(S)] symptoms is not enough to diagnose symptomatic UTI. The presence of either pyuria or a positive leukocyte esterase test alone are not enough to prove that the individual has a UTI, but the absence of pyuria or a negative leukocyte esterase test is fairly strong evidence that a UTI is not present. Further policy review revealed the physician would order appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Bacteriuria alone (asymptomatic UTI) should not be treated routinely, because treating it does not materially change outcomes, improve longevity or correct the underlying problem. This deficiency substantiates Complaint Number OH 461.

Based on record review, staff interviews, review of facility investigation documentation, local police interview, and review of personnel files, the facility failed to ensure a resident was not verbally and emotionally abused. Actual harm occurred when Resident #01 was spoken to in a disguised voice by State tested Nurse Aide (STNA) #201, telling her consequences would occur if she did not go to sleep, causing the resident to experience fear. This affected one (#01) of three residents reviewed for abuse. The census was 45. Findings include: Resident #01 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was mildly cognitively impaired. She sometimes understands/understood, had moderately impaired vision without corrective lenses, adequate hearing and was dependent on the physical assistance of one staff for the completion of activities of daily living including toileting. On 02/06/19 a nursing plan of care was revised addressing Resident #01's activities of daily living due to a self-care performance deficit related to limited mobility, left sided weakness, and impaired vision as evidenced by the residents [DIAGNOSES REDACTED]. Interventions included the resident required the extensive assistance of one staff to reposition and turn in bed, encourage resident to use call bell for assistance and requires extensive assistance of staff for toileting. Review of STNA #201's personnel file revealed a hire date of 02/01/19. There was an undated corrective action report listing an incident occurring on 08/13/19 and 08/15/19 in which rule violations for unsatisfactory behavior were of such a serious nature that immediate termination of employment is warranted. Details of the violation documented conduct detrimental to resident care and facility and being in violation of rules of conduct policy including failures in the performance of duties with respect to expectations on level of care. Failure to cooperate fully or being evasive during any facility investigation. Review of STNA #201's time clock activity punch source report noted STNA #201 working on 08/13/19 between 9:57 P.M. to 08/14/19 at 6:10 [NAME]M., and 08/15/19 at 9:59 P.M. to 08/16/19 at 6:15 [NAME]M. According to electronic care tracking documentation, STNA #201 made entries for Resident #01's behavioral and activity of daily living observations which were charted on the following dates and times: 08/14/19 between 2:17 [NAME]M. and 2:22 [NAME]M.; 08/14/19 between 1:10 [NAME]M. and 1:12 P.M.; and 08/15/19 between 11:38 P.M. and 11:39 P.M. Review of the faciltiy's Self-Reported Incident (SRI) dated 08/16/19 revealed the Administrator had received a call from the Long Term Care Ombudsman stating a the resident's family member had alleged abuse. On 08/16/19 at 3:00 P.M., the Administrator met with Resident #01's family and was provided an electronic voice recording that was allegedly obtained from Resident #01's room during the nights of 08/13/19 and 08/15/19. The recordings indicated a staff member spoke to the resident in a manner causing the resident to become scared and fearful. Recording excerpts noted the resident to respond to the individual fearfully by telling the individual to get out of the room, and was heard praying at times. On 08/16/19 following the meeting with Resident #01's family, the facility suspended all staff working the nights of 08/13/19 and 08/15/19 in addition to conducting an investigation. The facility conclusion revealed STNA #201 was identified as the staff member interacting with Resident #01 on the electronic recording and was subsequently terminated from employment. On 08/29/19 at 10:04 [NAME]M., telephone interview with Police Detective (PD) #01 revealed Resident #01's family provided a voice recording of interactions occurring inside Resident #01's room. According to the recording, interactions were between an unidentified staff member and Resident #01 during the dates of 08/13/19 and 08/15/19. PD #01 indicated STNA #201 was identified as the staff member. On the night shift of 08/13/19 and 08/15/19, STNA #201 disguised his voice and spoke to Resident #01 as a person named Martha. STNA #201 told Resident #01 to go to sleep or STNA #201 would take the resident outside for a cigarette. The resident could be heard praying and stating I'm gonna scream if you don't get out. Additional statements recorded STNA #201 stating a cigarette would be left in the bed. Resident #01 would respond with stating please don't. PD #01 stated Resident #01 appeared to be emotionally affected by the interactions and fearful. On 08/29/19 at 1:30 P.M., the electronic voice recordings, including verbal interactions between STNA #201 and Resident #01, were reviewed. Recording data on 08/13/19 between 9:43 P.M. and 08/14/19 at 2:51 [NAME]M. identify STNA #201 introducing himself, stating[NAME] remember me? Resident #01 stated ow! I hurt my hand now. STNA #201 responded stating you want the doctor to cut it off? Resident #01 states, No! Please stop saying that. Resident #01 is heard stating I know this woman. She's cruel. She smokes and tries to get everyone else to smoke. On 08/15/16 between 8:27 P.M. and 08/16/19 at 2:26 [NAME]M. recording data revealed STNA #201 stated It's[NAME]remember me? Resident #01 responded No go away. STNA #201 stated I got a pack of cigarettes and Resident #01 responds take them away. I don't want them. STNA #201 stated I come to take you to smoke. Resident #01 stated I don't want to smoke! You understand that? STNA #201 asks why not? Resident #01 states because I don't like them. STNA #201 responds stating Your mama must have never given you a cigarette. Resident #01 responded stating, No never, never. If you don't go away I'm gonna start screaming. STNA #201 stated Don't do that you'll wake everybody up. At that interval, Resident #01 stated What you doing? You're bad. Can't you be good? Further on in the recording STNA #201 states to Resident #01 You want to go to bed child or you want to go smoke a cigarette with me? Resident #01 stated I want to go to sleep and STNA #201 responds You promise? The recording indicates the resident was placed to bed and was told by STNA #201 I don't want to hear a peep from you. Resident #01 responded No. STNA #201 stated If you can't sleep I'll take you outside to smoke a cigarette with me. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation Prevention and Reporting Policy, revised (MONTH) (YEAR), documented no one should be subject to violent, abusive, humiliating, exploitive or neglectful behavior. The facility policy indicated an abuse prevention system including screening, and training of employees to help prevent abuse from occurring. This deficiency substantiates Master Complaint Number OH 726 and Complaint Number OH 619.